Symptoms of Borderline Personality Disorder

Trying to determine if someone in your life may suffer from Borderline Personality Disorder? This eight minute video is a good starting point (1).

You will soon find out, however, that this is a complex question. There are no simple behavioral checklists; no definitive tests. Identifying Borderline Personality Disorder requires having a working knowledge of the disorder and some insight into the past life of the person in question.

Borderline Personality Disorder is a disorder of the emotions. Imagine a person who is extremely sensitive to rejection (fearful of even perceived or anticipated rejection) and has a limited ability to modulate their emotional impulses (love, fear, anger, grief, etc.). To protect themselves from their own feelings, they are prone to adopt a multitude of dysfunctional rationalizations and cover-ups.

For example, a person suffering from BPD may so fear rejection in a new relatinship that they recreate themselves in the image of a person they believe would be lovable. When the negative emotions for making such a sacrifice surface – and not having the ability to modulate them, they lash out at the target of their affections for “making them do it” – rather than face their own feelings of inadequancy / fear of rejection, ultimately damaging the relationship they so fear losing, and reinforcing their feelings of inadequancy / fear of rejection.

What is going on in a Borderline Personality Disorder sufferer’s mind and how they are acting can be two entirely different things.

To the sufferer, BPD is about deep feelings, feelings often too difficult to express, feelings that are something along the lines of this (2):

If others really get to know me, they will find me rejectable and will not be able to love me; and they will leave me; 

I need to have complete control of my feelings otherwise things go completely wrong;

I have to adapt my needs to other people’s wishes, otherwise they will leave me or attack me;

I am an evil person and I need to be punished for it;

Other people are evil and abuse you;

If someone fails to keep a promise, that person can no longer be trusted;

If I trust someone, I run a great risk of getting hurt or disappointed;

If you comply with someone’s request, you run the risk of losing yourself;

If you refuse someone’s request, you run the risk of losing that person;

I will always be alone;

I can’t manage by myself, I need someone I can fall back on;

There is no one who really cares about me, who will be available to help me, and whom I can fall back on;

I don’t really know what I want;

I will never get what I want;

I’m powerless and vulnerable and I can’t protect myself;.

I have no control of myself;

I can’t discipline myself; 

My feelings and opinions are unfounded;

Other people are not willing or helpful.

To the family members, BPD behavior is often very frustrating can feel unfair and punitive – something like this (3):

You have been viewed as overly good and then overly bad;

You have been the focus of unprovoked anger or hurtful actions, alternating with periods when the family member acts perfectly normal and very loving;

Things that you have said or done have been twisted and used against you; 

You are accused of things you never did or said?

You often find yourself defending and justifying your intentions; 

You find yourself concealing what you think or feel because you are not heard;

You feel manipulated, controlled, and sometimes lied to. 

As such, the most obvious “symptom” of Borderline Personality Disorder is a lifelong pattern of instability in interpersonal relationships, self-image and emotions.

Why is Borderline Personality Disorder Difficult to Diagnose

Borderline Personality Disorder is a relatively recent addition to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM) and the World Health Organization International Statistical Classification of Diseases and Related Health Problems (ICD). Accordingly, the majority of practicing mental health professionals graduating prior to 2000 have not been trained on the diagnosis and the treatment of this complex disorder as part of their professional curriculum.

Additionally, the clinical definition of Borderline Personality Disorder is very broad. In the DSM-IV it is defined in terms of nine criteria of which 5 or more are indicative of the disorder. This translates to 256 clusters of criteria, or constellations as they are known, any one of which is diagnostic for BPD. Within these constellations, there are high functioning borderlines that operate well in society and whose disorder is not very obvious to new acquaintances or the casual observer. Also within these constellations are the low functioning borderlines who are more apparent as they can’t hold jobs, or they self-harm (cutting). Suicidal attempts/ideation and anorexia/bulimia are some of the most serious aspects of this disorder – yet, many with the disorder do not exhibit either.

Proper diagnosis and treatment of Borderline Personality Disorder is spotty at best with community healthcare providers, marriage counselors, and family therapists who are often hesitant to diagnose or treat the disorder. As a result, most borderlines are undiagnosed or in treatment for other maladies such as depression or PTSD. If you suspect Borderline Personality Disorder, it is best to use a specialist, preferably one associated with a University.

Below we have listed available testing resources for BPD as well as several characterizations of this disorder by professional organizations.

Below are several diagnostic testing methods.

Diagnostic Interview for Borderline Patients (DIB-R)

The Diagnostic Interview for Borderline Patients (DIB-R) is the best-known “test” for diagnosing BPD. The DIB is a semi structured clinical interview that takes about 50-90 minutes to administer. The test, developed to be administered by skilled clinicians, consist of 132 questions and observation using 329 summary statements. The test looks at areas of functioning associated with borderline personality disorder. The four areas of functioning include Affect (chronic/major depression, helplessness, hopelessness, worthlessness, guilt, anger, anxiety, loneliness, boredom, emptiness), Cognition (odd thinking, unusual perceptions, nondelusional paranoia, quasipsychosis), Impulse action patterns (substance abuse/dependence, sexual deviance, manipulative suicide gestures, other impulsive behaviors), and Interpersonal relationships (intolerance of aloneness, abandonment, engulfment, annihilation fears, counterdependency, stormy relationships, manipulativeness, dependency, devaluation, masochism/sadism, demandingness, entitlement). The test is available at no charge by contacting John Gunderson M.D. McLean Hospital in Belmont Massachusetts (617-855-2293).

Structured Clinical Interview (SCID-II)

The Structured Clinical Interview (now SCID-II) was formulated in 1997 by First, Gibbon, Spitzer, Williams, and Benjamin. It closely follows the language of the DSM-IV Axis II Personality Disorders criteria. There are 12 groups of questions corresponding to the 12 personality disorders. The scoring is either the trait is absent, subthreshold, true, or there is “inadequate information to code”. SCID-II can be self administered or administered by third parties (a spouse, an informant, a colleague) and yield decent indications of the disorder. The questionnaire is available from the American Psychiatric Publishing ($60.00).

