From: barry@webveranda.com (Barry Campbell) Newsgroups: soc.support.depression.manic, alt.support.depression.manic Subject: Bipolar Disorder FAQ v 1.1 (1 of 4) Date: 25 Sep 1996 14:58:34 GMT Message-ID: <barry-2509961101200001@cnc80244.concentric.net> Summary: This article contains information about Bipolar Disorder, based on contributions by readers and participants in Usenet support groups. Archive-name: support/depression/bipolar-faq/part1 Posting-Frequency: monthly ---------------------------------------------------------------------- | | | Bipolar Disorder Frequently Asked Questions (FAQ) File | | ------------------------------------------------------ | | | | | | Version: 1.1 | | | | Release Date: 25 September1996 | | | | Usenet Newsgroups: alt.support.depression.manic (ASDM) | | soc.support.depression.manic (SSDM) | | | | Maintainers: Barry Campbell (barry@webveranda.com) | | http://webveranda.com/barry/ | | | | Marco Anglesio (anglesio@cspo.queensu.ca) | | http://cspo.queensu.ca/~anglesio | | | | Archived at: http://www.moodswing.org/faq.html | | http://cspo.queensu.ca/~anglesio/faq | | | ---------------------------------------------------------------------- ****************************************************************************** DISCLAIMER AND COPYRIGHT NOTICE (IMPORTANT - PLEASE READ) The information presented in this FAQ is derived from published and unpublished sources, and from the experiences and contributions of readers of the Usenet newsgroups alt.support.depression.manic and soc.support.depression.manic. Some of it is fact. Some of it is opinion. Some of it might well be controversial in some circles. NONE of it should be relied upon as expert opinion. This FAQ is provided as-is, without any express or implied warranties. While we have made every effort to make it as accurate, responsible, and helpful as possible, this FAQ is NOT the place to go if you're seeking expert medical, psychological, or legal advice. The authors, maintainers, and contributors responsible for the content of this FAQ assume no responsibility for errors or omissions, or for damages resulting from the use of the information contained herein. If you have questions or concerns, contact a psychiatrist, psychologist, licensed clinical social worker, pharmacist, nurse, other qualified and licensed therapist or practitioner, or attorney, as the case may be. This FAQ may contain short, excerpted material from texts or electronic media. Where materials are directly quoted, complete references have been cited. The Bipolar Disorders FAQ has been assembled for educational and informational purposes only, and with no intent to profit; it is distributed free of charge. No violation of U.S. copyright law is intended; all quotations are made under the "Fair Use" doctrine. All authors of quoted material retain full copyright protection. The definitions of disorders used throughout this FAQ are those found in "Diagnostic and Statistical Manual of Mental Disorders," Fourth Edition (American Psychiatric Association, 1994). To obtain your own copy of this and other American Psychiatric Association publications in book or digital form, contact: American Psychiatric Association 1400 K Street, NW; Suite 1101 Washington, DC 20005-2403 Phone: 1-800-368-5777 (M-F, 9 a.m.-5 p.m., EST) Fax: 1-202-789-2648 http://www.appi.org This FAQ may be posted to any USENET newsgroup, on-line service, or BBS, or pointed to or included on any WWW page, as long as it is posted in its entirety and includes this copyright statement. This FAQ may not be distributed for financial gain. This FAQ may not be included in commercial collections or compilations without express permission from the author(s). ALL MATERIAL HEREIN NOT EXPRESSLY COVERED BY OTHER COPYRIGHT NOTICES IS COPYRIGHT 1996, ALL RIGHTS RESERVED, UNDER UNITED STATES LAW AND THE BERNE CONVENTION BY THE PRIMARY MAINTAINER, BARRY CAMPBELL (btc@concentric.net). THE AUTHOR OF ALL UNATTRIBUTED MATERIAL FOR PURPOSES OF THE BERNE CONVENTION IS BARRY CAMPBELL. THIS FAQ MAY NOT BE USED OR REPRODUCED IN CD-ROM COLLECTIONS, PRINTED REPRODUCTIONS, OR ANY OTHER MEDIA FORMAT WITHOUT EXPRESS WRITTEN PERMISSION. ****************************************************************************** ----------------- TABLE OF CONTENTS ----------------- 1.0 Introduction and Acknowledgments to Contributors 2.0 Revision history and archive locations 3.0 Definitions (DSM-IV and "Extended") 3.1 What is Bipolar Disorder? 3.2 What is Depression? 3.3 What is Mania? 3.4 What is Hypomania? 3.5 What is the difference between euphoria and dysphoria? 3.6 What is a Mixed State? 3.7 What is Rapid Cycling? 3.8 What are delusions and hallucinations? 3.9 How do you tell unipolar depression and bipolar disorder apart? 3.10 What is Cyclothymia? 3.11 What is Dysthymic Disorder? 3.12 What is Schizoaffective Disorder? 3.13 What is Seasonal Affective Disorder? 