Family Forum / Marriage / Marriage / July 2008

present what they hear as a third party; and what this one and his
hears, is that DH is a loving husband who wants to get back together
with his wife.  As for the OW, the question is can DH do something
to appease wife?  And DH says, yes, and wife says, not enough, but
no more is offered, and infact a contradiction is spotted by the
counsellor,
suggesting that wife may be not entirely justified in the facts about
jealousy,
and i would like to emphasize "suggesting".  So, at the end of the
day,
when the compatibility of a really well matched couple is observed,
the
decision of what to do is left up to us.

I understand all that.  The question has been, what decision should i
make
given that insight?  So, i have decided to take him back, still
believing that
the OW relationship is too close for my comfort, but taking all those
other
factors into account, and coming out with this balance.

Erin

Excuse me for the double post, i forgot to add, that
delusions and hallucinations are symtomatic typically
of schizophrenia not manic-depression, which is an
affective disorder.   I have never had a hallucination
in my life.  Though delusions i have seen to be more
common in normal people's beliefs than in mine.  I
don't think I have ever had a delusion that was not
a mistaken belief about a mathematical problem for example.

ALSO, See the DSM IV and the The Merck Medical Manual:

Bipolar Disorders

Bipolar disorders are characterized by mania and depression, which
usually alternate. Exact cause is unknown, but heredity, changes in
the level of brain neurotransmitters, and psychosocial factors may be
involved. Diagnosis is based on history. Treatment consists of drugs,
sometimes with psychotherapy.

Bipolar disorders usually begin in the teens, 20s, or 30s. Lifetime
prevalence is about 1%. Rates are about equal for men and women.

Bipolar disorders are classified partly based on long-term patterns of
episodes of more intense symptoms as bipolar I disorder, bipolar II
disorder, or bipolar disorder not otherwise specified (NOS). Forms
associated with a disorder or drug use are classified as bipolar
disorder due to their general physical condition or substance-induced
bipolar disorder.

Etiology

Exact cause is unknown. Heredity plays some role. There is also
evidence of dysregulation of serotonin and norepinephrine Some Trade
Names
LEVOPHED
Click for Drug Monograph
. Psychosocial factors may also be involved. Stressful life events are
often associated with initial development of symptoms and later
exacerbations, although cause and effect have not been established.

Bipolar disorders or symptoms of bipolar disorders can occur with
several physical disorders, as adverse effects of many drugs, or as
part of several other mental disorders (see Table 1: Mood Disorders:
Some Causes of Symptoms of Depression and ManiaTables).

Symptoms and Signs

Bipolar disorder begins with an acute phase of symptoms and is
followed by a repeating course of relapse and remission. Relapses are
episodes marked by more intense symptoms, lasting about 3 to 6 mo.
Episodes are manic, depressive, hypomanic, or a mixture (of depressive
and manic features). Cycles—time from onset of one episode to that of
the next—vary in length. Cyclicity is particularly accentuated in
rapid-cycling forms of bipolar disorder (usually defined as ≥ 4
episodes/yr). Disruption of developmental and social functioning is
common, especially when onset occurs between ages 13 and 18.

Psychotic symptoms may be present. In full-blown manic psychosis, the
mood is usually elation, but irritability and frank hostility with
cantankerousness are not uncommon.

Bipolar I disorder is defined by alternation of full-fledged manic and
major depressive episodes. It commonly begins with depression.
Depression can occur immediately before or after mania, or depression
and mania can be separated by months or years.

Bipolar II disorder is defined by a history of at least one major
depressive episode and at least one hypomanic episode. Depressive
episodes alternate with hypomania. During the hypomanic period, mood
brightens, the need for sleep decreases, and psychomotor activity
accelerates. Often, the switch follows circadian factors (eg, going to
bed depressed and waking early in the morning in a hypomanic state).
Hypersomnia and overeating are characteristic and may recur seasonally
(eg, in autumn or winter); insomnia and poor appetite occur during the
depressive phase. For some patients, hypomanic periods are adaptive
because they produce high energy, confidence, and supernormal social
functioning.