Personality Disorder Beliefs Questionnaire (PDBQ).

The Personality Disorder Beliefs Questionnaire (PDBQ) is a brief self administered test for Personality Disorder tendencies. We have included a list of questions most often answered as “yes” by people with Borderline Personality Disorder .

Other

Other commonly used assessment tests are rating tests such as the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD), and the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). In addition there are some free, informal tests available – some BPDFamily.com members have found that these tests are helpful.

Below are characterizations of the disorder by the National Institute of Health, The Mayo Clinic, and the American Psychiatric Association.

Symptoms of Borderline Personality Disorder – National Institute of Health

People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all.

Even with family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.

People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.

Symptoms of Borderline Personality Disorder – The Mayo Clinic

People with BPD often have an unstable sense of who they are. That is, their self-image or sense of self often rapidly changes. They typically view themselves as evil or bad, and sometimes they may feel as if they don’t exist at all. This unstable self-image can lead to frequent changes in jobs, friendships, goals, values and gender identity.

Relationships are usually in turmoil. People with BPD often experience a love-hate relationship with others. They may idealize someone one moment and then abruptly and dramatically shift to fury and hate over perceived slights or even misunderstandings. This is because people with the disorder have difficulty accepting gray areas — things are either black or white. For instance, in the eyes of a person with BPD, someone is either good or evil. And that same person may be good one day and evil the next.

In addition, people with BPD often engage in impulsive and risky behavior. This behavior often winds up hurting them, whether emotionally, financially or physically. For instance, they may drive recklessly, engage in unsafe sex, take illicit drugs or go on spending or gambling sprees. People with BPD also often engage in suicidal behavior or deliberately injure themselves for emotional relief.

Other signs and symptoms of borderline personality disorder may include:

* Strong emotions that wax and wane frequently
* Intense but short episodes of anxiety or depression
* Inappropriate anger, sometimes escalating into physical confrontations
* Difficulty controlling emotions or impulses
* Fear of being alone

Symptoms of Borderline Personality Disorder – American Psychiatric Association DSM-5

The DSM-5 work group is recommending that this disorder be reformulated in the DSM-5 as the Borderline Type.

Individuals who match this personality disorder type have an extremely fragile self-concept that is easily disrupted and fragmented under stress and results in the experience of a lack of identity or chronic feelings of emptiness. As a result, they have an impoverished and/or unstable self structure and difficulty maintaining enduring intimate relationships. Self-appraisal is often associated with self-loathing, rage, and despondency. Individuals with this disorder experience rapidly changing, intense, unpredictable, and reactive emotions and can become extremely anxious or depressed. They may also become angry or hostile, and feel misunderstood, mistreated, or victimized. They may engage in verbal or physical acts of aggression when angry. Emotional reactions are typically in response to negative interpersonal events involving loss or disappointment.

Relationships are based on the fantasy of the need for others for survival, excessive dependency, and a fear of rejection and/or abandonment. Dependency involves both insecure attachment, expressed as difficulty tolerating aloneness; intense fear of loss, abandonment, or rejection by significant others; and urgent need for contact with significant others when stressed or distressed, accompanied sometimes by highly submissive, subservient behavior. At the same time, intense, intimate involvement with another person often leads to a fear of loss of an identity as an individual. Thus, interpersonal relationships are highly unstable and alternate between excessive dependency and flight from involvement. Empathy for others is severely impaired.

Core emotional traits and interpersonal behaviors may be associated with cognitive dysregulation, i.e., cognitive functions may become impaired at times of interpersonal stress leading to information processing in a concrete, black-and white, all-or-nothing manner. Quasi-psychotic reactions, including paranoia and dissociation, may progress to transient psychosis. Individuals with this type are characteristically impulsive, acting on the spur of the moment, and frequently engage in activities with potentially negative consequences. Deliberate acts of self-harm (e.g., cutting, burning), suicidal ideation, and suicide attempts typically occur in the context of intense distress and dysphoria, particularly in the context of feelings of abandonment when an important relationship is disrupted. Intense distress may also lead to other risky behaviors, including substance misuse, reckless driving, binge eating, or promiscuous sex.

1. Negative Emotionality: Emotional Lability

Having unstable emotional experiences and mood changes; having emotions that are easily aroused, intense, and/or out of proportion to events and circumstances

2. Negative Emotionality: Self-harm

Engaging in thoughts and behaviors related to self-harm (e.g., intentional cutting or burning) and suicide, including suicidal ideation, threats, gestures, and attempts

3. Negative Emotionality: Separation insecurity

Fears of rejection by, and/or separation from, significant others; distress when significant others are not present or readily available

4. Negative Emotionality: Anxiousness

Feelings of nervousness, tenseness, and/or being on edge; worry about past unpleasant experiences and future negative possibilities; feeling fearful and threatened by uncertainty

5. Negative Emotionality: Low self-esteem

Having a poor opinion of one’s self and abilities; believing that one is worthless or useless; disliking or being dissatisfied with one’s self; believing that one cannot do things or do them well

6. Negative Emotionality: Depressivity

Having frequent feelings of being down/ miserable/ depressed/ hopeless; difficulty “bounding back” from such moods; belief that one is simply a sad/ depressed person

7. Antagonism: Hostility

Irritability, hot temperedness; being unfriendly, rude, surly, or nasty; responding angrily to minor slights and insults

8. Antagonism: Aggression

Being mean, cruel, or cold-hearted; verbally, relationally, or physically abusive; humiliating and demeaning of others; willingly and willfully engaging in acts of violence against persons and objects; active and open belligerence or vengefulness; using dominance and intimidation to control others

9. Disinhibition: Impulsivity

Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing and following plans; failure to learn from experience

10. Schizotypy: Dissociation Proneness

Tendency to experience disruptions in the flow of conscious experience; “losing time,” (e.g., being unaware of how one got to one’s location); experiencing one’s surroundings as strange or unreal

Symptoms of Borderline Personality Disorder – American Psychiatric Association DSM-IV

Personality disorders are diagnosed based on signs and symptoms and a thorough psychological evaluation. To be diagnosed with borderline personality disorder, someone must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM criteria note that people with BPD have a pattern of unstable relationships, self-image and mood, as well as impulsive behavior. These typically begin in early adulthood. This manual is published by the American Psychiatric Association and is used by mental health professionals to diagnose mental conditions and by insurance companies to reimburse for treatment.

