DSM: History of the Manual

The need for a classification of mental disorders has been clear throughout the history of medicine, but until recently there was little agreement on which disorders should be included and the optimal method for their organization. The many different classification systems that were developed over the past two millennia have differed in their relative emphasis on phenomenology, etiology, and course as defining features. Some systems included only a handful of diagnostic categories; others included thousands. Moreover, the various systems for categorizing mental disorders have differed with respect to whether their principle objective was for use in clinical, research, or statistical settings. Because the history of classification is too extensive to be summarized here, this summary focuses briefly only on those aspects that have led directly to the development of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and to the “Mental Disorders” sections in the various editions of the International Classification of Diseases (ICD).

Pre-World War II

In the United States, the initial stimulus for developing a classification of mental disorders was the need to collect statistical information. What might be considered the first official attempt to gather information about mental health in the United States was the recording of the frequency of “idiocy/insanity” in the 1840 census. By the 1880 census, seven categories of mental health were distinguished: mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy.

In 1917, the American Medico-Psychological Association, together with the National Commission on Mental Hygiene, formulated a plan that was adopted by the Bureau of the Census for gathering uniform statistics across mental hospitals. Although this system devoted more attention to clinical utility than did previous systems, it was still primarily a statistical classification. The American Psychiatric Association subsequently collaborated with the New York Academy of Medicine to develop a nationally acceptable psychiatric nomenclature that would be incorporated within the first edition of the American Medical Association’s Standard Classified Nomenclature of Disease. This nomenclature was designed primarily for diagnosing inpatients with severe psychiatric and neurological disorders.

In 1921, the American Medico-Psychological Association changed its name to the American Psychiatric Association.

Post-World War II

A much broader nomenclature was later developed by the U.S. Army (and modified by the Veterans Administration) in order to better incorporate the outpatient presentations of World War II servicemen and veterans (e.g., psychophysiological, personality, and acute disorders). Concurrently, the World Health Organization (WHO) published the sixth edition of International Classification of Diseases (ICD), which, for the first time, included a section for mental disorders. ICD-6 was heavily influenced by the Veterans Administration nomenclature and included 10 categories for psychoses and psychoneuroses and seven categories for disorders of character, behavior, and intelligence.

The American Psychiatric Association Committee on Nomenclature and Statistics developed a variant of the ICD-6 that was published in 1952 as the first edition of Diagnostic and Statistical Manual: Mental Disorders (DSM-I). DSM-I contained a glossary of descriptions of the diagnostic categories and was the first official manual of mental disorders to focus on clinical utility. The use of the term “reaction” throughout DSM-I reflected the influence of Adolf Meyer’s psychobiological view that mental disorders represented reactions of the personality to psychological, social, and biological factors.

In part because of the lack of widespread acceptance of the mental disorder taxonomy contained in ICD-6 and ICD-7, WHO sponsored a comprehensive review of diagnostic issues, which was conducted by the British psychiatrist Erwin Stengel. His report can be credited with having inspired many advances in diagnostic methodology–most especially the need for explicit definitions of disorders as a means of promoting reliable clinical diagnoses. However, the next round of diagnostic revisions, which led to DSM-II and ICD-8, did not follow Stengel’s recommendations to any great degree. DSM-II was similar to DSM-I but eliminated the term “reaction.”

Development of DSM-III

As had been the case for the Diagnostic and Statistical Manual of Mental Disorders, First Edition and Second Edition (DSM-I) and (DSM-II), the development of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) was coordinated with the development of the next version of the International Classification of Diseases (ICD), ICD-9, which was published in 1975 and implemented in 1978. Work began on DSM-III in 1974, with publication in 1980.

DSM-III introduced a number of important methodological innovations, including explicit diagnostic criteria, a multiaxial system, and a descriptive approach that attempted to be neutral with respect to theories of etiology. This effort was facilitated by extensive empirical work on the construction and validation of explicit diagnostic criteria and the development of semistructured interviews.

ICD-9 did not include diagnostic criteria or a multiaxial system largely because the primary function of this international system was to outline categories for the collection of basic health statistics. In contrast, DSM-III was developed with the additional goal of providing a medical nomenclature for clinicians and researchers. Because of dissatisfaction across all of medicine with the lack of specificity in ICD-9, a decision was made to modify it for use in the United States, resulting in ICD-9-CM (for Clinical Modification). The ICD-9-CM is still in use today.

