Psychopharmacology Update August 2004

August, 2004           PSYCHOPHARMACOLOGY UPDATE    Volume 4 Number 4

Diagnosis and Treatment of Bipolar Disorder

In 1976 Dunner and colleagues proposed two categories of bipolar disorder (manic-depressive illness). These categories were named bipolar I and bipolar II.

Diagnosis of Bipolar I Disorder:

Bipolar I disorder is characterized by depressive episodes alternating with manic episodes.  A manic episode is associated with grandiose psychotic features and danger to the self and, perhaps, to others. The severity of the symptoms usually demands that the patient be hospitalized for treatment.

Diagnosis of Bipolar II Disorder

Bipolar II disorder is characterized by depressive episodes alternating with hypomanic episodes. There exists some confusion regarding the term "hypomania" (below mania). A hypomanic episode is unassociated with psychotic features. Instead, a hypomanic episode is characterized by a 4-day (or more) period of persistently elevated, expansive, or irritable mood. The symptoms of hypomania can be characterized by the acronym DIGFAST:

• D = Distractibility
• I   = Insomnia
• G = Grandiosity
• F = Flight of ideas
• A = Activity in unexplained burst of energy
• S = Speech that is fast, pressured, hyperverbal or interrupting
• T = Thoughtlessness that leads of risk taking behavior such as inappropriate sexual liaisons, spending more money than suitable or driving fast/recklessly.

Distinguishing between Recurrent Unipolar Depression and Bipolar II Depression

Because bipolar II patients often demonstrate several episodes of depression before an initial hypomanic episode, patients with bipolar II depression may be falsely diagnosed as having recurrent unipolar depression. When compared to unipolar depressed patients, bipolar II depressed patients are more likely to have the following characteristics:

1.     Family history of mania,  bipolar illness or substance abuse

2.     Earlier age of onset of depression (adolescence or early 20s)

3.     A higher number of depressive episodes 

4.     Mood swings

5.     Non-response or agitation on antidepressants

Rapid Cycling

Rapid cycling, defined as the presence of 4 or more mood swings in a year, is much more prevalent in bipolar II patients than bipolar I patients. Brief, frequent episodes of depression are highly suggestive of rapid cycling bipolar II disorder. Antidepressants can exacerbate rapid cycling. Antidepressants can also precipitate a manic crisis in depressed patients that have undiagnosed bipolar illness.

Treatment

Depakote possesses antimanic effects, but more moderate antidepressant effects.

Lamictal is effective in the treatment of depression in bipolar disorder. 

Lamictal + Depakote may be required in combination to stabilize rapid cycling.

Lithium functions poorly in rapid cycling patients; and because the therapeutic dose of lithium is close to the toxic dose, lithium treatment must be used with caution, if at all.  

Hitch Hiking to Seattle

I didn’t want to leave the orphanage, but if I had to go I thought I would go in style. I packed my suitcase. I also packed my trunk and I had a duffle bag full of clothes. Father Martin a tall, thin man with an Adam’s apple bigger than his neck drove me to the Highway 59 intersection with Timber, the busiest street in Ruskin. I stuck out my thumb and turned the suitcase with the sign

SEATTLE OR BUST

            I was nervous and somewhat embarrassed as cars whisked by. After about 10 minutes, I was about to think I would never get picked up. I laugh when I write this because later I would wait 10 hours and remain determined to stand out on the highway until I got a ride.

            A car pulled up. I remember President John F. Kennedy’s words: “We stand today on the edge of a new frontier—the frontier of the 1960s, a frontier of unknown opportunities and perils, a frontier of unfulfilled hopes and threats.” During the election of 1960, my friend Joe Clarke whose father was Chief Operating Officer of the Ample Paper Mill was for Nixon. I later learned the difference between Republicans and Democrats. Republicans favored business. They were for low taxes and small government. The Democrats were for the little man; high taxes on the rich, and making hard workers pay the way for ner-do-wells. I supported Kennedy for President because he was handsome and vigorous appearing. Joe Clarke talked about ideology. I didn’t know what to say except I liked Kennedy. I didn’t want to say that I liked him because he looked more Presidential and didn’t sweat on television so I just said, “I like Kennedy the best.”