Borderline Personality Disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1.frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5

2.a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

3.identity disturbance: markedly and persistently unstable self-image or sense of self.

4.impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

5.recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

6.affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

7.chronic feelings of emptiness

8.inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

9.transient, stress-related paranoid ideation or severe dissociative symptoms

References:

(1)BPDFamily Staff Production included anonymous members Elphaba, LAPDR, United for Now, ForeverDad, NewLifeForHGG, and Skip, community leaders with professions in healthcare, education, and business.

(1)BPDFamily Staff Production.

(2) Assumptions in borderline personality disorder: specificity, stability
and relationship with etiological factors. Arntz, A., Dietzel, R., & Dreessen, L. (1999). Behaviour Research and Therapy, 37, 545–557

(3) Stop Walking on Eggshells, Paul Mason,MS and Randi Kreger, New Harbinger Publications; 1st edition (July 1998), ISBN-10: 157224108X

Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. Symptoms of bipolar disorder are severe. They are different from the normal ups and downs that everyone goes through from time to time. Bipolar disorder symptoms can result in damaged relationships, poor job or school performance, and even suicide. But bipolar disorder can be treated, and people with this illness can lead full and productive lives.

Bipolar disorder often develops in a person’s late teens or early adult years. At least half of all cases start before age 25.¹ Some people have their first symptoms during childhood, while others may develop symptoms late in life.

Bipolar disorder is not easy to spot when it starts. The symptoms may seem like separate problems, not recognized as parts of a larger problem. Some people suffer for years before they are properly diagnosed and treated. Like diabetes or heart disease, bipolar disorder is a long-term illness that must be carefully managed throughout a person’s life.

What are the symptoms of bipolar disorder?

People with bipolar disorder experience unusually intense emotional states that occur in distinct periods called “mood episodes.” An overly joyful or overexcited state is called a manic episode, and an extremely sad or hopeless state is called a depressive episode. Sometimes, a mood episode includes symptoms of both mania and depression. This is called a mixed state. People with bipolar disorder also may be explosive and irritable during a mood episode.

Extreme changes in energy, activity, sleep, and behavior go along with these changes in mood. It is possible for someone with bipolar disorder to experience a long-lasting period of unstable moods rather than discrete episodes of depression or mania.

A person may be having an episode of bipolar disorder if he or she has a number of manic or depressive symptoms for most of the day, nearly every day, for at least one or two weeks. Sometimes symptoms are so severe that the person cannot function normally at work, school, or home.

Symptoms of bipolar disorder are described below.

Symptoms of mania or a manic episode include:Symptoms of depression or a depressive episode include:Mood Changes

• A long period of feeling “high,” or an overly happy or outgoing mood
• Extremely irritable mood, agitation, feeling “jumpy” or “wired.”

Behavioral Changes

• Talking very fast, jumping from one idea to another, having racing thoughts
• Being easily distracted
• Increasing goal-directed activities, such as taking on new projects
• Being restless
• Sleeping little
• Having an unrealistic belief in one’s abilities
• Behaving impulsively and taking part in a lot of pleasurable,
  high-risk behaviors, such as spending sprees, impulsive sex, and impulsive business investments.

Mood Changes

• A long period of feeling worried or empty
• Loss of interest in activities once enjoyed, including sex.

Behavioral Changes

• Feeling tired or “slowed down”
• Having problems concentrating, remembering, and making decisions
• Being restless or irritable
• Changing eating, sleeping, or other habits
• Thinking of death or suicide, or attempting suicide.

In addition to mania and depression, bipolar disorder can cause a range of moods, as shown on the scale.

One side of the scale includes severe depression, moderate depression, and mild low mood. Moderate depression may cause less extreme symptoms, and mild low mood is called dysthymia when it is chronic or long-term. In the middle of the scale is normal or balanced mood.

At the other end of the scale are hypomania and severe mania. Some people with bipolar disorder experience hypomania. During hypomanic episodes, a person may have increased energy and activity levels that are not as severe as typical mania, or he or she may have episodes that last less than a week and do not require emergency care. A person having a hypomanic episode may feel very good, be highly productive, and function well. This person may not feel that anything is wrong even as family and friends recognize the mood swings as possible bipolar disorder. Without proper treatment, however, people with hypomania may develop severe mania or depression.

During a mixed state, symptoms often include agitation, trouble sleeping, major changes in appetite, and suicidal thinking. People in a mixed state may feel very sad or hopeless while feeling extremely energized.

Sometimes, a person with severe episodes of mania or depression has psychotic symptoms too, such as hallucinations or delusions. The psychotic symptoms tend to reflect the person’s extreme mood. For example, psychotic symptoms for a person having a manic episode may include believing he or she is famous, has a lot of money, or has special powers. In the same way, a person having a depressive episode may believe he or she is ruined and penniless, or has committed a crime. As a result, people with bipolar disorder who have psychotic symptoms are sometimes wrongly diagnosed as having schizophrenia, another severe mental illness that is linked with hallucinations and delusions.

People with bipolar disorder may also have behavioral problems. They may abuse alcohol or substances, have relationship problems, or perform poorly in school or at work. At first, it’s not easy to recognize these problems as signs of a major mental illness.

How does bipolar disorder affect someone over time?

Bipolar disorder usually lasts a lifetime. Episodes of mania and depression typically come back over time. Between episodes, many people with bipolar disorder are free of symptoms, but some people may have lingering symptoms.

