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 (BPNOS) 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 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. -----------------------------------------------------------------------------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: y 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. y 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?" y More recently, the anticonvulsant lamotrigine (Lamictal) received FDA approval for maintenance treatment of bipolar disorder. y 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. y 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. y 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. y 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. y 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 y 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. 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: y Restlessness y Dry mouth y Bloating or indigestion y Acne y Unusual discomfort to cold temperatures y Joint or muscle pain y Brittle nails or hair.31 Common side effects of other mood stabilizing medications include: y Drowsiness y Dizziness y Headache y Diarrhea y Constipation y Heartburn y 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: y Drowsiness y Dizziness when changing positions y Blurred vision y Rapid heartbeat y Sensitivity to the sun y Skin rashes y Menstrual problems for women. 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: y Headache, which usually goes away within a few days. y Nausea (feeling sick to your stomach), which usually goes away within a few days. y 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. y Agitation (feeling jittery). y Sexual problems, which can affect both men and women. These include reduced sex drive and problems having and enjoying sex. ------------------------------------------------------------------------------Psychotherapy
y

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 fullblown episode occurs. Usually done in a group, psychoeducation may also be helpful for family members and caregivers. ------------------------------------------------------------------------------Re-experiencing the trauma Rape victims may experience uncontrollable intrusive thoughts about the rape, essentially unable to stop remembering the incident. Many rape victims have realistic nightmares and dreams about the actual rape. In addition, victims may relive the event through flashbacks, during which victims experience the traumatic event as if it was happening now. Additionally, victims are distressed by any

event that symbolizes the trauma of rape. Victims avoid talking about the event and will avoid any stimuli or situations which remind them of the rape. Social withdrawal The second major RR-PTSD symptom for rape survivors is social withdrawal. It has been described as psychic numbing, denial and a feeling of being emotionally dead. They do not experience feelings of any kind. One way it shows up in the lives of survivors is a diminished interest in living. It is not that they are suicidal, but they have no interest in their children, in their jobs, and what feelings they do experience have a very narrow range. Victims experiencing RR-PTSD may not feel joy, pain, or really much of anything; many experience a kind of amnesia. In addition, victims with RR-PTSD may not remember the details of what happened to them. Avoidance behaviors and actions The third set of symptoms of RR-PTSD are avoidance behaviors and actions. Victims may experience a general tendency to avoid any thoughts, feelings, or cues which could bring up the catastrophic and most traumatizing elements of the rape. This may be characterized by refusing to drive near the spot where the rape occurred. Increased physiological arousal characteristics There may be an exaggerated startle response -- hyperalertness and hyper-vigilance -- which requires that the victim pay attention to every sound and sight in their environment. Many experience sleep disorders which result in poor sleep patterns for chronic RR-PTSD victims, such as trouble falling or staying asleep. In addition, memory may be impaired, and many victims have difficulties concentrating, which affects tasks that must be completed in their daily lives. Victims may exhibit a kind of irritability, hostility, rage and anger that produce further isolation. BEHAVIORAL TECHNIQUES Flooding

In flooding, the patient is trained in progressive relaxation and then a rapid exposure to a feared object is introduced. (Zimbardo, 1985). Flooding is not the best way to deal with patient suffering from rape trauma syndrome, because it is too narrow and in its original form, it would be too aversive to the client. Also, it does not offer what the victim needs most: support. However, rapid exposure in imagery might be used to reduce anxiety that is aroused by nightmares and flashbacks. (Matlin, 1989). Although this technique may work with some patients, it should be used with caution, because there may simply be patients who could not take it. Systematic desensitization Systematic desensitization is often employed to treat patients with fear and anxiety. Frank in 1988 conducted study comparing SD with cognitive-behavior therapy in treatment of rape victims. Both techniques seemed to be very successful. The victim is first taught progressive muscle relaxation, using Jacobson's method. In case of rape victims, the instruction should not be "allow your thought to ramble", since they would probably ramble to the scenes of the assault. Rather, they may be instructed to focus on a specific pleasant, happy scene., Then, the target complaint is broken into specific scenes, which are arranged in hierarchy. The patient engages in relaxation and imagines as vividly as possible the scenes, proceeding from the least threatening to the most threatening one. Eye movement desensitization Eye movement desensitization is a procedure in which the patient elicits sequences of large-magnitude, rhythmic saccadic eye movements while holding in mind the most salient aspect of traumatic memory. This results in a lasting reduction of anxiety, the cognitive assessment of the memory is changed and the frequency of flashbacks, intrusive thoughts and sleep disturbances decreases. This procedure seems to be very effective in only one session, as Shapiro (1989) claims. It does not require a hierarchical approach as systematic desensitization does, and it does

not produce in the patient as high anxiety levels as flooding does. Cognitive approach to rape trauma treatment COGNITIVO-BEHAVIORAL THERAPY