An Important Birthday

On April 13, 1970 Wende Lynn Walker was born in Galveston, Texas.  Her birth caused shock waves reaching toward the moon.

Apollo 13, with astronauts James Lovell Jr., John Swigert Jr. and Fred Haise Jr. aboard, was on its way to the moon to perform the third lunar landing in a planned series of seven when, about 56 hours into the mission, an oxygen tank blew up, knocking out the command module’s electricity, light and water supply. “Hey, Houston, we’ve had a problem here,” Lovell told mission control, adding that some kind of gas was escaping outside the spacecraft. It was oxygen, and the mission quickly shifted from landing on the moon to getting the astronauts back alive. At the time, Apollo 13 was roughly 200,000 miles from Earth.

The crew moved into the lunar module to escape the decreasing air pressure in the service module, then prepared to make the necessary swing around the moon in order to boomerang back to Earth. Debris from the explosion had knocked out the navigation system, so the crew used the sun to guide the crippled craft home. It took nearly four agonizing days after the explosion before they splashed down safely in the Pacific Ocean.

Bestselling Children’s Authors in the World

Ash notes that "based on total sales of their entire output", the following authors "have produced titles that have been bestsellers - especially those in numerous translations - over a long period."

• René Goscinny and Albert Uderzo
  "René Goscinny (1926-77) and Albert Uderzo (b. 1927) created the comic strip character Astérix the Gaul in 1959. They produced 30 books with total sales of some 250,000,000 copies."
• Hergé
  "Georges Rémi (1907-83), the Belgian author-illustrator who wrote under the pen name Hergé, created the comic strip character Tintin in 1929. Tintin appeared in book form from 1948 onward. He achieved worldwide popularity, and the books have been translated into about 45 languages and dialects. Total sales are believed to be at least 160,000,000."
• Enid Blyton
  "With sales of her Noddy books exceeding 60,000,000 copies, and with more than 700 children’s books to her name (UNESCO calculated that there were 974 translations of her works in the 1960s alone), total sales of her works are believed to be over 100,000,000, making her the best-selling English-language author of the 20th century."
• Dr. Seuss
  "His books in the U.S. Top 10 alone total about 30,000,000 copies: to this must be added those titles that have sold fewer than 5,000,000 in the U.S. and all foreign editions of his books, suggesting total sales of more than 100,000,000."
• Beatrix Potter
  "The Tale of Peter Rabbit (1902) was one of a series of books, the cumulative total sales of which probably exceed 50,000,000."
• Lewis Carroll
  "Total world sales of all editions of Carroll’s two classic children’s books, Alice’s Adventures in Wonderland and Alice Through the Looking Glass, are incalculable. However, just these two books probably place Lewis Carroll amon

Top Ten Best Selling Fiction Books of All Time

Bach, Richard. Jonathan Livingstone Seagull

Blatty, William. The Exorcist

Benchley, Peter. Jaws

Caldwell, Erskine. God’s Little Acre

Heller, Joseph. Catch-22

Lee, Harper. To Kill a Mockingbird

McCullough, Colleen. The Thorn Birds

Metalious, Grace. Peyton Place

Mitchell, Margaret. Gone With the Wind

Orwell, George. 1984, Animal Farm

Puzo, Mario. The Godfather

Robbins, Harold. The Carepetbaggers

Salinger, J.D. Catcher in the Rye

Cultivate Good Habits

Thoughts-actions-habits-character

Identifying the 20% who make trouble

Excuse making, blaming, refusing responsibility

Delaying gratification

Using pain and pleasure motivators  

Taking initiative by asking and acting

The confidence of a Christian with 4 aces

Follow the Golden Rule—Can I trust you?

Show you care—Do you care about me?

Do the best you can—are you committed to excellence?