3.14 How do I distinguish between and among all of these disorders? 4.0 How can I best take care of myself? 4.1 How can I assess my own mental status? (Includes: The Goldberg Depression and Mania Self-Rating Scales) 4.2 What treatment options are available? 4.3 How do I find a good health care provider? 4.4 What medications are commonly used in treatment? 4.5 What "alternative" therapies exist, and are they any good? 4.6 How do I pay for all this? (Insurance-related issues.) 4.7 What are my rights as a patient? 4.8 What are my rights as a person with Bipolar Affective Disorder? 4.9 How can I tell my (friends, family, coworkers)? Should I? 4.10 Resource organizations 5.0 How do I help a friend or loved one? 5.1 What to do (and what not to do) when someone you care about is diagnosed 5.2 What to do (and what not to do) if you suspect that someone you care about needs help, but resists seeking it for themselves. 6.0 Resources for education and support 6.1 Internet Resources 6.2 Books 6.3 Magazine and Journal Articles 7.0 Controversial Issues - making sense of them 7.1 To drug, or not to drug? 7.2 Should I participate in a study or other research program? 7.3 How do I evaluate "alternative" therapies? 7.4 The Psychiatric Survivors' Movement 7.5 Critics of Psychiatry and Psychology 8.0 Is there life (and hope) after diagnosis? 8.1 Coping hints from readers and participants 8.2 Research trends and directions ----------------------------------------------------------------------------- 1.0 Introduction and Acknowledgments to Contributors ----------------------------------------------------------------------------- The Bipolar Disorder FAQ is based largely on the FAQ from the Usenet newsgroup alt.support.depression.manic. The alt.support.depression.manic FAQ was originated and maintained until recently by PsyberNut/Bipolar Bear/Scott (lsm@crl.com), and this FAQ document contains much of his original work, essentially unmodified; in particular, the "more complete list of symptoms" sections are his writing. We gratefully acknowledge our enormous debt to Scott, and wish him the very best. Many readers of alt.support.depression.manic (ASDM) and soc.support.depression.manic (SSDM) have contributed directly and indirectly to the development of this FAQ; many more have read it and offered comments and criticism. So have readers and contributors to the PENDULUM mailing list. A few contributors, in particular, must be singled out for their extraordinary contributions. Thanks to: Joy Ikelman (parrot@frii.com), who allowed us to ransack her "Media File," an excellent resource for finding mood disorder information and references in print. Joy also completely rewrote and updated the "definitions" section of the FAQ, based on DSM-IV, and read early drafts, giving many helpful editorial criticisms along the way. Millie Niss (millie@gauss.math.brown.edu), for her well-researched contributions to the Drug Therapy section of the FAQ. Dr. Ivan K. Goldberg, M.D (psydoc@netcom.com) for his permission to reproduce the Goldberg Depression and Mania Scales. ----------------------------------------------------------------------------- 2.0 Revision history and archive locations ----------------------------------------------------------------------------- This is Version 1.1 of the Bipolar Disorder FAQ, released 25 September 1996. This FAQ is posted periodically to the Usenet newsgroups alt.support.depression.manic and soc.support.depression.manic. The current version of the Bipolar Disorder FAQ may always be found on the World Wide Web at: http://www.moodswing.org/faq.html (in the US) and http://cspo.queensu.ca/~anglesio/faq (in Canada) We're always looking for folks who are willing to locate the FAQ for us in their own countries. The Web IS international by definition, but it's always nicer to hit a nearby server if you can. :-) It is also available via anonymous FTP from ftp://members.aol.com/bipolarfaq/public/ ----------------------------------------------------------------------------- 3.0 Definitions (DSM-IV and "Extended") ----------------------------------------------------------------------------- There are many different mood disorders, and discussing them all thoroughly is beyond the scope of this FAQ. This FAQ focuses on the mood disorders which tend to be characterized by "mood swings": alternating cycles of abnormally depressed and elevated (manic) moods. You're up, you're down, you're up, you're down, you're up... and some (or most) of the time, you're in the middle, trying to figure out what happened. While reading these definitions, it may be useful to think of Bipolar Disorder and related disorders as existing along a continuum of "affects," or moods. ------------------------------ 3.1 What is Bipolar Disorder? ------------------------------ Bipolar Disorder is the medical name for Manic Depression; at various times, it has also