Doctors usually diagnose mental disorders using guidelines from the Diagnostic and Statistical Manual of Mental Disorders, or DSM. According to the DSM, there are four basic types of bipolar disorder:

1. Bipolar I Disorder is mainly defined by manic or mixed episodes that last at least seven days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, the person also has depressive episodes, typically lasting at least two weeks. The symptoms of mania or depression must be a major change from the person’s normal behavior.
2. Bipolar II Disorder is defined by a pattern of depressive episodes shifting back and forth with hypomanic episodes, but no full-blown manic or mixed episodes.
3. Bipolar Disorder Not Otherwise Specified (BP-NOS) is diagnosed when a person has symptoms of the illness that do not meet diagnostic criteria for either bipolar I or II. The symptoms may not last long enough, or the person may have too few symptoms, to be diagnosed with bipolar I or II. However, the symptoms are clearly out of the person’s normal range of behavior.
4. Cyclothymic Disorder, or Cyclothymia, is a mild form of bipolar disorder. People who have cyclothymia have episodes of hypomania that shift back and forth with mild depression for at least two years. However, the symptoms do not meet the diagnostic requirements for any other type of bipolar disorder.

Some people may be diagnosed with rapid-cycling bipolar disorder. This is when a person has four or more episodes of major depression, mania, hypomania, or mixed symptoms within a year.² Some people experience more than one episode in a week, or even within one day. Rapid cycling seems to be more common in people who have severe bipolar disorder and may be more common in people who have their first episode at a younger age. One study found that people with rapid cycling had their first episode about four years earlier, during mid to late teen years, than people without rapid cycling bipolar disorder.³ Rapid cycling affects more women than men.⁴

Bipolar disorder tends to worsen if it is not treated. Over time, a person may suffer more frequent and more severe episodes than when the illness first appeared.⁵ Also, delays in getting the correct diagnosis and treatment make a person more likely to experience personal, social, and work-related problems.⁶

Proper diagnosis and treatment helps people with bipolar disorder lead healthy and productive lives. In most cases, treatment can help reduce the frequency and severity of episodes.

What illnesses often co-exist with bipolar disorder?

Substance abuse is very common among people with bipolar disorder, but the reasons for this link are unclear.⁷ Some people with bipolar disorder may try to treat their symptoms with alcohol or drugs. However, substance abuse may trigger or prolong bipolar symptoms, and the behavioral control problems associated with mania can result in a person drinking too much.

Anxiety disorders, such as post-traumatic stress disorder (PTSD) and social phobia, also co-occur often among people with bipolar disorder.^8-10 Bipolar disorder also co-occurs with attention deficit hyperactivity disorder (ADHD), which has some symptoms that overlap with bipolar disorder, such as restlessness and being easily distracted.

People with bipolar disorder are also at higher risk for thyroid disease, migraine headaches, heart disease, diabetes, obesity, and other physical illnesses.^{10, 11} These illnesses may cause symptoms of mania or depression. They may also result from treatment for bipolar disorder.

Other illnesses can make it hard to diagnose and treat bipolar disorder. People with bipolar disorder should monitor their physical and mental health. If a symptom does not get better with treatment, they should tell their doctor.

What are the risk factors for bipolar disorder?

Scientists are learning about the possible causes of bipolar disorder. Most scientists agree that there is no single cause. Rather, many factors likely act together to produce the illness or increase risk.

Genetics

Bipolar disorder tends to run in families, so researchers are looking for genes that may increase a person’s chance of developing the illness. Genes are the “building blocks” of heredity. They help control how the body and brain work and grow. Genes are contained inside a person’s cells that are passed down from parents to children.

Children with a parent or sibling who has bipolar disorder are four to six times more likely to develop the illness, compared with children who do not have a family history of bipolar disorder.¹² However, most children with a family history of bipolar disorder will not develop the illness.

Genetic research on bipolar disorder is being helped by advances in technology. This type of research is now much quicker and more far-reaching than in the past. One example is the launch of the Bipolar Disorder Phenome Database, funded in part by NIMH. Using the database, scientists will be able to link visible signs of the disorder with the genes that may influence them. So far, researchers using this database found that most people with bipolar disorder had:¹³

• Missed work because of their illness
• Other illnesses at the same time, especially alcohol and/or substance abuse and panic disorders
• Been treated or hospitalized for bipolar disorder.

The researchers also identified certain traits that appeared to run in families, including:

• History of psychiatric hospitalization
• Co-occurring obsessive-compulsive disorder (OCD)
• Age at first manic episode
• Number and frequency of manic episodes.

Scientists continue to study these traits, which may help them find the genes that cause bipolar disorder some day.

But genes are not the only risk factor for bipolar disorder. Studies of identical twins have shown that the twin of a person with bipolar illness does not always develop the disorder. This is important because identical twins share all of the same genes. The study results suggest factors besides genes are also at work. Rather, it is likely that many different genes and a person’s environment are involved. However, scientists do not yet fully understand how these factors interact to cause bipolar disorder.

Brain structure and functioning

Brain-imaging studies are helping scientists learn what happens in the brain of a person with bipolar disorder.^{14, 15} Newer brain-imaging tools, such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET), allow researchers to take pictures of the living brain at work. These tools help scientists study the brain’s structure and activity.

Some imaging studies show how the brains of people with bipolar disorder may differ from the brains of healthy people or people with other mental disorders. For example, one study using MRI found that the pattern of brain development in children with bipolar disorder was similar to that in children with “multi-dimensional impairment,” a disorder that causes symptoms that overlap somewhat with bipolar disorder and schizophrenia.¹⁶ This suggests that the common pattern of brain development may be linked to general risk for unstable moods.

Learning more about these differences, along with information gained from genetic studies, helps scientists better understand bipolar disorder. Someday scientists may be able to predict which types of treatment will work most effectively. They may even find ways to prevent bipolar disorder.

How is bipolar disorder diagnosed?

The first step in getting a proper diagnosis is to talk to a doctor, who may conduct a physical examination, an interview, and lab tests. Bipolar disorder cannot currently be identified through a blood test or a brain scan, but these tests can help rule out other contributing factors, such as a stroke or brain tumor. If the problems are not caused by other illnesses, the doctor may conduct a mental health evaluation. The doctor may also provide a referral to a trained mental health professional, such as a psychiatrist, who is experienced in diagnosing and treating bipolar disorder.