DSM-III-R and DSM-IV

Experience with Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) revealed a number of inconsistencies in the system and a number of instances in which the criteria were not entirely clear. Therefore, the American Psychiatric Association appointed a work group to revise DSM-III, which developed the revisions and corrections that led to the publication of DSM-III-R in 1987.

Several years later, in 1994, the last major revision of DSM, DSM-IV, was published. It was the culmination of a six-year effort that involved more than 1000 individuals and numerous professional organizations. Much of the effort involved conducting a comprehensive review of the literature to establish a firm empirical basis for making modifications. Numerous changes were made to the classification (e.g., disorders were added, deleted, and reorganized), to the diagnostic criteria sets, and to the descriptive text based on a careful consideration of the available research about the various mental disorders. Developers of DSM-IV and the 10th Edition of the International Classification of Diseases (ICD-10) worked closely to coordinate their efforts, resulting in increased congruence between the two systems and fewer meaningless differences in wording. ICD-10 was published in 1992.

Adminiistartion @ http://www.bipolarandsupport.com

DSM

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders used by mental health professionals in the United States. It is intended to be applicable in a wide array of contexts and used by clinicians and researchers of many different orientations (e.g., biological, psychodynamic, cognitive, behavioral, interpersonal, family/systems). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the current edition and has been designed for use across clinical settings (inpatient, outpatient, partial hospital, consultation-liaison, clinic, private practice, and primary care), with community populations. It can be used by a wide range of health and mental health professionals, including psychiatrists and other physicians, psychologists, social workers, nurses, occupational and rehabilitation therapists, and counselors. It is also a necessary tool for collecting and communicating accurate public health statistics.
The DSM consists of three major components: the diagnostic classification, the diagnostic criteria sets, and the descriptive text.

Diagnostic Classification

The diagnostic classification is the list of the mental disorders that are officially part of the DSM system. “Making a DSM diagnosis” consists of selecting those disorders from the classification that best reflect the signs and symptoms that are exhibited by the individual being evaluated. Associated with each diagnostic label is a diagnostic code, which is typically used by institutions and agencies for data collection and billing purposes. These diagnostic codes are derived from the coding system used by all health care professionals in the United States, known as the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM).

Diagnostic Criteria Sets

For each disorder included in DSM, a set of diagnostic criteria indicate what symptoms must be present (and for how long) as well as symptoms, disorders, and conditions that must not be present in order to qualify for a particular diagnosis. Many users of DSM find these diagnostic criteria particularly useful because they provide a concise description of each disorder. Furthermore, use of diagnostic criteria has been shown to increase diagnostic reliability (i.e., likelihood that different users will assign the same diagnosis to an individual). However, it is important to remember that these criteria are meant to be used as guidelines informed by clinical judgment and are not meant to be used in a cookbook fashion.

Descriptive Text

Finally, the third component of DSM is the descriptive text that accompanies each disorder. The text of DSM-5 systematically describes each disorder under the following headings: “Diagnostic Features”; “Associated Features Supporting Diagnosis”; “Subtypes and/or Specifiers”; “Prevalence”; “Development and Course”; “Risk and Prognostic Factors”; “Diagnostic Measures”; “Functional Consequences”; “Culture-Related Diagnostic Issues”; “Gender-Related Diagnostic Issues”; “Differential Diagnosis”; and “Recording Procedures”.

Administration @ http://www.bipolarandsupport.com

Bipolar Disorder: Preventing Manic Episodes

Introduction:

The more you know about bipolar disorder, the better you will be able to cope with this lifelong illness. There are many steps that you can take—or help a loved one take—to recognize and better manage manic episodes.

Learn the warning signs of a manic episode and get early treatment to avoid disruption in your life.
At the same time each day, record your mood and any symptoms.
Take medicines as instructed by your doctor to help reduce the number of manic episodes.

To help prevent a manic episode, avoid triggers such as caffeine, alcohol or drug use, and stress.
Exercise, eat a balanced diet, get a good night’s sleep, and keep a consistent schedule. This can help reduce minor mood swings that can lead to more severe episodes of mania.
Have an action plan in place so that if you do have a manic episode, those who support you can follow the plan and keep you safe.

How do I manage a manic episode?

Know the warning signs
Learn to recognize your early warning signs. One of the most important ways to avoid a manic episode is to identify early signs and seek treatment.