been known as Bipolar Affective Disorder and Manic-Depressive Illness. It is a mood disorder that affects approximately 1% of the adult population of the United States--and roughly the same percentage in other countries, as far as we know. :-) It's in the same family of illnesses (called "affective disorders") as clinical depression. However, unlike clinical depression, which seems to affect far more women than men, Bipolar Disorder seems to affect men and women in approximately equal numbers. It's characterized by mood swings. Though there is no known cure, most forms of bipolar disorder are eminently treatable with medication and supportive psychotherapy. The textbook definition of Bipolar Disorder is: one or more Manic or Hypomanic Episodes, accompanied by one or more Major Depressive Episodes. These episodes typically happen in cycles. All of these terms will be defined at greater length below...but in plain English, a person who has Bipolar Disorder will be severely up some of the time, severely down some of the time, and in the middle some or most of the time. There are two main types of Bipolar Disorder: -- Bipolar I is the "classic" form of Bipolar Disorder. It most often involves widely spaced, long-lasting bouts of mania followed by long-lasting bouts of depression and vice-versa. However, the essential definition is depression plus mania, or "mixed states." -- Bipolar II involves at least one Hypomanic Episode and one Major Depressive Episode, but never either a full-blown Manic Episode or Cyclothymia. The essential definition is depression plus hypomania. Although the shifts from one state to another are usually gradual, they can be quite sudden. The "rapid-cycling" form of the disorder involves four or more complete mood cycles within a year's time, and some rapid-cyclers can complete a mood cycle in a matter of days--or, more rarely, in hours. It is also possible for someone who has Bipolar Disorder to be in a "mixed state." This means that they're in a mood state which has some characteristics of depression and some of mania or hypomania. There are a few rare documented cases of mania without depression, but DSM-IV does not currently include a category for just "mania". (This diagnosis was present in DSM-III, but is unaccountably absent in DSM-IV!) Using DSM-IV, a person exhibiting the symptoms of mania will almost always be diagnosed as bipolar. The general feeling in the mental health community seems to be that what or whom goes up, must eventually come down. The DSM-IV and "extended" definitions of depression and mania are presented in the sections that follow. It is very important to remember the following: -- These definitions are not a guide for self-diagnosis! -- One does not need to exhibit *all* of the symptoms of depression to be depressed, nor does one need to display *all* of the symptoms of mania to be manic. ------------------------ 3.2 What is Depression? ------------------------ ****************************************************************************** Criteria for Major Depressive Episode (DSM-IV, p. 327) A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations. (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g. appears tearful). Note: In children and adolescents, can be irritable mood. (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) (3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. (4) insomnia or hypersomnia nearly every day (5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) (6) fatigue or loss of energy nearly every day (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) (8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide B. The symptoms do not meet criteria for a Mixed Episode. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. ****************************************************************************** Well, the APA gives us a good starting point, but it all sounds sort of clinical. Here's a more complete list of symptoms of depression that our readers and participants have identified: * Reduced interest in activities (like writing FAQs) * Indecisiveness (maybe) * Feeling sad, unhappy, or blue (pervasive attitude that life sucks) * Irritability, dammit. * Getting too much (hypersomnia) or too little (insomnia) sleep. * Loss of, um, what were we talking about? Oh yeah, concentration. * Increased or decreased appetite (my ex-mother-in-law's cooking notwithstanding) * Loss of self-esteem, such as my understanding that I suck. * Decreased sexual desire. * Problems with, whaddya call it? Oh yeah, memory. * Despair and hopelessness * Suicidal thoughts. * Reduced pleasurable feelings. * Guilt feelings, which are all my fault anyway. * Crying uncontrollably and/or for no apparent reason. * Feeling helpless, which I can't do anything about. * Restlessness, especially when I can't hold still. * Feeling disorganized (hell, look at my