The doctor or mental health professional should conduct a complete diagnostic evaluation. He or she should discuss any family history of bipolar disorder or other mental illnesses and get a complete history of symptoms. The doctor or mental health professionals should also talk to the person’s close relatives or spouse and note how they describe the person’s symptoms and family medical history.

People with bipolar disorder are more likely to seek help when they are depressed than when experiencing mania or hypomania.¹⁷ Therefore, a careful medical history is needed to assure that bipolar disorder is not mistakenly diagnosed as major depressive disorder, which is also called unipolar depression. Unlike people with bipolar disorder, people who have unipolar depression do not experience mania. Whenever possible, previous records and input from family and friends should also be included in the medical history.

How is bipolar disorder treated?

To date, there is no cure for bipolar disorder. But proper treatment helps most people with bipolar disorder gain better control of their mood swings and related symptoms.^18-20 This is also true for people with the most severe forms of the illness.

Because bipolar disorder is a lifelong and recurrent illness, people with the disorder need long-term treatment to maintain control of bipolar symptoms. An effective maintenance treatment plan includes medication and psychotherapy for preventing relapse and reducing symptom severity.²¹

Medications

Bipolar disorder can be diagnosed and medications prescribed by people with an M.D. (doctor of medicine). Usually, bipolar medications are prescribed by a psychiatrist. In some states, clinical psychologists, psychiatric nurse practitioners, and advanced psychiatric nurse specialists can also prescribe medications. Check with your state’s licensing agency to find out more.

Not everyone responds to medications in the same way. Several different medications may need to be tried before the best course of treatment is found.

Keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events can help the doctor track and treat the illness most effectively. Sometimes this is called a daily life chart. If a person’s symptoms change or if side effects become serious, the doctor may switch or add medications.

Some of the types of medications generally used to treat bipolar disorder are listed on the next page. Information on medications can change. For the most up to date information on use and side effects contact the U.S. Food and Drug Administration (FDA).

1. Mood stabilizing medications are usually the first choice to treat bipolar disorder. In general, people with bipolar disorder continue treatment with mood stabilizers for years. Except for lithium, many of these medications are anticonvulsants. Anticonvulsant medications are usually used to treat seizures, but they also help control moods. These medications are commonly used as mood stabilizers in bipolar disorder:

• Lithium (sometimes known as Eskalith or Lithobid) was the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) in the 1970s for treatment of mania. It is often very effective in controlling symptoms of mania and preventing the recurrence of manic and depressive episodes.
• Valproic acid or divalproex sodium (Depakote), approved by the FDA in 1995 for treating mania, is a popular alternative to lithium for bipolar disorder. It is generally as effective as lithium for treating bipolar disorder.^{23, 24} Also see the section in this booklet, “Should young women take valproic acid?”
• More recently, the anticonvulsant lamotrigine (Lamictal) received FDA approval for maintenance treatment of bipolar disorder.
• Other anticonvulsant medications, including gabapentin (Neurontin), topiramate (Topamax), and oxcarbazepine (Trileptal) are sometimes prescribed. No large studies have shown that these medications are more effective than mood stabilizers.

Valproic acid, lamotrigine, and other anticonvulsant medications have an FDA warning. The warning states that their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored for new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional.

Lithium and Thyroid Function

People with bipolar disorder often have thyroid gland problems. Lithium treatment may also cause low thyroid levels in some people.²² Low thyroid function, called hypothyroidism, has been associated with rapid cycling in some people with bipolar disorder, especially women.

Because too much or too little thyroid hormone can lead to mood and energy changes, it is important to have a doctor check thyroid levels carefully. A person with bipolar disorder may need to take thyroid medication, in addition to medications for bipolar disorder, to keep thyroid levels balanced.

Should young women take valproic acid?

Valproic acid may increase levels of testosterone (a male hormone) in teenage girls and lead to polycystic ovary syndrome (PCOS) in women who begin taking the medication before age 20.^{25, 26} PCOS causes a woman’s eggs to develop into cysts, or fluid filled sacs that collect in the ovaries instead of being released by monthly periods. This condition can cause obesity, excess body hair, disruptions in the menstrual cycle, and other serious symptoms. Most of these symptoms will improve after stopping treatment with valproic acid.²⁷ Young girls and women taking valproic acid should be monitored carefully by a doctor.

2. Atypical antipsychotic medications are sometimes used to treat symptoms of bipolar disorder. Often, these medications are taken with other medications. Atypical antipsychotic medications are called “atypical” to set them apart from earlier medications, which are called “conventional” or “first-generation” antipsychotics.

• Olanzapine (Zyprexa), when given with an antidepressant medication, may help relieve symptoms of severe mania or psychosis.²⁸ Olanzapine is also available in an injectable form, which quickly treats agitation associated with a manic or mixed episode. Olanzapine can be used for maintenance treatment of bipolar disorder as well, even when a person does not have psychotic symptoms. However, some studies show that people taking olanzapine may gain weight and have other side effects that can increase their risk for diabetes and heart disease. These side effects are more likely in people taking olanzapine when compared with people prescribed other atypical antipsychotics.
• Aripiprazole (Abilify), like olanzapine, is approved for treatment of a manic or mixed episode. Aripiprazole is also used for maintenance treatment after a severe or sudden episode. As with olanzapine, aripiprazole also can be injected for urgent treatment of symptoms of manic or mixed episodes of bipolar disorder.
• Quetiapine (Seroquel) relieves the symptoms of severe and sudden manic episodes. In that way, quetiapine is like almost all antipsychotics. In 2006, it became the first atypical antipsychotic to also receive FDA approval for the treatment of bipolar depressive episodes.
• Risperidone (Risperdal) and ziprasidone (Geodon) are other atypical antipsychotics that may also be prescribed for controlling manic or mixed episodes.

