DYSPHORIC MANIA AND MIXED STATES –
It is possible to have the symptoms of major depression and mania at the same time. This is called a mixed, or dysphoric state. It is estimated that 31% of patients presenting with mania have a mixed state. It is characterized by distinct periods of abnormally and persistently elevated, expansive, and/or irritable mood with depression (neither is due to just drug abuse.)
While the absolute changes in the brain chemistry are not fully known, mixed mania may be associated with brain transmitters that are too high (dopamine and norepinephrine), and/or too low, (serotonin). Mixed states sometimes occur during transitions from one phase of mood to the other.
In mixed mood states it is essential to treat the mania before treating the depression. Starting treatment with an antidepressant is like throwing kerosene on a fire because it can trigger a manic state.

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RAPID CYCLING –
Persons with rapid cycling have at least 4 episodes per year of mania/hypomania, and/or major depression. It is estimated that 13-20% of bipolar patients are rapid cyclers. It is more common in women, probably because women have more hypothyroidism.
Rapid cycling is frequently caused by low thyroid. Some experts recommend keeping thyroid levels within the top 25% of normal range of free T4. This can be measured by a standard blood test. Note: Many doctors only test the TSH for thyroid disorders. Testing only TSH is not adequate for secondary thyroid disorders.
Rapid cycling is difficult to treat and may respond better to a mood stabilizer than Lithium. Lamictal has the best controlled studies for treatment of rapid cycling.

Highly recurrent major depression, especially if onset is early in life, tends to do better on mood stabilizers than antidepressants. These people tend to have more frequent and severe episodes, have a positive family history for Bipolar, and not do well on antidepressants. They are probably genetically related to someone with Bipolar. Children who become depressed are also more likely to be Bipolar.

One study found patients to be on the following to control symptoms:
One medication – 19%
2 medications – 28%
3 medications – 28%
4 or more – 25%

Alcohol Abuse/Dependence Lifetime:
• 13% in general population
• 21% in depressed population
• 46% in bipolar population

Drug Abuse Lifetime:
• 6% in general population
• 18% in depressed population
• 41% in bipolar population

Bipolar I: Severe mania, with depression
Distinct periods of elevated, expansive or irritable mood
Inflated self esteem/grandiosity
Decreased need for sleep
More talkative than usual
Racing thoughts/ideas
Distractibility by the irrelevant
Increased goal directed activity, psychomotor agitation
Excessive/impulsive behavior in pleasurable activities
Bipolar II: Major depression, hypomania (milder mania)
Mood elevated or irritable
More energy than usual
Talkative
Decreased sleep
Inflated self-esteem
Hypersexuality
Excessive involvement in pleasurable acitivities
Major depression:
No interest or pleasure (Most common symptom)
Depressed mood
Weight loss/gain
Insomnia/hypersomnia
Psychomotor retardation
Fatigue or loss of energy
Feelings of worthlessness/guilt
Decreased concentration
Recurrent thoughts of death
Cyclothymia:
For at least 2 years, periods of
hypomania and depression symptoms that do not meet major depression criteria
Bipolar NOS:
Official diagnosis for significant
bipolar symptoms, but not
enough to qualify for BPI, II, CT

Mood stabilizing medications treat depression and mania:
Anticonvulsants
Depakote*
Lamictal**
Tegretol
Trileptal
Gabitril
Topamax
Keppra

Atypical Antipsychotics
Zyprexa* **
Risperdal* ****
Seroquel*
Geodon*
Clozaril
Abilify*
Other Options
Lithium* **
Thyroid
Symbyax***
FDA approval for:
*Mania
**Maintenance (Stabilization)
***Bipolar depression
****Mixed episodes

The spectrum of bipolar disorders is characterized by mood instability and impulsivity. About 1% (2 million) of the population is bipolar I. Bipolar has multiple forms. It ranges in severity from mildly disruptive to life destroying. As in other medical conditions such as diabetes and hypertension, the vulnerability to bipolar disorder is inherited. Once you have it, you have it for life. Fortunately, like hypertension, it can be medically controlled.
Mood swings usually start in the 20’s, but can start in childhood or during the teens. If depression is present in these early years, there is an increased risk of bipolar. Sometimes, the first major mood swing doesn’t occur until the 30’s or occasionally, later.
If mood is compared to room temperature, (too cold equals depression and too hot equals mania), bipolar disorder is like having a defective thermostat. The thermostat gets
stuck at one extreme (mania or depression) and the temperature (mood) goes out of control.
Mood swings can occur abruptly. They may be induced by seasonal changes, hormonal changes, certain medications (such as steroids, decongestants, antidepressants, stimulants, recreational drugs), or too much or too little sleep.
One of the biggest problems facing those with bipolar disorder is what is described as the “kindling effect.” This means that every episode of abnormal mood (low or high), increases the sensitivity of the brain’s mood regulators. This makes it easier to have mood swings in the future.
Many of my patients are unquestionably bipolar and many show no signs of the disorder. But, patients that fall in a “gray” area with some symptoms present, make pinpointing the diagnosis very difficult. These individuals often appear to be primarily oppositional, substance abusers, or have personality disorders. This group is the greatest challenge to psychiatry and requires the closest scrutiny. Because of its complexity, bipolar disorder usually needs to be treated by a Psychiatrist.

• 40-50% of people with SAD also have depression
• SAD is the most common anxiety disorder
• 13% of the population will have SAD in their lifetime
• 50% of those with SAD do not finish high school
• 22.3% of those with SAD are on welfare
• 50% of those with SAD are single, divorced, or separated
• Onset of SAD is usually age 14-16
• 50% of those with SAD also have another psychiatric disorder, especially
alcohol abuse
• 35% of SAD occurs before age 10
• Behavior treatment with medication is the most effective treatment for SAD
• 25% of patients with SAD decline when offered behavioral treatment
• Only 5% with SAD get treatment

Cognitive behavioral therapy has proven to be very effective in treating social anxiety disorder.
Behavioral therapy focuses on specific steps to lessen anxiety and reduce the likelihood of recurrence. The patient is asked to face the thing they fear (exposure), and not avoid to cope with the situation.

Patients must be willing to endure temporary increases in anxiety and other symptoms in order to attain long term reduction of symptoms. The therapy is time consuming. Hard work is required by the patient to insure symptomatic relief.
The cognitive part of therapy involves replacing negative thoughts (self-talk) with positive. e.g., Instead of, “they will think I’m stupid”, replace it with “I know I’m smart.” Optimists see things better than they are. Pessimists see things worse than they are. Realists see things as they are.
Optimists have the highest quality of life and live longer.
Exposure therapy:
Real life (in vivo)-involves having the patient place themselves in actual anxiety provoking situations until they experience at least a 50% reduction of anxiety.
Every treatment outcome study utilizing exposure has produced significant reductions in social anxiety symptoms. The therapy requires repetitive patient exposure to all anxiety triggers for best results. This will include reduction of anticipatory anxiety and increased comfort levels in social situations.
Social Skills Training-some people benefit from learning techniques to become more assertive, make small talk more effectively, improve eye contact, etc.

• Stuttering
• Butterflies
• Sweating
• Palpitations
• Trembling/shaking