desk). * Difficulty doing things (again, like finishing this FAQ) * Lack of energy and feeling tired. * Self-critical thoughts * Moving and thinking slooooooowwwwwwwly. * Feeling that one is in a stupor, or that one's head is in a fog. * Speeeeeeeakiiinnnnng slooooooowwwwwwwly. * Emotional and/or physical pain. * Hypochondriacal worries; fears or illnesses which prove to be psychosomatic. * Feeling dead or detached. * Delusions of guilt or of financial poverty. * Hallucinating. ------------------- 3.3 What is Mania? ------------------- ****************************************************************************** Criteria for Manic Episode (DSM-IV, p. 332) A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: (1) inflated self-esteem or grandiosity (2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep) (3) more talkative than usual or pressure to keep talking (4) flight of ideas or subjective experience that thoughts are racing (5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) (6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The symptoms do not meet criteria for a Mixed Episode. D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatments) or a general medical condition (e.g., hyperthyroidism). Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder. ****************************************************************************** Again, the APA gives us a good starting point for studying mania, but the language is awfully clinical. Here's a plain-English version, with some extensions: * Decreased need for sleep. * Restlessness. * Feeling full of energy. * Distractibility (what was that?) * Increased talkativeness (or increased typeativeness) * Creative thinking. * Increase in activities. * Feelings of elation. * Laughing inappropriately * Inappropriate humor. * Speeded up thinking. * Rapid, pressured speech, that you can teach, eating a peach, while on a beach. * Impaired judgment * Increased religious thinking or beliefs. * Feelings of exhilaration. * Racing thoughts, which can't be taught, and can't be bought, although they ought, you might get caught. * Irritability (dammit, there it is again!) * Excitability. * Inappropriate behaviors. * Impulsive behaviors. * Increased sexuality (also known as "platoon-of-Marines-on- shore-leave syndrome")... or * "clang associations" (the association of words based on their sound, a possible reason so many poets are bipolar, also why we have pun fun) * _decreased_ interest in sex, or any other interpersonal relationships, due to obsessive interest in some other subject or activity * Inflated self-esteem (so prove I'm NOT the world's leading authority!) * Financial extravagance. * Grandiose thinking. * Heightened perceptions. * Bizarre hallucinations. * Disorientation. * Disjointed thinking. * Incoherent speech. * Paranoia, delusions of being persecuted. * Violent behavior, hostility * Severe insomnia * Profound weight loss * Exhaustion ----------------------- 3.4 What is Hypomania? ----------------------- Hypomania means, literally, "mild mania." It's sometimes difficult to draw a distinct line between "manic" and "hypomanic," as "marked impairment" is a necessarily subjective evaluation. Also, one of the reasons that bipolar disorder often has a delayed diagnosis may be that hypomanic episodes are often overlooked amid the "Sturm und Drang" of adolescense and early adulthood. The associated features of mania are present in Hypomanic Episodes, except that delusions are never present and all other symptoms are *generally* less severe than they would be in Manic Episodes. ****************************************************************************** Criteria for Hypomanic Episode (DSM-IV, p. 338) A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood. B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: (1) inflated self-esteem or grandiosity (2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep) (3) more talkative than usual or pressure to keep talking (4) flight of ideas or subjective experience that thoughts are racing (5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) (6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder. ****************************************************************************** ------------------------------------------------------------ 3.5 What is the difference between euphoria and dysphoria? ------------------------------------------------------------ There are two basic types of mania (or hypomania): euphoric and dysphoric. A person can experience both types when they have bipolar disorder. In euphoria, a person is high, in love with the world, one with the world, feeling boundless energy, talking a mile a minute, mind is racing, deluded with grandiose thoughts, etc. This kind of mania is generally the kind described in the popular literature. Dysphoria is another type of mania. In dysphoria one is "high" but in a