3. Antidepressant medications are sometimes used to treat symptoms of depression in bipolar disorder. People with bipolar disorder who take antidepressants often take a mood stabilizer too. Doctors usually require this because taking only an antidepressant can increase a person’s risk of switching to mania or hypomania, or of developing rapid cycling symptoms.²⁹ To prevent this switch, doctors who prescribe antidepressants for treating bipolar disorder also usually require the person to take a mood-stabilizing medication at the same time.

Recently, a large-scale, NIMH-funded study showed that for many people, adding an antidepressant to a mood stabilizer is no more effective in treating the depression than using only a mood stabilizer.³⁰

• Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and bupropion (Wellbutrin) are examples of antidepressants that may be prescribed to treat symptoms of bipolar depression.

Some medications are better at treating one type of bipolar symptoms than another. For example, lamotrigine (Lamictal) seems to be helpful in controlling depressive symptoms of bipolar disorder.

What are the side effects of these medications?

Before starting a new medication, people with bipolar disorder should talk to their doctor about the possible risks and benefits.

The psychiatrist prescribing the medication or pharmacist can also answer questions about side effects. Over the last decade, treatments have improved, and some medications now have fewer or more tolerable side effects than earlier treatments. However, everyone responds differently to medications. In some cases, side effects may not appear until a person has taken a medication for some time.

If the person with bipolar disorder develops any severe side effects from a medication, he or she should talk to the doctor who prescribed it as soon as possible. The doctor may change the dose or prescribe a different medication. People being treated for bipolar disorder should not stop taking a medication without talking to a doctor first. Suddenly stopping a medication may lead to “rebound,” or worsening of bipolar disorder symptoms. Other uncomfortable or potentially dangerous withdrawal effects are also possible.

FDA Warning on Antidepressants

Antidepressants are safe and popular, but some studies have suggested that they may have unintentional effects on some people, especially in adolescents and young adults. The FDA warning says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor. For the latest information visit the FDA website.

The following sections describe some common side effects of the different types of medications used to treat bipolar disorder.

1. Mood Stabilizers

In some cases, lithium can cause side effects such as:

• Restlessness
• Dry mouth
• Bloating or indigestion
• Acne
• Unusual discomfort to cold temperatures
• Joint or muscle pain
• Brittle nails or hair.³¹

Lithium also causes side effects not listed here. If extremely bothersome or unusual side effects occur, tell your doctor as soon as possible.

If a person with bipolar disorder is being treated with lithium, it is important to make regular visits to the treating doctor. The doctor needs to check the levels of lithium in the person’s blood, as well as kidney and thyroid function.

These medications may also be linked with rare but serious side effects. Talk with the treating doctor or a pharmacist to make sure you understand signs of serious side effects for the medications you’re taking.

Common side effects of other mood stabilizing medications include:

• Drowsiness
• Dizziness
• Headache
• Diarrhea
• Constipation
• Heartburn
• Mood swings
• Stuffed or runny nose, or other cold-like symptoms.^32-37

2. Atypical Antipsychotics

Some people have side effects when they start taking atypical antipsychotics. Most side effects go away after a few days and often can be managed successfully. People who are taking antipsychotics should not drive until they adjust to their new medication. Side effects of many antipsychotics include:

• Drowsiness
• Dizziness when changing positions
• Blurred vision
• Rapid heartbeat
• Sensitivity to the sun
• Skin rashes
• Menstrual problems for women.

Atypical antipsychotic medications can cause major weight gain and changes in a person’s metabolism. This may increase a person’s risk of getting diabetes and high cholesterol.³⁸A person’s weight, glucose levels, and lipid levels should be monitored regularly by a doctor while taking these medications.

In rare cases, long-term use of atypical antipsychotic drugs may lead to a condition called tardive dyskinesia (TD). The condition causes muscle movements that commonly occur around the mouth. A person with TD cannot control these moments. TD can range from mild to severe, and it cannot always be cured. Some people with TD recover partially or fully after they stop taking the drug.

3. Antidepressants

The antidepressants most commonly prescribed for treating symptoms of bipolar disorder can also cause mild side effects that usually do not last long. These can include:

• Headache, which usually goes away within a few days.
• Nausea (feeling sick to your stomach), which usually goes away within a few days.
• Sleep problems, such as sleeplessness or drowsiness. This may happen during the first few weeks but then go away. To help lessen these effects, sometimes the medication dose can be reduced, or the time of day it is taken can be changed.
• Agitation (feeling jittery).
• Sexual problems, which can affect both men and women. These include reduced sex drive and problems having and enjoying sex.

Some antidepressants are more likely to cause certain side effects than other types. Your doctor or pharmacist can answer questions about these medications. Any unusual reactions or side effects should be reported to a doctor immediately.

For the most up-to-date information on medications for treating bipolar disorder and their side effects, please see the online NIMH Medications booklet.

Should women who are pregnant or may become pregnant take medication for bipolar disorder?

Women with bipolar disorder who are pregnant or may become pregnant face special challenges. The mood stabilizing medications in use today can harm a developing fetus or nursing infant.³⁹ But stopping medications, either suddenly or gradually, greatly increases the risk that bipolar symptoms will recur during pregnancy.⁴⁰

Scientists are not sure yet, but lithium is likely the preferred mood-stabilizing medication for pregnant women with bipolar disorder.^{40, 41} However, lithium can lead to heart problems in the fetus. Women need to know that most bipolar medications are passed on through breast milk.⁴¹ Pregnant women and nursing mothers should talk to their doctors about the benefits and risks of all available treatments.

Psychotherapy

In addition to medication, psychotherapy, or “talk” therapy, can be an effective treatment for bipolar disorder. It can provide support, education, and guidance to people with bipolar disorder and their families. Some psychotherapy treatments used to treat bipolar disorder include:

1. Cognitive behavioral therapy (CBT) helps people with bipolar disorder learn to change harmful or negative thought patterns and behaviors.
2. Family-focused therapy includes family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their loved one. This therapy also improves communication and problem-solving.
3. Interpersonal and social rhythm therapy helps people with bipolar disorder improve their relationships with others and manage their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
4. Psychoeducation teaches people with bipolar disorder about the illness and its treatment. This treatment helps people recognize signs of relapse so they can seek treatment early, before a full-blown episode occurs. Usually done in a group, psychoeducation may also be helpful for family members and caregivers.