Bipolar disorder NOS refers to disorders with clear bipolar features
that do not meet the specific criteria for other bipolar disorders.

Mania: A manic episode is defined as ≥ 1 wk of a persistently
elevated, expansive, or irritable mood, accompanied by ≥ 3 additional
symptoms: inflated self-esteem or grandiosity, decreased need for
sleep, greater talkativeness than usual, persistent elevation of mood,
flight of ideas or racing of thoughts, distractibility, increased goal-
directed activity, and excessive involvement in pleasurable activities
with a higher risk of undesirable consequences (eg, injury, loss of
money). Symptoms impair functioning.

Typically, patients in a manic episode are exuberant and flamboyantly
or colorfully dressed; they have an authoritative manner with a rapid,
unstoppable flow of speech. Patients make clang associations: New
thoughts are triggered by word sounds rather than meaning. Easily
distracted, patients may constantly shift from one theme or endeavor
to another. However, they tend to believe they are in their best
mental state. Lack of insight and an increased capacity for activity
often lead to intrusive behavior and can be a dangerous combination.
Interpersonal friction results and may lead to paranoid delusions that
they are being unjustly treated or persecuted. Accelerated mental
activity is experienced as racing thoughts by patients, is observed as
flights of ideas by the physician, and, in its extreme form, is
difficult to distinguish from the loose associations of schizophrenia.
Psychotic symptoms develop in some patients with bipolar I disorder.
Need for sleep is decreased. Manic patients are inexhaustibly,
excessively, and impulsively involved in various activities without
recognizing the inherent social dangers.

Hypomania: A hypomanic episode is a distinct episode of ≥ 4 days that
is distinctly different from the patient's usual nondepressed mood.
The episode is marked by ≥ 4 symptoms that occur during a manic
episode, but the symptoms are relatively less intense, so that
functioning is not markedly impaired.

Mixed state: A mixed episode blends depressive and manic or hypomanic
features. The most typical examples are momentary switches to
tearfulness during the height of mania or racing thoughts during a
depressive period. In at least 1⁄3 of people with bipolar disorder,
the entire episode is mixed. A common presentation consists of a
dysphorically excited mood, crying, curtailed sleep, racing thoughts,
grandiosity, psychomotor restlessness, suicidal ideation, persecutory
delusions, auditory hallucinations, indecisiveness, and confusion.
This presentation is called dysphoric mania (ie, prominent depressive
symptoms superimposed on manic psychosis).

Diagnosis

Some patients who experience hypomania or mania do not report it
unless they are specifically questioned. Skillful questioning may
reveal morbid signs (eg, excesses in spending, impulsive sexual
escapades, stimulant drug abuse). Such information is more likely to
be provided by relatives. Diagnosis is based on the symptoms and signs
described above. All patients must be asked gently but directly about
suicidal ideation, plans, or activity.

A review of substance (especially amphetamines, particularly
methamphetamine—see Drug Use and Dependence: Amphetamines) and
prescription drug use and of body systems is needed to exclude drugs
and physical disorders. Although no laboratory findings are
pathognomonic for bipolar disorders, routine blood tests should be
done to screen for physical disorders; thyroid-stimulating hormone
(TSH) excludes hyperthyroidism. Other physical disorders (eg,
pheochromocytoma) occasionally confuse the diagnosis. Anxiety
disorders (eg, social phobia, panic attacks, obsessive-compulsive
disorders) may also confuse the diagnosis.

