Home Study

• The Don't Panic Self-Help Kit,
  Section R: Practice Breathing Skills
  Tape 2A: Practicing the Breathing Skills
• Don't Panic,
  Chapter 10. The Calming Response
  Chapter 11. The Breath of Life

During an emergency, our breathing rate and pattern change. Instead of breathing slowly from our lower lungs, we begin to breathe rapidly and shallowly from our upper lungs. If during this time we are not physically exerting ourselves, then it can produce a phenomenon called "hyperventilation." This in turn can explain many of the uncomfortable symptoms during panic:

• dizziness
• shortness of breath
• a lump in the throat
• tingling or numbness in the hands or feet
• nausea
• confusion.

The good news is that by changing your breathing you can reverse these symptoms.

By shifting your breathing rate and pattern, you can stimulate the body's parasympathetic response. This is the body's equally powerful and opposite system to the Emergency Response and is often called the relaxation response. For our purposes I will call it the Calming Response.

The table below lists the physical changes that take place in the Calming Response. As you can see, all of the primary changes of the Emergency Response are reversed in this process. One of the differences in these two physical responses is that of time. The Emergency Response takes place instantly in what is called a mass action: all the changes occur together. Once we flip on that emergency switch, it takes awhile for the body to respond to our calming skills. For this reason it is important for you to know what specific skills will reverse this emergency response and will help calm your body and clear your mind.

The Calming Response (Parasympathetic Response)

• oxygen consumption decreases

• breathing slows

• heart rate slows

• blood pressure decreases

• muscle tension decreases

• growing sense of ease in body, calmness in mind

You will now be introduced to three breathing skills. In later steps you will learn how to change your fearful thinking and your negative imagery, because each time you frighten yourself with catastrophic thoughts or images, you re-stimulate your body's emergency response. To begin with, however, you need a solid foundation in proper breathing.

Calming Your Breath

People who are anxious tend to breathe in their upper lungs (upper chest) with shallow, rapid breaths, instead of breathing into their lower lungs (lower chest). This is one contribution to hyperventilation: shallow, upper lung breathing.

The three breathing skills that I will describe next start with inhaling into your lower lungs. This is a deeper, slower breath. Below the lungs is a sheet-like muscle, the diaphragm, which separates the chest form the abdomen. When you fill your lower lungs with air, the lungs push down on the diaphragm and cause your abdominal region to protrude. Your stomach looks as though it is expanding and contracting with each diaphragmatic breath.

Two kinds of breathing, upper chest (thoracic) above, and lower chest (diaphragmatic) below.

The first breathing skill is called Natural Breathing, or abdominal breathing. In fact, this is a good way to breathe all day long, unless you are involved in physical activity. In other words, you should practice breathing this way all day long, since it provides for sufficient oxygen intake and controls the exhalation of carbon dioxide.

It's very simple and it goes like this:

Gently and slowly inhale a normal amount of air through your nose, filling your lower lungs. Then exhale easily. You might first try it with one hand on your stomach and one on your chest. As you inhale gently, your lower hand should rise while your upper hand stays still. Continue this gentle breathing pattern with a relaxed attitude, concentrating on filling only the lower lungs.

Natural Breathing

1. Gently and slowly inhale a normal amount of air through your nose, filling only your lower lungs. (Your stomach will expand while your upper chest remains still.)

2. Exhale easily.

3. Continue this gentle breathing pattern with a relaxed attitude, concentrating on filling only the lower lungs.

As you see, this breathing pattern is opposite of that which comes automatically during anxious moments. Instead of breathing rapidly and shallowly into the upper lungs, which expands the chest, you breathe gently into the lower lungs, expanding the abdomen.

The second technique is deep diaphragmatic breathing and can be used during times when you are feeling anxious or panicky. It is a powerful way to control hyperventilation, slow a rapid heartbeat and promote physical comfort. For this reason we will call it the Calming Breath.

Here's how it goes:

Calming Breath

1. Take a long, slow breath in through your nose, first filling your lower lungs, then your upper lungs.

2. Hold your breath to the count of "three."

3. Exhale slowly through pursed lips, while you relax the muscles in your face, jaw, shoulders, and stomach.

Practice this Calming Breath at least ten times a day for several weeks. Use it during times of transition, between projects or whenever you want to let go of tension and begin to experience a sense of calmness. This will help you become familiar and comfortable with the process. And use it any time you begin to feel anxiety or panic building. When you need a tool to help you calm down during panic, you will be more familiar and comfortable with the process.

The third technique is called Calming Counts. It has two benefits over Calming Breath. First, it takes longer to complete: about 90 seconds instead of 30 seconds. You will be spending that time concentrating on a specific task instead of paying so much attention to your worried thoughts. If you can let time pass without such intense focus on your fearful thoughts, you will have a better chance at controlling those thoughts. Second, Calming Counts, like Natural Breathing and the Calming Breath, help access the Calming Response. That means you will be giving yourself 90 seconds to cool your body out and quiet your thoughts. Then, after that time has passed, you will less anxious than you were.