Accept your limitations

The Top 10 Bestselling Books of All Time:

1. The Bible
   "No one really knows how many copies of the Bible have been printed, sold, or distributed. The Bible Society’s attempt to calculate the number printed between 1816 and 1975 produced the figure of 2,458,000,000. A more recent survey, for the years up to 1992, put it closer to 6,000,000,000 in more than 2,000 languages and dialects. Whatever the precise figure, the Bible is by far the bestselling book of all time."
2. Quotations from Chairman Mao Tse-tung (Little Red Book)
   "Chairman Mao’s Little Red Book could scarcely fail to become a bestseller: between the years 1966 and 1971 it was compulsory for every Chinese adult to own a copy."
3. American Spelling Book by Noah Webster
   "First published in 1783, this reference book by the American man of letters Noah Webster (1758-1843) remained a bestseller in the U.S. throughout the 19th century."
4. The Guinness Book of Records
   "First published in 1955, The Guinness Book of Records stands out as the greatest contemporary publishing achievement. There have now been 37 editions in the UK alone (it was not published annually until 1964), as well as numerous foreign-language editions."
5. The McGuffey Readers by William Holmes McGuffey
   "Published in numerous editions from 1853, some authorities have put the total sales of these educational textbooks, originally compiled by American anthologist William Holmes McGuffey (1800-73), as high as 122,000,000. It has also been claimed that 60,000,000 copies of the 1879 edition were printed, but - since this is some 10,000,000 more than the entire population of the U.S. at that time - the publishers must have been extremely optimistic about its success."
6. A Message to Garcia by Elbert Hubbard
   "Now forgotten, Hubbard’s polemic on the subject of labor relations was published in 1899 and within a few years had achieved these phenomenal sales, largely because many American employers purchased bulk supplies to distribute to their employees."
7. The Common Sense Book of Baby and Child Care by Dr. Benjamin Spock
   "Dr. Spock’s 1946 manual became the bible of infant care for subsequent generations of parents. Most of the sales have been of the paperback edition of the book."
8. World Almanac
   "Having been published annually since 1868 (with a break from 1876 to 1886), this wide-ranging reference book has remained a constant bestseller ever since."
9. The Valley of the Dolls by Jacqueline Susann
   "This tale of sex, violence, and drugs by Jacqueline Susann (1921-74), first published in 1966, is perhaps surprisingly the world’s bestselling novel. Margaret Mitchell’s Gone With the Wind, which has achieved sales approaching 28,000,000, is its closest rival."
10. In His Steps: "What Would Jesus Do?" by Rev. Charles Monroe Sheldon
    "Although virtually unknown today, American clergyman Charles Sheldon (1857-1946) achieved fame and fortune with this 1896 instructive religious treatise on moral dilemnas."

Make the Most of Your Time

First things first

Learn to say “no” to the unproductive 

Success depends on what you neglect

JESUS AT THE MASTERS

 

             The caddies didn’t believe it was Jesus Christ, not at first.

            True, John Daly said he had asked him to come down for some golf. John said he had offered up some prayers asking for help with his drinking and gambling problems. Next thing he knows, Jesus had qualified to play in the Masters.

            “I haven’t met him yet,” Daly told Sports Illustrated. “I’ve been in court dealing with my fourth wife’s demand for increased alimony, but I’ve read a little about him and I’m eager to talk to him in person.”

            By then a rusty 1963 Corvair wheezed into view, the engine sputtering before dying in the groundskeepers parking area. When a man giving off a glow of radiant light stepped out of the car, we knew he was a special chap who put no value in transportation safety.           

            Jesus was mobbed, first by tens, then hundreds, all asking for autographs that they could sell on E-Bay. He wore blue jeans, a Texas Aggie T-shirt, and a WWJD? Wristband. “What Would Jesus Do?” shouted a woman in the crowd.

            “Nah,” Christ said with a laugh. “What Would Jack Do? My Dad and I are huge Nicklaus fans. Not only could he play golf, but also he designs great courses. We’re kind of partial to creative talent.”

            Christ continued, “Money is ruining sports. Man cannot serve two masters,”

            The crowd was a little puzzled by the masters thing. “Everyone knows there is only one Masters Golf Tournament,” Clete Purcell, a tournament official, said.