Prognosis and Treatment

Most patients with hypomania can be treated as outpatients. Acute
mania usually requires inpatient management. Typically, mood
stabilizers are used to induce remission in patients with acute mania
or hypomania. Lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
and certain anticonvulsants, especially valproate Some Trade Names
DEPAKENE
Click for Drug Monograph
, carbamazepine Some Trade Names
TEGRETOL
Click for Drug Monograph
, oxcarbazepine Some Trade Names
TRILEPTAL
Click for Drug Monograph
, and lamotrigine Some Trade Names
LAMICTAL
Click for Drug Monograph
, act as mood stabilizers and are similarly effective. Choice of a
mood stabilizer depends on the patient's medical history and adverse
effects of the specific mood stabilizer.

Two thirds of patients with uncomplicated bipolar disorder respond to
lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
. Several therapeutic mechanisms have been proposed but are unproved.
Predictors of a good response include a euphoric mania as part of a
primary mood disorder, < 2 episodes/yr, and a personal and family
history of response to lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
. Lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
is less effective in patients with a mixed state, rapid-cycling forms
of bipolar disorder, comorbid anxiety, substance abuse, or a
neurologic disorder.

Lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
carbonate is started at 300 mg po bid or tid and increased over 7 to
10 days until a blood level of 0.8 to 1.2 mEq/L is reached. Lithium
Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
levels should be maintained between 0.8 and 1.0 mEq/L, usually by
giving 450 to 900 mg sustained-release po bid. Adolescents, whose
glomerular function is excellent, need higher doses of lithium Some
Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
; elderly patients need lower doses. During a manic episode, patients
retain lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
and excrete Na; oral dosage and lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
blood level need to be higher during acute treatment than during
maintenance prophylaxis.

Because lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
's onset of action has a 4- to 10-day latency period, an antipsychotic
may be necessary initially; it is given as needed until the manic
stage is controlled. Acute manic psychosis is being increasingly
managed with 2nd-generation antipsychotics, such as risperidone Some
Trade Names
RISPERDAL
Click for Drug Monograph
(usually 4 to 6 mg po once/day), olanzapine Some Trade Names
ZYPREXA
Click for Drug Monograph
(usually 10 to 20 mg po once/day), quetiapine Some Trade Names
SEROQUEL
Click for Drug Monograph
(200 to 400 mg po bid), ziprasidone Some Trade Names
GEODON
Click for Drug Monograph
(40 to 80 mg po bid), and aripiprazole Some Trade Names
ABILIFY
Click for Drug Monograph
(10 to 30 mg once/day) because risk of extrapyramidal adverse effects
is minimal. For extremely hyperactive psychotic patients with poor
food and fluid intake, giving an antipsychotic IM with supportive care
for 1 wk before initiating lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
is preferable. Noncompliant, cantankerous manic patients are
customarily given a depot phenothiazine (eg, fluphenazine Some Trade
Names
PROLIXIN DECANOATE
PROLIXIN
Click for Drug Monograph
12.5 to 25 mg IM q 3 to 4 wk) instead of an oral antipsychotic. Many
patients with bipolar disorder and mood-incongruent psychotic features
beyond the usual boundaries of pure mood disorder require intermittent
courses of depot antipsychotics. Lorazepam Some Trade Names
ATIVAN
Click for Drug Monograph
or clonazepam Some Trade Names
KLONOPIN
Click for Drug Monograph
2 to 4 mg IM or po tid given early in acute management can reduce the
doses need of the antipsychotic.

Although lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
attenuates bipolar mood swings, it has no effect on normal mood. It
also appears to have an antiaggressive action, but whether this action
occurs in people without a bipolar disorder is unclear. Lithium Some
Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
can cause sedation and cognitive impairment directly or indirectly by
causing hypothyroidism. The most common acute, mild adverse effects
are fine tremor, fasciculation, nausea, diarrhea, polyuria, thirst,
polydipsia, and weight gain (partly attributed to drinking high-
calorie beverages). These effects are usually transient and often
respond to decreasing the dose slightly, dividing the dose (eg, tid),
or using slow-release forms. Once dosage is established, the entire
dose should be given after the evening meal. This dosing may improve
compliance, and the troughs in blood levels are believed to protect
the kidneys. A β-blocker (eg, atenolol Some Trade Names
TENORMIN
Click for Drug Monograph
25 to 50 mg po once/day) can control severe tremor. Some β-blockers
may worsen depression.

Lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
toxicity is manifested initially by gross tremor, increased deep
tendon reflexes, persistent headache, vomiting, and confusion and may
progress to stupor, seizures, and arrhythmias. Toxicity is more likely
to occur in elderly patients and in patients with decreased creatinine
clearance or with Na loss, which may result from fever, vomiting,
diarrhea, or use of diuretics. NSAIDs other than aspirin Some Trade
Names
BUFFERIN
ECOTRIN
GENACOTE
Click for Drug Monograph
may contribute to hyperlithemia. Lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
blood levels should be measured, including each time the dose is
changed and at least q 6 mo. Lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
may precipitate hypothyroidism, particularly when there is a family
history of hypothyroidism. Therefore, TSH levels should be monitored
when lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
is started and at least annually if there is a family history or if
symptoms suggest thyroid dysfunction or at least biannually for all
other patients.

Lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
commonly and chronically exacerbates acne and psoriasis and can cause
nephrogenic diabetes insipidus, which may respond to dose reduction or
temporary interruption of lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
. Patients with a history of parenchymal renal disease may be at risk
of structural damage to the distal tubule. Renal function should be
assessed at baseline, and serum creatinine levels should be monitored
over time.

Anticonvulsants that act as mood stabilizers, especially valproate
Some Trade Names
DEPAKENE
Click for Drug Monograph
, carbamazepine Some Trade Names
TEGRETOL
Click for Drug Monograph
, and oxcarbazepine Some Trade Names
TRILEPTAL
Click for Drug Monograph
, are often used for acute mania and for mixed states (mania and
depression). Their precise therapeutic action in bipolar disorder is
unknown but may involve γ-aminobutyric acid mechanisms and ultimately
G-protein signaling systems. Their main advantages over lithium Some
Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
include a wider therapeutic margin and lack of renal toxicity. The
loading dose is 20 mg/kg, then 250 to 500 mg po tid for valproate Some
Trade Names
DEPAKENE
Click for Drug Monograph
. Carbamazepine Some Trade Names
TEGRETOL
Click for Drug Monograph
should not be loaded; the dose should be increased gradually to reduce
risk of toxicity. Oxcarbazepine Some Trade Names
TRILEPTAL
Click for Drug Monograph
has fewer adverse effects and is moderately effective.

Combining mood stabilizers is often necessary for optimal results,
especially when episodes of mania or mixed states are severe.
Electroconvulsive therapy is sometimes used for cases refractory to
mood stabilizers.

Treatment of an initial manic or hypomanic episode with a mood
stabilizer should continue for at least 6 mo, then tapered and
stopped. The mood stabilizer is restarted for recurrent episodes and
maintained if episodes are < 3 yr apart. Maintenance therapy with
lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
should be initiated after 2 classic manic episodes < 3 yr apart.

In patients with recurrences, depressive episodes should be treated
with antidepressants and mood stabilizers (the anticonvulsant
lamotrigine Some Trade Names
LAMICTAL
Click for Drug Monograph
may be particularly effective) because antidepressants (especially
heterocyclics), given alone, may trigger hypomania.

Prevention of rapid cycling: Antidepressants, even when given with a
mood stabilizer, can induce rapid cycling in some patients (eg,
patients with bipolar II disorder). Antidepressants should not be used
prophylactically unless previous depressive episodes have been severe
and, if used, should be given for only 4 to 12 wk. When disruptive
psychomotor acceleration or mixed states supervene, adding 2nd-
generation antipsychotics (eg, risperidone Some Trade Names
RISPERDAL
Click for Drug Monograph
, olanzapine Some Trade Names
ZYPREXA
Click for Drug Monograph
, quetiapine Some Trade Names
SEROQUEL
Click for Drug Monograph
) to the regimen can stabilize the patient.