Here's how this skill works:

Calming Counts

1. Sit comfortably.

2. Take a long, deep breath and exhale it slowly while saying the word "relax" silently.

3. Close your eyes.

4. Let yourself take ten natural, easy breaths. Count down with each exhale, starting with "ten."

5. This time, while you are breathing comfortably, notice any tensions, perhaps in your jaw or forehead or stomach. Imagine those tensions loosening.

6. When you reach "one," open your eyes again.

As you apply these skills, keep two things in mind. First, our breathing is dictated in part by our current thoughts, so make sure you also work on changing your negative thoughts, as well as your breathing, during panic. And second, these skills work to the degree you are willing to concentrate on them. Put most of your effort into not thinking about anything else -- not your worried thoughts, not what you will do after you finish the breathing skill, not how well you seem to be at this skill -- while you are following the steps of these skills.

You will find an audiotape in the Don't Panic Self-Help Kit called "Practicing Your Breathing Skills." It will train you in these three skills: Natural Breathing, Calming Breath and Calming Counts.

next: Step 5: Practice Formal Relaxation Skills - Part 2
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~ anxiety-panic library articles
~ all anxiety disorders articles

Killer Workout

The virtues of dieting and physical fitness pervade our consciousness. But either can go too far, leading to self-starvation or compulsive exercising--or both. In fact, one may actually cause the other, warns W. David Pierce, Ph.D., of the Sociology and Neuroscience faculties at the University of Alberta. Here, he discusses a dangerous and increasingly pervasive phenomenon called "activity anorexia."

Nancy K. Dess: What is activity anorexia?

W. David Pierce: Activity anorexia is a problematic behavior pattern in which a drastic decrease in eating causes progressively more exercise, which further reduces eating, in a vicious cycle.

NKD: How have you studied this in the laboratory?

WDP: In a typical experiment, rats live in a cage with a running wheel. At first, they can eat and run freely. Then they are shifted to one daily meal. Rats with no chance to run stay healthy, but rats allowed to run develop startling effects: Their running increases from hundreds to thousand of revolutions per day, and their eating decreases. Not all rats develop this pattern to the same degree, but many would die if it continued.

NKD: Why does this happen?

WDP: Consider Darwin's theory of evolution through natural selection. Animals would have gained a survival advantage by migrating when food was scarce, and by staying on the move until an adequate supply was found. A trek moved them away from famine and increased the odds of finding food--and surviving to pass on this trait.

We've shown that as food becomes scarce, rats, especially females, will work harder to earn a chance to run. Thus, events in the distant evolutionary past can be traced to a behavioral reinforcement process.

NKD: How does that play out for humans in contemporary culture?

WDP: Our culture brings dieting and exercise together. Current cultural values of thinness and fitness ensure that many people--especially women--receive social reinforcement for dieting and exercising. At some point, for some people, the eating/activity mechanisms begin to operate independently of culture. Their original goals or motivations become irrelevant.

NKD: What about anorexia nervosa, which is clinically diagnosed on the basis of extreme thinness, fear of fat and distorted body image. How is that related to activity anorexia?

WDP: Professionals' definitions make them sound completely different, but they may not be. The diagnostic criteria for "anorexia nervosa" focus on what people think and feel--about themselves, their bodies, and so forth. Activity anorexia is about what people do--how much they eat and exercise. My colleagues and I have argued that most cases diagnosed as anorexia nervosa, a "mental illness," are actually cases of activity anorexia, a problematic behavior pattern. You see, what people consciously think can be misleading.

NKD: For example?

WDP: A Canadian woman denied exercising but said she liked to walk. When asked where she walked, she replied, "To..."

NKD: Cleveland.

WDP: Basically, yes. To the mall--five kilometers away, four or five times a day. She didn't think of it as exercising. So careful assessment of actual behavior, in addition to what people think or feel, is critical.

NKD: But does it really matter how we define the problem?

WDP: I think so. Of those receiving a diagnosis of anorexia nervosa, between 5% and 21% will die. If eating and exercising are central to the problem, then more attention should be focused on these behaviors. Specifically, sudden changes in exercise or eating--"crash" dieting--are warning signs, at least as important as a desire to be thin. Understanding this problem fully is key to figuring out how to prevent it or treat it effectively--which is literally a matter of life and death.

next:

Letting go is not complicated. It is simple. Not easy. Simply identify the situation you want to let go of and ask yourself, "Am I willing to waste my energy further on this matter?" If the answer is "no," then that's it! Let go. Telling someone is a bonus. Detachment is only for you, never for another. It promotes healing. Choice is always present when you let go. You do not have to let go and there are consequences.

Letting go of behavioral patterns that no longer serve us often feels as though we are risking our safety and comfort.

Calculated risks taken for the benefit of our own well being are worth taking. This form of movement is safer than standing still. Those who remain stationary become an easy target for misery of their own creation.

The energy we expend by holding on often leaves us drained and with a feeling of hopelessness.

Letting go does not mean you should stop doing whatever it takes to make your relationship work. Let go of your expectations about how you think it might work out and instead focus all your energy on what you want, not what you don't want.