            “Let’s tee-em up,” Christ said, walking over and putting his arm around Daly who wept uncontrollably because of the forgiving and unconditional love he felt from Jesus.

            Christ gave Daly the honors. Shaken-up by his encounter with Jesus, Daly hit a dogleg hook into the woods. Jesus, nodding empathetically toward Daly, quickly approached his ball. With no practice swing, he struck the ball. Ka-Boom! The ball took off like Elijah’s chariot and zoomed upward and onward, quickly rising higher and higher disappearing behind an immense cloud that flashed with lightening.

            “Out of practice, Christ said. “ I need to remember to reduce the power in my swing when I’m here on earth.”

             He shrugged, smiled toward the crowd, and placed a second ball on the tee. His next shot zoomed 350 yards, landing in the middle of the fairway.

            The huge crowd following him must have numbered at least 5,000. They were surprised to discover that Christ kept up a running banter as he played. “Keeps me loose,” Christ explained. 

            “I used to play golf just about everyday—except Sundays, of course—with Adam. Talk about a beautiful course! No one could top the one we had in Eden. The only problem was the snake kept swallowing the ball. After Eve came along, Adam had so many ‘honey-do’ projects he didn’t have time for golf.”                       

            Teeing-up for the fifth hole, he continued, “ I didn’t play again until Moses came to Midian. That was a rough course.  Bushes everywhere. Moses always took a mighty swing trying to get the ball from the tee-box to the green so he wouldn’t have to probe around in the bushes. One day he took a prodigious swing and the ball sailed right over the green. That’s when Moses had his ‘burning bush’ experience and had to take the next camel to Egypt.”           

            On the sixth hole, Christ hit his first shot into some tall grass.  The ball rested under a tree limb. Without hesitation, Christ took a vicious swing. The ball ricocheted off the tree limb, hit a fairway marker, careened off a rock, and bounded into the middle of the fairway. Christ shrugged his shoulders, looked toward the crowd, then up to heaven. “Praise God,” he sang out.

            The seventh hole brought near disaster. Hitting a two-iron, Christ sliced his ball into a lake. He absentmindedly walked on top of the lake and fished the ball out of the water, all the time talking, “I dearly wanted to play a round of golf with David.  Dad thought he would play well—liked his heart. But with Bathsheba, Nathan, and Absalom crowding his schedule, he never could find the time for golf.”

            With a fluid swing, Christ hit the ball off the top of the water. The ball left his club crisply never rising higher than five feet until it glanced off the water and skipped three times onto dry land.

            Without a pause Jesus continued, “I tried a game or two with the prophets—what bores. They would ruin the fun by telling you where the ball was going before you hit it.”

            Christ continued, “After that, I got a little busy and it wasn’t until the dark ages that I tried to play again. I wanted to play with Richard-the-Lion-Hearted—what a great name for a golfer—that’s where Earl Woods came up with Tiger’s name—but Richard couldn’t play a lick what with all that armor he wore.”

            Taking the seven-iron out of the bag, he hit the ball three hundred feet where it landed on the green and rolled into the cup for a birdie. By then the crowds kept getting larger and larger blocking play. As the multitude swelled, the Masters Committee Chairman asked Christ to leave. “No problem,” Christ said, “I’m used to rapid departures. I just wish I could have played Amen Corner.”

            When asked if he wanted a ride, He replied with a twinkle in his eye, “Thanks, but no need.”  He found Daly in the crowd rounding up people for an Alcoholics Anonymous chapter. Christ hugged him. With that, there was a blinding flash and they were gone.

            The line on Christ: five pars, one bogie, one birdie, and one saved soul.

 

PREVENTING OVERWORK

            Vacation, a time of rest and freedom from work, can be experienced each and everyday. Duke University psychiatrist, John Rhoads, MD, studied successful, effective, and healthy executives who worked at least sixty hours weekly and compared these individuals with executives who developed burnout from working over sixty hours weekly. The following table summarizes those findings.           