A licensed psychologist, social worker, or counselor typically provides these therapies. This mental health professional often works with the psychiatrist to track progress. The number, frequency, and type of sessions should be based on the treatment needs of each person. As with medication, following the doctor’s instructions for any psychotherapy will provide the greatest benefit.

For more information, see the Substance Abuse and Mental Health Services Administrationweb page on choosing a mental health therapist.

Recently, NIMH funded a clinical trial called the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). This was the largest treatment study ever conducted for bipolar disorder. In a study on psychotherapies, STEP-BD researchers compared people in two groups. The first group was treated with collaborative care (three sessions of psychoeducation over six weeks). The second group was treated with medication and intensive psychotherapy (30 sessions over nine months of CBT, interpersonal and social rhythm therapy, or family-focused therapy). Researchers found that the second group had fewer relapses, lower hospitalization rates, and were better able to stick with their treatment plans.⁴² They were also more likely to get well faster and stay well longer.

NIMH is supporting more research on which combinations of psychotherapy and medication work best. The goal is to help people with bipolar disorder live symptom-free for longer periods and to recover from episodes more quickly. Researchers also hope to determine whether psychotherapy helps delay the start of bipolar disorder in children at high risk for the illness.

Visit the NIMH Web site for more information on psychotherapy.

Other treatments

1. Electroconvulsive Therapy (ECT)—For cases in which medication and/or psychotherapy does not work, electroconvulsive therapy (ECT) may be useful. ECT, formerly known as “shock therapy,” once had a bad reputation. But in recent years, it has greatly improved and can provide relief for people with severe bipolar disorder who have not been able to feel better with other treatments.Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. He or she does not consciously feel the electrical impulse administered in ECT. On average, ECT treatments last from 30–90 seconds. People who have ECT usually recover after 5–15 minutes and are able to go home the same day.⁴³Sometimes ECT is used for bipolar symptoms when other medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severely depressive, manic, or mixed episodes, but is generally not a first-line treatment.

   ECT may cause some short-term side effects, including confusion, disorientation, and memory loss. But these side effects typically clear soon after treatment. People with bipolar disorder should discuss possible benefits and risks of ECT with an experienced doctor.⁴⁴

2. Sleep Medications—People with bipolar disorder who have trouble sleeping usually sleep better after getting treatment for bipolar disorder. However, if sleeplessness does not improve, the doctor may suggest a change in medications. If the problems still continue, the doctor may prescribe sedatives or other sleep medications.

People with bipolar disorder should tell their doctor about all prescription drugs, over-the-counter medications, or supplements they are taking. Certain medications and supplements taken together may cause unwanted or dangerous effects.

Herbal Supplements

In general, there is not much research about herbal or natural supplements. Little is known about their effects on bipolar disorder. An herb called St. John’s wort (Hypericum perforatum), often marketed as a natural antidepressant, may cause a switch to mania in some people with bipolar disorder.⁴⁵ St. John’s wort can also make other medications less effective, including some antidepressant and anticonvulsant medications.⁴⁶ Scientists are also researching omega-3 fatty acids (most commonly found in fish oil) to measure their usefulness for long-term treatment of bipolar disorder.⁴⁷ Study results have been mixed.⁴⁸ It is important to talk with a doctor before taking any herbal or natural supplements because of the serious risk of interactions with other medications.

What can people with bipolar disorder expect from treatment?

Bipolar disorder has no cure, but can be effectively treated over the long-term. It is best controlled when treatment is continuous, rather than on and off. In the STEP-BD study, a little more than half of the people treated for bipolar disorder recovered over one year’s time. For this study, recovery meant having two or fewer symptoms of the disorder for at least eight weeks.

However, even with proper treatment, mood changes can occur. In the STEP-BD study, almost half of those who recovered still had lingering symptoms. These people experienced a relapse or recurrence that was usually a return to a depressive state.⁴⁹ If a person had a mental illness in addition to bipolar disorder, he or she was more likely to experience a relapse.⁴⁹ Scientists are unsure, however, how these other illnesses or lingering symptoms increase the chance of relapse. For some people, combining psychotherapy with medication may help to prevent or delay relapse.⁴²

Treatment may be more effective when people work closely with a doctor and talk openly about their concerns and choices. Keeping track of mood changes and symptoms with a daily life chart can help a doctor assess a person’s response to treatments. Sometimes the doctor needs to change a treatment plan to make sure symptoms are controlled most effectively. A psychiatrist should guide any changes in type or dose of medication.

How can I help a friend or relative who has bipolar disorder?

If you know someone who has bipolar disorder, it affects you too. The first and most important thing you can do is help him or her get the right diagnosis and treatment. You may need to make the appointment and go with him or her to see the doctor. Encourage your loved one to stay in treatment.

To help a friend or relative, you can:

• Offer emotional support, understanding, patience, and encouragement
• Learn about bipolar disorder so you can understand what your friend or relative is experiencing
• Talk to your friend or relative and listen carefully
• Listen to feelings your friend or relative expresses-be understanding about situations that may trigger bipolar symptoms
• Invite your friend or relative out for positive distractions, such as walks, outings, and other activities
• Remind your friend or relative that, with time and treatment, he or she can get better.

Never ignore comments about your friend or relative harming himself or herself. Always report such comments to his or her therapist or doctor.

Support for caregivers

Like other serious illnesses, bipolar disorder can be difficult for spouses, family members, friends, and other caregivers. Relatives and friends often have to cope with the person’s serious behavioral problems, such as wild spending sprees during mania, extreme withdrawal during depression, poor work or school performance. These behaviors can have lasting consequences.

Caregivers usually take care of the medical needs of their loved ones. The caregivers have to deal with how this affects their own health. The stress that caregivers are under may lead to missed work or lost free time, strained relationships with people who may not understand the situation, and physical and mental exhaustion.