Expectations vs. Needs! We often expect our love partner to make the best choices for themselves and our relationship and when they are not our choices, we often get angry or disappointed. . . or both. Most people call this situation a problem: a problem we create by our expectations. Try this: "no expectations, fewer disappointments." It's that simple. Not easy. Simple. No expectations equals unconditional love.

We all experience the need to have healthy choices exercised and when they don't show up, we either choose to have conversations about them or not. If the choices are abusive and therefore unacceptable, we begin to think about making a responsible choice to leave the relationship. However, always picking our lover apart because their choices are not the ones we would make can only point the relationship in the direction of failure.

If we could accept the notion that everyone is doing the best they can, regardless of whether their choices are our choices, our attitude about our relationship would improve and perhaps the relationship we have would become the relationship we enjoy being in.

We must learn to distinguish between expectations and needs. Everyone has a need to be loved, to be understood, to be accepted and to be forgiven when necessary. For us to have expectations about how those needs get fulfilled can only cause disappointment.

continue story below

Unfulfilled expectations always causes problems. It is important to allow our love partner the freedom to fulfill our needs in their own best way. To do so, can only inspire a love that goes far beyond what we ever could have imagined! What you can be with in life. . . lets you be!

It takes no strength to let go; only courage. Courage is a byproduct of a positive self-image.

When there seems to be a lack of love, it is only that you are keeping it away.

Whenever you feel lonely, deprived or rejected, tell yourself that there is never a lack of love. Love is always available everywhere, especially inside of you. Then stop and realize, you can always open your heart. You can give to others the love you have been longing for. When you do this, not only do you feel better, but love from others soon comes streaming back to you.

Exercise: Look around and see who is right there around you. Find something positive about that. Become aware of your negative judgments of them and let them go. Become aware of the distance that you are creating between the two of you by your own thoughts. Now, find something else positive about them. If you feel you can, tell them. (This step make take awhile to do. It is not absolutely necessary in the beginning, just finding something positive is a great help as well).

This action of finding something positive about another person, and "letting go" of negative, judgmental thoughts about them, is in itself an act of love. It is a way of exercising our love giving-receiving ability, strengthening our muscles and seeing the beauty in everyone.

We are strongest when we are letting go of what doesn't work. That's change in action. When we open our mind to behave in a different way, we create the freedom to love. To open our hearts to love is perhaps the greatest gift we can give to ourselves.

When you finally understand that it is "not" unfashionable to negotiate situations rather than standing firm and allowing the past to rule your present, relationships become relationships you can live with.

When you understand that time spent justifying your position that is not working is futile, you can then move forward with a velocity that frees you to address the issues and deploy solutions that are clearly essential to everyone's well-being.

We use reasons to explain away why we don't want to do something different; reasons why we don't want to change. If we know that doing something different might help the situation, not doing something different is called "stupid." The best reason why has never solved the problem.

Often reasons why are understandable, however what is not understandable is why we feel the need to have our lives dominated by reasons why we didn't do something different instead of results. When we make the decision to go for results in our love relationships. . . that's the real moment we make a decision to grow and prosper.

May all your prayers be "Thank Yous!"

next: No One Can Hurt You

• No Expectations, Fewer Disappointments!
• The Keys to Self-Acceptance
• Is Your Relationship Stranded at Malfunction Junction?
• I Was Wrong and I Am Sorry
• Larry James Selected "Best Officiant" in the Greater Phoenix Area!
• Building Better Business Relationships
• New Things are Happening!
• Who YOU are Being Makes a Difference!
• Getting Your Needs Met MUST Be a HIGH Priority
  
• Me Change? Yuk!!
• Relationships Require Attention
• 10 Ways to Simplify Your Life
• I Hate Snakes!
• There is no Second Place!
• Random Thoughts to a Coaching Client
• No One Can Hurt You
• Forgiveness
• Never Intentionally Say Hurtful Words to Your Partner
• Audioapathy
• Do What Works!
• The Essence of Romance
• It's Time for the 3rd Degree!
• Catch Your Partner Doing Something Right!
• Relationships NEVER End!
• Unfulfilled Expectations
• Relationship Derailment

back to: Celebrate Love Homepage

Left picture, Jed Diamond, author of the bestseller Male Menopause.

The most common problem associated with male menopause is depression which is closely related to impotence and problems with male sexuality. Approximately 40% of men in their 40s, 50s and 60s will experience some degree of difficulty in attaining and sustaining erections, lethargy, depression, increased irritability, and mood swings that characterize male menopause. The symptoms of depression in men are commonly not recognized for several reasons:

• The symptoms of male depression are different than the classic symptoms we think of as depression
• Men deny they have problems because they are supposed to "be strong"
• Men deny they have a problem with their sexuality and don't understand the relationship with depression
• The symptom cluster of male depression is not well known so family members, physicians, and mental health professionals fail to recognize it.