 

THOSE WHO EXPERENCE WORK SUCCESS	THOSE WHO EXPERIENCE work burnout
Postpone thinking about problems	Ruminate about work problems
Take time off when productivity begins to diminish	Take their computer and cell phone on their vacations to keep-up with work activities
Use exercise, hobbies, and sports to deal with work stress	Use drugs or alcohol to deal with work stress
Enjoy scheduled vacations	Tend to postpone vacations
Cultivate a stable family life	Spend very little time with their family
Maintain friendships	Have a difficult time cultivating friendships
Exercise regularly	Watch television regularly
Have varied interest outside of work	Feel uncomfortable away from work
Can laugh at themselves	Take life and themselves too seriously

 

DO YOU KNOW HOW TO HAVE FUN?

	LITTLE OF THE TIME 1-pt/each √	SOME OF THE TIME 2-pt/each √	A LOT OF THE TIME 3-pt/each √	MOST OF THE TIME 4-pt/each √
I enjoy hobbies without feeling guilty about not working.
I am optimistic and cheerful.
I surround my self with happy, positive, and fun-loving people.
I correct my mistakes and blunders, but don’t continue to worry about them
I take a long weekend away from work when I begin to feel burned out and tired.
Leisure activity helps me feel rested.
Sports and games bring me more laughs than frowns because I play to have fun not necessarily to win.
I enjoy creative play—dancing, painting, party games, playing a musical instrument, etc.
I laugh at least once a day.
I take vacations without worrying about the job.
Multiply √ by the value given in each column

 

Add the total for each column to get the GRAND TOTAL = ________

Scoring

10-14 points = President of Eeyore International

15-24 points = Party pooper

25-34 points = Fun to be around

34-40 points = Life of the party

DO YOU KNOW HOW TO HAVE FUN?

	LITTLE OF THE TIME 1-pt/each √	SOME OF THE TIME 2-pt/each √	A LOT OF THE TIME 3-pt/each √	MOST OF THE TIME 4-pt/each √
I enjoy hobbies without feeling guilty about not working.
I am optimistic and cheerful.
I surround my self with happy, positive, and fun-loving people.
I correct my mistakes and blunders, but don’t continue to worry about them
I take a long weekend away from work when I begin to feel burned out and tired.
Leisure activity helps me feel rested.
Sports and games bring me more laughs than frowns because I play to have fun not necessarily to win.
I enjoy creative play—dancing, painting, party games, playing a musical instrument, etc.
I laugh at least once a day.
I take vacations without worrying about the job.
Multiply √ by the value given in each column

 

Add the total for each column to get the GRAND TOTAL = ________

Scoring

10-14 points = President of Eeyore International

15-24 points = Party pooper

25-34 points = Fun to be around

34-40 points = Life of the party

Problems of an Increased Workload

            A self-induced increased workload causes deterioration in marriage and family life, undermining the main source of non-work related support. Likewise, avoiding vacation time leads to a decline in efficiency and initiative resulting in an increasing spiral of mistakes and complaints from associates and customers. Paradoxically, rather resulting in approve from others over­work eventually results in criticizes from family, colleagues, and employers.

             Usually those who fail to take regular vacations become cynical, negative, rigid, and inflexible. Accompanying poor work performance is the inability to relax and enjoy recreational pursuits.

The Vacationless Life

            A vacation-less life may be caused, in part, by cultural factors. Emotional conflicts that contribute to the overwork syndrome may be associated with the following:

Ø    Compensation for feelings of inferiority or insecurity

Ø    Identification with a demanding parental expectations

Ø    Recompense for physical limitations such as poor health or aging.

Ø    A solution for prob­lems of aggression and guilt

Ø    A need for approval

Ø    Excessive competitive drive

Ø    An attempt to enhance self-esteem

Ø    The desire to improve social status

Ø    The need for excessive financial gain

Ø    A fascination with the accumulation of material objects

Ø    The inability to refuse the requests of others

Ø    Self-imposed demands for perfection           

Vacation Statistics

            Research clearly demonstrates that an annual vacation significantly cuts risks of most diseases by 20-30 percent. The Multiple Risk Factor Intervention Trial of 12,000 American men revealed that during a 5-year study period those who took the most vacations had 20 percent less risk of dying from any cause than those who took the fewest vacations. A 1999 Dutch study found that overcommittment to work without an annual vacation increased physical and emotional illnesses.