For an established case of rapid cycling, antidepressants, stimulants,
caffeine, benzodiazepines, and alcohol must be gradually stopped.
Hospitalization may be required. Lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
(or divalproex Some Trade Names
DEPAKOTE
Click for Drug Monograph
) may be given with bupropion Some Trade Names
WELLBUTRIN
ZYBAN
Click for Drug Monograph
. Carbamazepine Some Trade Names
TEGRETOL
Click for Drug Monograph
may also be useful. Some experts combine an anticonvulsant with
lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
, trying to keep both drugs at 1⁄2 to 2⁄3 their usual dose and blood
levels in an appropriate and safe range. Because borderline
hypothyroidism also predisposes to rapid cycling (especially in
women), TSH should be checked. Thyroid replacement should be given if
TSH is high.

Phototherapy: Phototherapy is a relatively new approach to seasonal
bipolar or bipolar II disorder (with autumn-winter depression and
spring-summer hypomania). It is probably most useful as augmentation
(see Mood Disorders: Phototherapy).

Precautions during pregnancy: Most drugs used to treat bipolar
disorder must be tapered and stopped before pregnancy or during early
pregnancy. Women who wish to have a baby should have at least 2 yr of
maintenance therapy with no episodes before lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
is stopped. Lithium Some Trade Names
ESKALITH
LITHOBID
LITHONATE
Click for Drug Monograph
is stopped during the 1st trimester to avoid risk of Epstein's
anomaly, a heart defect. Carbamazepine Some Trade Names
TEGRETOL
Click for Drug Monograph
and divalproex Some Trade Names
DEPAKOTE
Click for Drug Monograph
should also be stopped during the 1st trimester because they may cause
neural tube defects. Other mood stabilizers (eg, lamotrigine Some
Trade Names
LAMICTAL
Click for Drug Monograph
, oxcarbazepine Some Trade Names
TRILEPTAL
Click for Drug Monograph
), if absolutely necessary, can be used during the 2nd and 3rd
trimesters but should be stopped 1 to 2 wk before delivery and resumed
a few days postpartum. For a severe relapse during the 1st trimester,
electroconvulsive therapy is safer. For early manic recurrence, potent
antipsychotics are relatively safe. Women taking mood stabilizers
should not breastfeed because these drugs pass into the milk.

Education and psychotherapy: Enlisting the support of loved ones is
crucial to preventing major episodes. Group therapy is often
recommended for patients and their partner; there, they learn about
bipolar disorder, its social sequelae, and the central role of mood
stabilizers in treatment. Individual psychotherapy may help patients
better cope with problems of daily living and adjust to a new way of
identifying themselves.

Patients, particularly those with bipolar II disorder, may not comply
with mood-stabilizer regimens because they believe that these drugs
make them less alert and creative. The physician can explain that
decreased creativity is relatively uncommon because mood stabilizers
usually provide opportunity for a more even performance in
interpersonal, scholastic, professional, and artistic pursuits.

Patients should be counseled to avoid stimulant drugs and alcohol, to
minimize sleep deprivation, and to recognize early signs of relapse.
If patients tend to be financially extravagant, finances should be
turned over to a trusted family member. Patients with a tendency to
sexual excesses should be given information about conjugal
consequences (eg, divorce) and infectious risks of promiscuity,
particularly AIDS. (See also the American Psychiatric Association's
practice guideline Treating Bipolar Disorder: A Quick Reference
Guide.)

Last full review/revision November 2005

Content last modified November 2005

------------------

Are you sure you're bipolar pennyshiny?

Erin

Then I'd say they are all out to lunch.   Or you're misinterpreting what
they think.

Oh?    Wasn't the same thing said for many of the German troups during WWII?
Listen to the majority?  (and boy, did they!)    Was the "majority" right
then?   (rhetorical)

I think it already has, but you have to be able to see and take in the sign
posts.
Perhaps it's like ... seeing the forest, for the trees.