Male depression is a disease with devastating consequences. To paraphrase from Jed Diamond's book Male Menopause:

• 80% of all suicides in the US are men
• The male suicide rate at midlife is three times higher; for men over 65, seven times higher
• The history of depression makes the risk of suicide seventy-eight times greater (Sweden)
• 20 million American will experience depression sometimes in their lifetime
• 60-80% of depressed adults never get professional help
• It can take up to ten years and three health professionals to properly diagnose this disorder
• 80-90% of people seeking help get relief from their symptoms

Differences between Male and Female depression:

Men are more likely to act out their inner turmoil while women are more likely to turn their feelings inward. The following chart from Jed Diamond's book Male Menopause illustrates these differences.

next: Antidepressants May Cause Premature Delivery
~ depression library articles
~ all articles on depression

David, My Bipolar Story I am 30 years old and live in East Texas. While many people with bipolar disorder have a hard time staying in a relationship, I have been blessed to be able to stay married for 11.5 years now.

I have been diagnosed as bipolar 1 rapid cycling, and while my diagnosis is only a few years old, I have been bipolar for most if not all of my life, exhibiting symptoms that my parents remember as early as four years of age. One interesting thing about my bipolar experience is that I am one of the weird ones who happens to cycle up more than down and under normal circumstances reaches higher than lower. While that sounds like fun to many, there are downsides, such as I tend to have psychotic manias.

I am a photgrapher and digital artist. I love to create and attribute much of my creativity to my illness. I also write poetry and fiction and recently completed my first poetry chapbook, which I am quite proud of, titled ~In Search of Grace.~ I am also working on a novel which has a bipolar main character.

As much as I have had my life torn apart by bipolar disorder and have suffered through horrible psychotic manias and suicidal depressions, I usually feel that having bipolar disorder is a blessing rather than a curse. While I do hope for the right meds to help lift the bottom of the lows and put a ceiling on the highs, I do not hope for a cure. I honestly believe that if a cure was discovered tomorrow, I would refuse it. Too much of the person I am, a person I have struggled for years to accept and love and finally do, is molded and shaped by this illness, that at this point I am afraid of who I would become without it.

David

back to: Juliet: What Hypomania, Mania and Mixed State Feels Like to Me
~ bipolar disorder library
~ all bipolar disorder articles

Acceptance is an attitude I am learning to extend toward other people and myself, and toward certain types of circumstances.

Acceptance toward People
Not everyone needs to be changed, just because I believe they should. "Should" thinking has become a warning sign to me.

In recovery, I have worked to acquire an open-minded willingness to receive people as they are in the present, with the understanding that all people are in the process of becoming. I need to allow other people their process, without any interference from me.

My alternative to accepting people was to reject them. By nature, I tended to reject any person whom I perceived as different from me, more or less gifted than me, would not listen to my unsolicited advice, etc. This was my ego—pure and simple. This was also insanity, because my thinking was based on the belief that others should perfectly match my expectations! When they didn't, I had a justifiable reason for rejecting them.

Now, I am learning how to make allowances for the fact that every person is unique and valuable despite background, ideology, religion, sex, etc. Most importantly, acceptance helps me to remember that each person is "in process" (i.e., at different stages of growth). For example, it is easy to accept that a newborn baby cannot eat a ten ounce steak. Adults allow a baby time and space to grow and mature. And in the meantime, the infant is given suitable baby food. Granted, this is an obvious example, but often adults expect children to behave like adults: "Big boys don't cry" and "You should know better" and "Don't be such a baby about every little thing." As an adult, I sometimes forget that other adults still carry within themselves that precious and vulnerable child. Where they are at this moment in their growth is different from me, and I need to be sensitive and accepting of that fact.

It was also important for me to distinguish the difference between acceptance and approval. I allow myself to feel approval or disapproval of other people's actions and choices. I am also free to express my feelings in healthy ways. When necessary, I can take steps to protect myself if another person's actions put me in danger. My boundary is: if another person's choices and actions do not affect me, then their choices and actions are none of my business.

Acceptance toward Myself
When I began my recovery, I was too hard on myself. I inflicted guilt on myself for all my problems. I blamed myself for my life circumstance. I berated and hated myself for being in the condition where I found myself. By choosing acceptance, I am learning to be gentle with myself. I am also learning to extend patience toward myself. Like others, I too am in the process of becoming. If I am accepting of others, I can extend the same courtesy toward myself. I can be patient and loving to my own inner child. Regarding guilt, it was necessary for me to accept responsibility for the actions and choices I'd made in the past. But the past is past, and I must accept the past. There is no reason to go on living in guilt, forever re-living the past in the present.

Acceptance toward Circumstances
Through recovery, I am also learning how to willingly suspend and set aside my preconceived ideas, desired outcomes, expectations, and personal agendas in the face of circumstances I previously would have sought to control or change.

I am learning to make a conscious and deliberate choice to receive circumstances as they are, with the belief that the eventual result will be beneficial. Acceptance is beneficial for me, because I am relieved of anxiety, controlling, "helping", and other unhealthy behavior. Acceptance is beneficial for my Higher Power, because it allows God to order circumstances for the best possible timing, again, without my interference.

Choosing the attitude of acceptance is a powerful and beneficial recovery tool.

next: Patience

Recently I have meditated on the power of forgiveness available to those of us in recovery. My thinking was sparked by a letter I received through the alt.recovery.codependency newsgroup. In particular, these words struck deep in my heart:

"Forgiveness is a natural process that occurs when you have reached a certain stage of acceptance about another person's limitations, character flaws, and their incapacity to behave in a way you had hoped and expected. When you get some glimmer that it was impossible for that person to respect and honor you in the way you wanted, you can forgive them for not having that ability."