Cognitive-behavior therapy is a combination of techniques and principles of both cognitive and behavioral therapies. Since the victim of rape often needs to acquire new coping skills to deal with her anxiety and her situation, cognitive-behavior therapy may be helpful to the victim. Stress inoculation in Resick's study (1988), for example, produced lasting effects. In stress inoculation, as in other cognitivebehavior therapies, the patient goes through three phases. the first sequence consists of uncovering the patients existing coping skills by both the therapist and the patient. This phase may also include an educative part, in which the victims learn about the development of fear and anxiety following the rape. In the second sequence, new coping skills are acquired. The patient learns progressive relaxation, new cognitive techniques, such as thought-stopping, guided selfdialogs and covert rehearsal. The third sequence involves application and practice. The patient practices new skills in fear-producing but not dangerous situations. In this way, she learns to control fear and she attempts to interrupt the avoidance behavior. (Zimbardo, 1985; Resick, 1988). The stress inoculation program may be used in individual therapy or in a group therapy for rape victims. The latter has several advantages, which will be discussed in the cognitive therapy section. COGNITIVE THERAPY Cognitive therapies attempt to change irrational or faulty beliefs, expectations, appraisals and attributions.

The rape victim can benefit greatly from cognitive therapy, especially in dealing with self-blame, anxiety attacks and some aspects of sleep disturbances. (Rosenhan et al., 1989). A woman who feels guilty and blames herself probably has some problems with attributions and appraisals. Anxiety attacks signify some distortion of expectations and appraisals. With these problems, the therapist may deal at the cognitive level. He may explain how and why fear and anxiety develop following the rape, why the victim tries to attribute the blame to herself, and why her automatic thoughts are inappropriate. The therapist, together with the patient, tries to find other solutions, other ways to cope with her anxiety attacks. The patient may learn new coping skills to deal with her problems. Coping imagery may be used to reduce severity of anxiety attacks and sleep disturbances. It is very useful to combine imagery with deep muscle relaxation. Calming imagery may be substituted for scenes in which the patient relives the trauma. Also, assertiveness imagery may be used with a client who feels vulnerable in many life situations. (Rosenhan et al., 1989) The victim would imagine as vividly as she can herself as an assertive person in a situation that she fears. This helps her to get used to such thoughts and the image becomes less threatening. Alternative treatment of rape trauma Relaxation In addition to any therapy, the patient should learn deep muscle relaxation or progressive relaxation. These techniques may help the victim overcome anxiety attacks, help them fall asleep, decrease

severity of crying outbursts and headaches.(Rosenhan et al, 1989). Rational-emotive therapy Rational-emotive therapy may be used to overcome the feelings that the victim will never get over this trauma, and the feeling that anybody around may attack her. Principles of RET may also be applied in assertion training. (Rosenhan et al., 1989) Group therapy The effects of group therapy are very beneficial for rape victims. Many rape crisis centers are based on crisis theory and supportive psychotherapy groups. They rely on dissemination of information, active listening and emotional support (Resick et al., 1988). Group sharing of experience may affect patients' numbness, isolation and fear of isolation. (Rosenhan et al., 1989) Cryer and Beutler (1980) found that most members of the group improved significantly in measures of fear and anxiety. Supportive psychotherapy may include not only exchange of feelings, perceptions and support, but also an educational phase. The victims may be given the information concerning fear and anxiety. Members of the support group select topics they want to discuss. (Resick et al., 1988) Often they would include fear, anxiety, reactions of family and friends, their own reaction to rape and to stimuli that remind them of the trauma. Hypnosis Hypnosis is another option in finding ways to help victims of sexual assault. Under hypnosis, victims may find relief of fears, feeling of helplessness, anxiety and social isolation. (Ebert, 1988). Hutchinson (1986)

suggests that feminist self-hypnosis group helped victims to remove their false sense of guilt, and enabled them to understand the social context in which the assault occurred. Hypnosis may also be used in fusion with family therapy. Somer (1990), for example, tried brief simultaneous hypnotherapy with a rape victim and her husband. Hypnosis allowed the victim to share her experience with her husband, who was otherwise too upset and enraged whenever the victim wanted to share her rape-related feelings. The traumatic scene was reshaped under hypnosis and the result was rescuing behavior on the part of the husband and expression of anger toward the rapist. This technique helped the husband to deal in better ways with his anger and the victim to decrease her feeling of abandonment. Family/couple therapy Family or couple therapy by itself is also an appropriate way to deal with rape victims. Since the reaction of significant others is often blaming the victim, sometimes even rejection, the members of the victim's family should participate in the therapy. Frequent responses by partners and parents are feelings of helplessness, anger, frustration and homicidal fantasies toward the rapist. (Emm, McKenry, 1988). For these reasons, it may be beneficial to participate in therapy in order to be able to reorganize and rectitude the family's integrity. In family/couple therapy, the family members may discuss cognitive and emotional components of their responses to the trauma. Feinauer and Hippolite (1987) used short metaphoric stories and symbolic rituals, in which each

individual member and the family as whole could reexperience and decide how they would respond to the trauma. Existential therapy Later in therapy, principles of existential psychology may be applied to help the victim to overcome her helplessness, feelings of loss of control, and to find meaning in life even with such traumatic experience. Patient's numbness may be reduced through taking responsibility. Humanistic approach Across all possible therapies, a humanistic approach should be taken. The patient needs understanding, acceptance and support from the therapist. The clientcentred therapy would help the victim to express herself, to consider different responses and choose the most appropriate one. .