Stress from caregiving can make it hard to cope with a loved one’s bipolar symptoms. One study shows that if a caregiver is under a lot of stress, his or her loved one has more trouble following the treatment plan, which increases the chance for a major bipolar episode.⁵⁰ It is important that people caring for those with bipolar disorder also take care of themselves.

How can I help myself if I have bipolar disorder?

It may be very hard to take that first step to help yourself. It may take time, but you can get better with treatment.

To help yourself:

• Talk to your doctor about treatment options and progress
• Keep a regular routine, such as eating meals at the same time every day and going to sleep at the same time every night
• Try to get enough sleep
• Stay on your medication
• Learn about warning signs signaling a shift into depression or mania
• Expect your symptoms to improve gradually, not immediately.

Where can I go for help?

If you are unsure where to go for help, ask your family doctor. Others who can help are listed below.

• Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
• Health maintenance organizations
• Community mental health centers
• Hospital psychiatry departments and outpatient clinics
• Mental health programs at universities or medical schools
• State hospital outpatient clinics
• Family services, social agencies, or clergy
• Peer support groups
• Private clinics and facilities
• Employee assistance programs
• Local medical and/or psychiatric societies.

Bipolar disorder is not a widely discussed illness in the public arena. Other illnesses, such as depression (What is depression? See Here), have been in the limelight for much longer, and it is clear that some misconceptions about bipolar disorder have emerged during this illness‘s time in the shadows. Hopefully this article will help to clear up some of the most commonly reported and dreadful misconceptions about bipolar disorder.

The first misconception is that bipolar disorder is not a real illness, but an excuse for selfish individuals to behave in their selfish ways. There is physical evidence in the form of PET (positron emission tomography) scans taken during depressed and manic states. These scans display the level of glucose consumed in the brain, and increased glucose consumption corresponds to increased brain activity.

During manic mania states, consumption levels are outrageously high, but the scans of the depressed brain show only faint blips of consumption (Myers, 481). It should also be noted that patients experience marked changed in physical state during episodes. Changes occur in energy level, appetite, the amount of sleep, and the person’s general state of health(Hales, 98). So, contrary to some beliefs, bipolar disorder does present symptoms physically.

People diagnosed with bipolar disorder did not “do something” to get the illness. The symptoms of bipolar disorder are primarily caused by abnormal brain functioning. Thecauses of bipolar disorder are still largely unknown, but the biggest suspect is genetics. Other chemical, psychological, social, and developmental factors may play a role, but most doctors agree that genetics is by far the leading cause of bipolar disorder (Hales, 100). According to the National Institute of Mental Health, a child with one parent diagnosed with bipolar disorder has a 15 to 30% risk of also having bipolar disorder. When both parents have bipolar disorder, the risk increases to 50 to 75% (DBSA).

Bipolar disorder is not a uniform illness. Even within the different categories or types, many differences remain. For this reason, many patients with bipolar disorder will not receive an accurate diagnosis for up to 10 years, and only one in four are reported to receive an accurate diagnosis within 3 years (DBSA).

Bipolar disorder does not completely disable a person from experiencing regular moods. A reaction of anger, sadness, or happiness does not mean that an individual is experiencing a manic, mixed, or depressive state. Like people without a diagnosed mental illness, individuals diagnosed with bipolar disorder will continue to react to the environment during periods of stability.

There are quite a few negative stereotypes about bipolar disorder involving infidelity, substance abuse, and parenting skills. The stereotype about infidelity arises from the tendency for some individuals to become hypersexual during manic mania episodes, but this does not mean that infidelity is particularly more common with a bipolar partner involved in a relationship (Hales, 103). Substance abuse is a problem with some individuals, but it is not a problem that cannot be overcome.

Individuals may self-medicate due to a lack of diagnosis, a lack of medications, or ineffective medications. Due to these behaviors, the  National Institute of Mental Healthreports that 61% of people with bipolar disorder develop a substance abuse or dependence disorder (Hales, 105). Individuals with bipolar disorder are just as capable of being goodparents as any other group of individuals. With proper treatment and medication, the prognosis for bipolar disorder is good, but mood swings may continue to occur (Hales, 112).

Some people may be under the impression that bipolar disorder is “easier” than some other mental illnesses because manic mania is a time of great happiness. It is true thatmanic mania does hold a great deal of euphoria for many individuals with bipolar disorder, but this does not apply to many, possibly most, suffering from this disease.Manic mania episodes can be absolutely terrifying periods of time because some unfortunate sufferers will actually lose touch with reality (Hales, 97).

Others may experience feelings of hostility and paranoia, rather than the elation for whichmanic mania is known (Hales, 101). Some individuals with bipolar disorder experience episodes called mixed states, which have characteristics of manic mania and depressive episodes, and these episodes can be far more draining and terrible than either mania ordepression (Hales, 97).

Bipolar disorder has a great deal of undeserved stigma attached to the diagnosis. Hopefully, some of the more harmful misconceptions have been corrected. Living with this disease is difficult, but sometimes living with the stigma is far worse than any diagnosis.

References:
DBSA: Depression and Bipolar Support Alliance. “Bipolar Disorder Statistics.” 4 May 2006.http://www.dbsalliance.org/site/PageServer?pagename=about_statistics_bipolar

Hales, Dianne and Robert E. Hales, M.D. Caring for the Mind: The Comprehensive Guide toMental Health. New York: Bantam Books, 1995.

Myers, David G. Exploring Psychology. Holland, Michigan: Worth Publishers, 2008.

What is Depakote for? What is this medication? Depakote is a prescription medicine that is used for treating epilepsy and manic mania episodes associated with bipolar disorder. It is also approved to help prevent migraine headaches. Some possible side effects of Depakote include nausea or vomiting, drowsiness, shakiness, and headaches. Studies have shown that woman taking Depakote in the first 12 weeks of pregnancy have a 1 in 20 chance of having a child with birth defects.

Still shocked because Bill asked me how many eggs there are in a Bolognese…

PESCHIERA