For so long, I was bitter toward my ex-wife and her family for the way they treated me during our separation and divorce. I resented them taking away the privilege of seeing my children on a daily basis. I detested them for taking the stance that they were so right and I was so wrong. I despised them for the one-sided and narrow-minded myopia they displayed when I asked to be forgiven. I resented how they turned their back on me and have ignored me for the past five years—though they claim to be Christians. No matter what I did, I could not earn their forgiveness.

Yet, I was unable and unwilling to forgive them as well.

Oh, yes, I thought I had forgiven them—until I caught myself the other day—actually grinding my teeth at the mere thought of how my ex-wife used to treat me.

I still have much recovery work to do!

But I also realized that my wife and her family have a basic incapacity to behave in the way I expect them to behave. I used to think they were unwilling. But now, I see their incapacity to truly forgive, to really love, and to be honestly open-minded.

And it's not their fault. They are just products of their environment and training and their choices.

They can't do any better, because they don't know any better.

Oh, they may have intellectual knowledge of what forgiveness and love are about—but they can't live it when the opportunity arises.

I, on the other hand, am also incapable of understanding deep in my heart and soul, how hurt they were by my behavior. How much they are still hurting - whether by choice or not. I cannot live up to their expectations, either.

But recovery has taught me that I can (and must) forgive them for their incapacity to forgive. That is very powerful stuff. So powerful that it has raised me to a totally new level of awareness and perspective on life and relationships.

I can also forgive myself for my incapacity to forget how I was treated. I can forgive myself for expecting too much of them.

So, what I am now impelled to develop is my capacity to forgive my ex-wife and her family—to overlook what appeared to me as simple-minded, intransigent, stubbornness.

I must develop this same power in all my relationships. The capacity to forgive others for not living up to my expectations. And, the capacity to forgive myself for expecting others to live up to my expectations.

Thank You, God for the power of forgiveness. Thank You for the power You have given me to forgive and be forgiven. Thank You for bringing me a few steps closer to heartfelt forgiveness of myself, as well as others. Amen.

next: Morning Meditation

Bipolar disorder in geriatric populations and which bipolar medications are effective for treating seniors with bipolar.

"With respect to bipolar disorder in geriatric populations, we, in fact, do not have published guidelines," began Martha Sajatovic, MD, in her address at the 17th Annual Meeting of the American Association for Geriatric Psychiatry. While there are guidelines for the treatment of bipolar disorder in general populations, these guidelines are "certainly not cookbooks for clinicians but really offer us some guideposts and helpful recommendations for a very complex condition in our patients," she acknowledged.

But what do the guidelines, such as those published by the American Psychiatric Association, the Veterans Administration (VA), and the British Association for Psychopharmacology, say about treatment for late-life bipolar disorder? Dr. Sajatovic cautioned that this sizable patient population has unique issues, since older individuals who develop bipolar disorder may have a new-onset form of the illness. "We can estimate, based on existing data, that the prevalence rate is 10% in individuals older than 50. And that surprises a lot of people who have the idea it is a rare bird."

No Data, Just the Facts

While treatment for older patients may follow the same principles as for other patient groups, there is a severe scarcity of data specific to late-life bipolar disorder, explained Dr. Sajatovic, who is Associate Professor in the Department of Psychiatry at Case Western Reserve University School of Medicine, Cleveland. "In fact, if you look at treatment guidelines, they really only address the care of older people with bipolar disorder in very general ways. A lot is speculation. What we do not have are clear and specifically focused treatment guidelines for bipolar disorder in later life."

What happens in the absence of clear, evidence-based guidelines? She cited a study by Shulman et al in which his team analyzed community prescription trends in individuals older than 66 from an Ontario, Canada, drug benefit program from 1993 to 2001. "Very interestingly, during that time period, the number of new lithium prescriptions fell from 653 to 281. The number of new valproate users went from 183 to over 1,000 in 2001.

"The number of new valproate users surpassed the number of new lithium users in 1997, so while the curve from the lithium was going down, the curve for the valproate was going up, and crossed in 1997. This trend was seen even when patients with dementia were excluded from the analysis, so really, it was for late-life bipolar disorder. Clearly, clinicians and patients are talking with their feet here. We do not have data that say this is what you should do, but this is what's happening."

VA vs Community

Dr. Sajatovic also reviewed a study of a VA psychosis registry, looking at bipolar disorder in the VA system and age-related modifiers of clinical care. Interestingly, she reported, there are more than 65,000 individuals in the VA database with bipolar disorder, and more than a quarter are older than 65. "You don't have to be a statistician to figure out where we're going with this. There are a large number of individuals who are progressing into a later-life diagnosis of bipolar disorder."