            A study by the World Tourism Organization study showed that vacation time for Americans lags well behind other industrialized countries. The WTO listed the average annual vacation days by country as follows: Italy (42), France (37), Germany (35), Brazil (34), Britain (28), Canada (26), South Korea (25), Japan (25), the United States (13).                         

More than one third of Americans fail to use their full vacation times. Of those who do take full time away from their regular jobs much of their vacation time is spent on activities other than rest and relaxation:

Ø    19 percent spend their vacation time on family or personal responsibilities, including illness, funerals, caring for sick children or parents

Ø    Another 13 percent spend vacation time going to school, working at another job, or participating in reserve military service.

Ø    One in five vacationers are contacted about work matters during non-work times

Ø    23 percent of employed adults in the United States report checking work email or voicemail while vacationing           

CONNECTIONS

Most nights our house is empty. The kids are grown and gone; our grandchildren have moved with them. So, at night I read to Vicki. This tradition goes back to my grandfather who read to my mother, uncles, and aunts. My mother and uncles read to my brother and me. When my grandmother was dying of lymphoma, I read Huckleberry Finn to her. My grandfather, an uncle and his wife, and Vicki would listen. Later I read to our son and daughter just before bedtime. They, in turn, read to their children. The best reader is our daughter Wende. When she begins to read, we all stop what we are doing and gather around. Her intonations, accents, and pacing turn sounds into pictures.
For the past few nights, I’ve been reading my favorite of all read-out-loud-books, Peter Pan. Later, Vicki and I began talking about James M. Barrie and his connection with Daphne du Maurier.

George du Maurier


Sylvia Llewelyn Davies Gerald du Maurier

George Jack Peter Michael Nicholas Daphne Angela

Setting Goals To Achieve Your Dreams

A dream without a goal is similar to taking an automobile trip without a road map. You will surely arrive, but where? To make certain that you achieve your dreams set specific, measurable goals that are compatible with your dreams.

Break goals down into small steps, review them daily and revise them regularly. List activities that will help you attain your goals. Develop a detailed, scheduled plan of action, then take one small step at a time to move toward your goals.

Henry David Thoreau said, "If one marches confidently in the direction of his dreams and endeavors to lead the life he has imagined, he will meet with success unexpected in common hours."

You can strengthen the belief that your goals will be reached by acting as if they have already been met.

Speak, think, act, and live the traits and qualities you desire. You then become that person.

In establishing goals, keep these guidelines in mind:

1. Goals should be for you and not for someone else.
2. Goals should be realistic and believable.
3. Goals must be achievable, so attack big goals in short steps, one at a time. For example, to lose 50 pounds, establish a goal to lose one pound a week for 50 weeks.
4. Goals should allow you to enjoy life. Don't tackle so much work that you don't have enough time to relax. The purpose of goal setting is to reduce, not increase frustration.

Follow these steps in making your goals useful:

1. Write your goals on a single sheet of paper.
2. Read your goals every day.
3. Each day question your resolve: "Am I doing those things that will help me achieve my goals?"

And remember:

1. Unwritten goals are simply wishes.
2. Successful achievement depends on commitment to your goal. Review reinforces commitment.
3. Asking yourself the activity question-"Am I doing those things that I need to do to achieve my goals?" - will help focus your energy.
4. As you change, change your goals.

Learn Something Useful

Learn more about those things about which you have little or no interest and you will find yourself becoming fas¬cinated by the subject. The more you know about some¬thing, the more your enthusiasm soars. Make an effort to learn all you can about people-ask about their occupation, their families, their hobbies, their dreams and ideas. Keep asking and you're certain to find something to get enthusi¬astic about. The more you get to know people, the more attractive you will find them.