different sense: agitated, destructive, full of rage, talking a mile a minute, mind racing, deluded with grandiose thoughts, paranoid, full of anxiety, panic-stricken. In addition, dysphoria can also come into the depressive side. These are often referred to as "mixed episodes." Mixed episodes are quite dangerous; suicidal ideation often accompanies this state. What's the difference between agitated depression and dysphoric (hypo)mania? Dr. Ivan Goldberg (psydoc@netcom.com) explains: "While folks in an agitated depression show increased motor activity, they never show increased sociability, increased creative thinking, joking and punning that may be seen in someone experiencing a dysphoric (hypo)manic state." --------------------------- 3.6 What is a Mixed State? --------------------------- ****************************************************************************** Criteria for Mixed Episode (DSM-IV, p. 335) A. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period. B. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). ****************************************************************************** Comment: This may be an instance in which the DSM-IV definition is a bit too narrow. Many readers and participants in ASDM and SSDM report experiencing mixed states with hypomanic, but not fully manic, features. --------------------------- 3.7 What is Rapid Cycling? --------------------------- The "rapid-cycling" form of Bipolar Disorder involves four or more complete mood cycles within a year's time, and some rapid-cyclers can complete a mood cycle in a matter of days--or, more rarely, in hours. Studies show that women are more likely than men to be diagnosed as rapid-cyclers. -------------------------------------------- 3.8 What are delusions and hallucinations? -------------------------------------------- -- What are delusions? Delusions are, in general, "false beliefs." The DSM-IV (p. 763) defines a delusion as: A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. People who are in a manic or depressed episode may have delusions. Some of these might include delusions of reference, where the individual feels like events, objects, or other persons have a particular and unusual significance. The individual may also have grandiose delusions or delusions of persecution (such as paranoia). It's important to note that delusions must be diagnosed in terms of cultural, social, and religious norms. A belief that one is in direct communication with God, for example, might be either a delusion or an expression of certain kinds of religious faith. :-) -- Can people with bipolar disorder have hallucinations? Most certainly. The DSM-IV (p. 766) defines a hallucination as: A sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ. Hallucinations should be distinguished from illusions, in which an actual external stimulus is misperceived or misinterpreted. Some people know that they are having hallucinations, and others do not. Most people who have bipolar disorder realize that the hallucinations are not actual perceptions of reality. However, this realization does not keep them from occurring. -- What kind of hallucinations are there? Hallucinations may occur in any of the senses: auditory (for example, hearing voices or music), gustatory (for example, unpleasant tastes), olfactory (for example, unpleasant smells), somatic (for example, a feeling of "electricity"), tactile (for example, a sensation of being touched, or "skin crawling" sensations), visual (for example, flashes of light, colors, images on the periphery). ---------------------------------------------------- 3.9 How do you tell unipolar depression and bipolar disorder apart? ---------------------------------------------------- If the person in question is known to have had even a single Manic or Hypomanic Episode, then there is virtually no question; the diagnosis is a form of bipolar disorder (or, in the case of hypomania, possibly cyclothymia.) If the person in question is currently depressed, and his or her history is not known, or is incomplete, the following guidelines by Dr. Ivan Goldberg may prove to be useful: The things that make me suspect bipolarity in a patient diagnosed as unipolar are: - oversleeping when depressed - overeating when depressed - a history of bipolarity in the family - a patient who when depressed can still joke and laugh - anyone with a history of frequent depressive episodes (rapidly cycling unipolar disorder) - success as a salesperson, politician, or actor (in school or real world) - extreme rejection sensitivity - a history of having ever been diagnosed as bipolar or given lithium (except to potentiate antidepressants) Of course, a unipolar patient can still sleep too much, unipolar depression or bipolar disorder can surface earlier or later in life, and so on. These are guidelines, not hard-and-fast rules. CONTINUED IN PART 2.