Once the bipolar disorder group was identified, Dr. Sajatovic focused on their drug treatment patterns, which contrasted with those of Shulman et al's findings. Individuals were stratified into three age-groups: 30 and younger, 31 to 59, and 60 and older. She found that 70% of patients who had been prescribed a mood stabilizer were receiving lithium. "In the VA system, lithium was the mood stabilizer of choice, by a long shot. Very different from what's happening in the community," she noted. Dr. Sajatovic allowed that it was not clear if these were patients already being treated with lithium, or if the findings were a reflection of the VA population, which is followed for a longer time than a fragmented community sample.

The use of valproate was seen in 14% to 20% of the VA population, which is quite a bit lower than the use of lithium; carbamazepine use was similar to valproate. "There were a small number who were on two or more agents—again, different from a community sample where you see a lot more polypharmacy," she observed.

It is an interesting story, as well, with the use of antipsychotic medications, as Dr. Sajatovic reported that 40% of patients were prescribed oral antipsychotics. Olanzapine was the most commonly prescribed atypical antipsychotic in the VA system, across age-groups, followed by risperidone, although risperidone did not yet have an FDA indication for bipolar disorder.

The Pros and Cons of Lithium

Lithium is the most extensively studied medication for bipolar disorder in the elderly. It is an effective mood stabilizer in older adults and has an antidepressant effect with some patients, said Dr. Sajatovic. The frequency of acute toxicity with lithium in geriatric patients is reported to range from 11% to 23%, and in medically ill patients the rate can be as high as 75%.

Based on her experiences, Dr. Sajatovic made the following recommendations to clinicians: When prescribing lithium for the elderly, reduce the dose by one third to half of that given to younger patients; the dose should not exceed 900 mg/day. A baseline screening for renal function, electrolytes, and fasting blood glucose, as well as an EKG, should be conducted. "There is some controversy about target serum concentrations. What we know from the geriatric data is that patients who are at higher blood levels have better control of their bipolar disorder symptoms but are more likely to get toxic. So they are likely to tolerate lower blood levels and need to maintain their treatment with lower blood levels." Lithium can be a problem, especially at the higher blood levels, she said.

Other Agents - Valproate and Carbamazepine

Valproate is increasingly used for bipolar disorder by many clinicians as a first-line agent, "but again, we don't have controlled data. There are no randomized controlled trials in bipolar disorder that have been published." Though there are no controlled data for the use of valproate in secondary mania, Dr. Sajatovic recommended—after an EKG and screening for liver enzymes and blood platelets—a typical starting dose of 125 to 250 mg/day with a gradual dose titration. For patients with bipolar disorder, the usual dose range should be 500 to 1,000 mg/ day; patients with dementia may require lower doses.

Valproate is not without its dangers, she warned, especially at higher serum levels. A therapeutic range of 65 to 90 mg/day has been recommended in the literature. Carbamazepine is used with moderate frequency; although its side effects may be more problematic than those of valproate, it may be preferable to lithium in secondary manias, she explained. The screening is quite similar to that for valproate, and the appropriate dose is 100 mg once or twice daily and may be increased to 400 to 800 mg/day. "A little kicker about carbamazepine is that auto-induction may occur during the first three to six weeks and you may require an increased dosage during this timeframe. Check serum levels prior to doing that," Dr. Sajatovic advised.

What About Atypical Antipsychotics?

The VA database indicates that 40% of older patients are treated with antipsychotics; unfortunately, most reports are open label and retrospective, Dr. Sajatovic said. Clozapine, risperidone, olanzapine, and quetiapine have all been reported to be of benefit to elderly patients with bipolar disorder. All except for clozapine, she pointed out, have FDA approval for the treatment of bipolar disorder. Clozapine is used for treatment of refractory illness, primarily with mania. "We actually underutilize clozapine in refractory mania. And that's certainly true in the VA," she opined.

The use of lamotrigine is increasingly becoming an issue, and again, there are no data specific to lamotrigine, Dr. Sajatovic pointed out. According to data she presented at the American Psychiatric Association's 2004 annual meeting, it appears that older adults may tolerate lamotrigine better than lithium, which was not an unexpected finding, given the existing toxicity data. "The downside of lamotrigine is that you're not going to be able to titrate it quickly. You need a month to get people up to therapeutic doses." Accordingly, she does not recommend it as a first-line agent for mania, and studies do not support this use. "But particularly for people with recurrent bipolar depression, this could be a very nice compound," she allowed, and there are case studies published supporting its use in the elderly.

Should clinicians change patient medications based on concerns about side effects? "The party line of the British guidelines is to go with lithium unless there's a reason not to, such as side effects. US psychiatry appears to be a little more open to other agents, atypicals in particular, although some of this could be due to marketing forces. The point that there is no guarantee that a patient will respond to an atypical is valid."

Source: Neuropsychiatry Reviews, Vol. 5, No. 4, June 2004

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Comprehensive list of questions and answers about signs, symptoms and treatment of bipolar disorder and other related mood disorders.

1. What is bipolar disorder?
2. What are the differences between bipolar I and bipolar II disorders?
3. What is rapid cycling?
4. At what age does bipolar disorder appear?
5. Is bipolar disorder genetic?
6. How is bipolar disorder treated?
7. What medications are used to treat bipolar disorder?
8. What is a manic episode?
9. What is hypomania?
10. What is dysthymia?
11. What is major depression?
12. What is atypical depression?
13. What is meant by a mixed state?
14. What is seasonal affective disorder?
15. What is postpartum depression?
16. What is schizoaffective disorder?
17. What resources are available for people suffering from bipolar disorder?
18. How can family members assist the bipolar patient?
19. What are the challenges of bipolar disorder?

1. What is bipolar disorder?

Bipolar disorder is a common, recurrent, severe psychiatric illness that affects an individual's mood, behavior and ability to think clearly. It occurs in 1% to 2% of the population in the United States. A variant, called bipolar II disorder, is probably even more common and occurs in up to 3% of the general population in this country.

2. What are the differences between bipolar I and bipolar II disorders?

Bipolar I disorder is characterized by episodes of mania that alternate with periods of depression or periods in which individuals have simultaneously occurring manic and depressive symptoms called mixed states. In contrast, bipolar II disorder is characterized by recurrent episodes of depression and milder symptoms of mania, called hypomania. Hypomanic episodes typically do not impair an individual's ability to function to the extent that full-blown manic episodes do Additionally, hypomanic episodes are not complicated by psychotic symptoms.

3. What is rapid cycling?

The term rapid cycling was originally coined by David Dunner, M.D., and Ron Fieve, M.D., in the 1970s when they identified a group of individuals who did not respond well to lithium. These patients typically had four or more episodes of mania or depression in the 12-month interval prior to lithium treatment. This definition has been adopted formally by DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.) and specifically means the occurrence of four or more mood episodes within the preceding year. In severe cases, rapid cycling can occur even within a one-day period.

4. At what age does bipolar disorder appear?

Bipolar disorder most commonly presents in the late teens and early 20s. Unfortunately, for most individuals, lifelong treatment may be required to prevent recurrent manic and depressive episodes. Equally unfortunate is evidence that the illness often goes undiagnosed and untreated for many years; the longer the illness progresses without treatment, the greater the impairment in an individual's psychological, educational and vocational development. Additionally, untreated bipolar disorder carries a high risk of suicide.

5. Is bipolar disorder genetic?

Bipolar disorder, among all psychiatric illnesses, may have the greatest genetic contribution. For instance, if an individual has a parent with bipolar disorder, the chance that the individual's child will have bipolar disorder is about nine-fold greater than in the general population, with the risk rising from about 1% to about 10%. The inheritability of this illness is estimated to be anywhere from 50% to 80%. On the other hand, if a person with bipolar disorder is thinking about having children, there are still good odds that the child will not have bipolar illness. So the genetic determinants of the illness are complicated.

6. How is bipolar disorder treated?

The cornerstone of treatment is medications that treat acute manic, depressive or mixed episodes, and which, in the long run, attempt to prevent the recurrence of these episodes. Such medications include lithium, divalproex (Depakote) and, more recently, some of the atypical antipsychotics as well as antidepressants.

Psychotherapy plays an important role in improving the course and outcome of this illness in people. In particular, those with bipolar disorder often have strained relationships with loved ones because of their experiences during manic or depressive episodes; psychotherapy can help repair these torn relationships. In addition, psychotherapy can educate people about the signs and symptoms of their illness, how to pay attention to warning signs and how to nip emerging episodes in the bud. Psychotherapy can also help individuals cope with the stress that can sometimes precipitate manic or depressive episodes.

7. What medications are used to treat bipolar disorder?

There are a number of medications for the treatment of people with bipolar disorder, among them a group of medications called mood stabilizers. These include lithium and divalproex and possibly some other anticonvulsants and atypical antipsychotic drugs. The therapeutic strategy is to treat acute manic episodes and then continue long-term administration to prevent episode recurrence. These medications seem to be somewhat less effective than antidepressants in treating acute depressive episodes.

Antidepressants may be used in conjunction with a mood-stabilizing drug to pull someone out of a depressive episode. Such antidepressants include the older tricyclic antidepressants, the monoamine oxidase inhibitors and the newer selective serotonin reuptake inhibitors, venlafaxine (Effexor) and buproprion (Wellbutrin). There is some evidence that these new medications are better tolerated than the older antidepressants and may have less risk of precipitating hypomanic or manic episodes.

8. What is a manic episode?

A manic episode is a discrete, recognizable psychiatric state that is often a medical emergency. It is characterized by severe alterations in mood consisting of euphoria, expansiveness, irritability and, sometimes, severe depression. In addition, people who are manic may have racing thoughts and speak very quickly in an uninterrupted fashion. Their behavior is characterized by increased activity, diminished sleep, a tendency to be distracted, engaging in many activities at once and disorganization.

Mania can occasionally become so severe that it is accompanied by psychotic symptoms such as delusions, hallucinations and very disorganized thinking, similar to schizophrenia. In addition, people in manic episodes can be very impulsive and occasionally violent. Often, unfortunately, they have little insight into their behavior during the throes of an actual manic episode.

9. What is hypomania?

Hypomania is a milder form of mania. Someone who is hypomanic typically is more active and energetic than usual. They may have accelerated thinking and speak very quickly but, overall, their functioning is not substantially impaired. The symptoms are not so severe as to hinder their ability to interpret reality or function in most areas of life.

10. What is dysthymia?

Dysthymia is a state of chronic depression severe enough that people are plagued by some symptoms of depression, but not so severe that the number of depressive symptoms meet criteria for a full-blown major depressive episode. It is a chronic, mild depression rather than a frank, severe depressive episode. There is evidence, however, that people who have dysthymia suffer from as much or more disability over the long run, as compared to those who have severe depressive episodes but recover in between. Like major depression, dysthymia is an illness that can be successfully treated with antidepressant medications.

11. What is major depression?

Major depression is a well-characterized medical illness that consists of a number of discrete symptoms. These include a persistently depressed mood for several weeks or longer and an inability to experience pleasure or enjoy normal activities.

Changes in basic functions include sleep and appetite disturbances, diminished interest in sex, and difficulty in making day-to-day decisions. Sufferers may also feel physically or cognitively anxious, agitated or very slow. Most conspicuously, they may sometimes have suicidal thoughts or even attempt suicide.

12. What is atypical depression?

Atypical depression distinguishes people who seem to have many of the symptoms of major depression, but have difficulty staying asleep or seem to sleep too much. Additionally, instead of having a diminished appetite, they have a marked increase in appetite, a sensitivity to interpersonal rejection and leaden paralysis-a feeling of being so depressed that it is major effort to do even basic tasks. Atypical depression resembles hibernation in that metabolism is slowed and sufferers sleep great lengths and eat excessively.

13. What is meant by a mixed state?

A mixed state is a combination of manic and depressive symptoms. While common, mixed states are underrecognized, with an estimated 40% of people who present with manic symptoms having a sufficient number of depressive symptoms to be diagnosed as being in a mixed manic and depressive state. Some studies have shown that suicidal thoughts are greatly increased in people in the midst of a mixed state. Treatment has been poorly studied, but recent evidence indicates that some of the newer medications, such as divalproex and olanzapine (Zyprexa), may be more beneficial than older drugs like lithium.

14. What is seasonal affective disorder?

Seasonal affective disorder (SAD) is a mood disorder occurring at a specific time of the year. The most common seasonal pattern is recurrent depression in late fall and early winter or sometimes in the late spring or early summer around the time of the solstices. There clearly seems to be some biologic component to this, perhaps having to do with ambient light and its duration and intensity. There has been a great deal of study in using bright-light therapy as a treatment intervention for mood disorder. In addition, standard treatments such as antidepressant medicines are also effective for treating people with a seasonal pattern to their mood disorder.

15. What is postpartum depression?

Postpartum depression is a major depressive episode following the delivery of a child. The length of the postpartum period for risk of depression varies, but the greatest risk is within the first one to three months after delivery. This is an especially vulnerable period, and obstetricians and pediatricians need to be especially vigilant during this time. Recognizing postpartum depression not only alleviates illness and suffering in the mother, but also prevents secondary effects on the growth and development of the infant.

16. What is schizoaffective disorder?

Schizoaffective disorder is really two different illnesses: schizoaffective disorder bipolar type, and schizoaffective disorder depressive type. The bipolar type resembles bipolar disorder with recurrent manic and depressive episodes over time, but has psychotic symptoms outside the manic or depressive episodes. The psychosis is more chronic punctuated by manic and depressive episodes. The depressive subtype resembles schizophrenia with chronic psychotic symptoms, but has recurrent depressive episodes.

17. What resources are available for people suffering from bipolar disorder?

There has never been a time of greater hope for people with this illness. There have been substantial advances in treatment in the last 10 years. Twenty years ago there was really only one medication, lithium, that was widely regarded to be effective. There are now a number of alternative mood stabilizers; there is a whole new generation of antidepressants for depression and another group of medications that may, over time, improve upon older mood stabilizers. There have also been advances in psychotherapy, including group therapy to improve functioning, cognitive therapy to reduce stress and improve functioning, and substantial support from consumer advocacy groups like the National Depressive and Manic Depressive Association (NDMDA).

18. How can family members assist the bipolar patient?

The first step for any family member is to educate themselves as well as the family member who has the illness about bipolar disorder. They should try to identify the features of the illness that are distinct to that individual, including the warning signs of recurrent manic or depressive episodes, so that someone in treatment can get immediate help to ward off those symptoms.

In addition, education helps people understand what is and is not within the control of an individual who has this illness. Family members can also assist with medication compliance and should be supportive in a health-supporting way for the family member with the illness. This will also prevent their own burnout and exhaustion.

19. What are the challenges of bipolar disorder?

There are still people who do not respond well to available medication. Compliance with treatment still remains a problem, as does access to treatment for many patients. People with serious psychiatric illnesses sometimes have problems obtaining appropriate mental health insurance coverage.

Furthermore, bipolar disorder is still underrecognized and underappreciated in the general population. People with bipolar disorder require individualized treatment. Many people do well with pharmacology-based treatment, but others need in-depth psychotherapy and support from community services, including rehabilitation and long-term treatment.

Source: Answers provided by Paul Keck, M.D., professor of psychiatry at the University of Cincinnati College of Medicine.

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