Common early warning signs of a manic episode include:

Needing less sleep.
Being more active.
Feeling unusually happy, irritable, or energetic.
Making unrealistic plans or focusing intensely on a goal.
Being easily distracted and having racing thoughts.
Having unrealistic feelings of self-importance.
Becoming more talkative.

The best way to manage bipolar disorder is to prevent manic episodes. Although that is not always possible, you can identify and try to avoid the triggers that may lead to a mood swing. One of the most important aspects of managing your illness is to stay on a routine, particularly keeping a stable sleep pattern.

Managing a manic episode

Maintain a stable sleep pattern. Go to bed about the same time each night, and wake up around the same time each morning. Too much or too little sleep or changes in your normal sleep patterns can alter the chemicals in your body. And this can trigger mood changes or make your symptoms worse.

Stay on a daily routine. Plan your day around a fairly predictable routine. For example, eat meals at regular times, and make exercise or other physical activity a part of your daily schedule. You might also practice meditation or another relaxation technique each night before bed.

Set realistic goals. Having unrealistic goals can set you up for disappointment and frustration, which can trigger a manic episode. Do the best you can to manage your illness. But expect and be prepared for occasional setbacks.
Do not use alcohol or illegal drugs. It may be tempting to use alcohol or drugs to help you get through a manic episode. But this can make symptoms worse. Even one drink can interfere with sleep, mood, or medicines used to treat bipolar disorder.

Get help from family and friends. You may need help from your family or friends during a manic episode, especially if you have trouble telling the difference between what is real and what is not real (psychosis). Having a plan in place before any mood changes occur will help your support network help you make good decisions.
Reduce stress at home and at work. Try to keep regular hours at work or at school. Doing a good job is important, but avoiding a depressive or manic mood episode is more important. If stress at work, school, or home is a problem, counselling may help improve the situation and decrease stress.

Keep track of your mood every day. After you know your early warning signs, check your mood daily to see whether you may be heading for a mood swing. Write down your symptoms in a journal. Or record them on a chart or a calendar. When you see a pattern or warning signs of a mood swing, seek treatment.
Continue treatment.

It can be tempting to stop treatment during a manic episode because the symptoms feel good. But it is important to continue treatment as prescribed to avoid taking risks or having unpleasant consequences from a manic episode. If you have concerns about treatment or the side effects of medicines, talk with your doctor. Do not adjust the medicines on your own.

Administration….Jan & Laura

Get the facts:

Your options:

Take medicines for panic disorder.
Don’t take medicines. Try home treatment and counselling to deal with your symptoms.
Key points to remember

Two types of medicines work well for treating panic attacks. Benzodiazepines can help you feel better right away. You can take antidepressants for long-term treatment.

Counselling may work just as well as medicines.

If you take medicines, follow your doctor’s directions with care. You may have side effects such as headaches or trouble sleeping. Some medicines can treat both depression and panic attacks.
For some people, taking medicines along with getting counselling works best.
Don’t feel bad about taking medicines. Panic disorder is a medical problem, not a weakness. The medicines won’t change your personality.

Compare your options:

Compare

Take medicines for panic disorder Don’t take medicines
What is usually involved?
For antidepressants, you take pills or liquids every day or on certain days of the month, for months or years.
For benzodiazepines, you take pills or liquids as needed.

You may also try counselling along with taking medicine.
You try counselling, such as cognitive-behaviour therapy, to control your symptoms.
What are the benefits?
Medicines for panic disorder work well.
Counselling works as well as medicine for many people who have panic disorder.
You don’t have side effects from taking medicine.
What are the risks and side effects?

Medicine may cause side effects such as:

Nausea.
Headaches.
Nervousness.
Tiredness.
Trouble sleeping.

Benzodiazepines can lead to addiction. (Antidepressants do NOT lead to addiction.)
Your panic disorder may get worse if you have no treatment.

Personal stories about people deciding whether to take medicine to treat panic disorder

These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.

As an executive, I have to travel a lot for my job. A few months ago, I was boarding a plane for a business trip, and I began to feel very apprehensive. I felt trapped and got off the plane because I was shaking and sweating and my heart was pounding. I wasn’t sure exactly what was wrong, but I felt like I was dying. I had a drink at the bar and was still shaky but took a later flight. After that I began to feel nervous if I even thought about flying, and I had several more similar attacks. Then I had an attack on the subway. I felt like everyone was watching me and there was no escape. I didn’t even want to go to the office after that because I was afraid I could have an attack at any moment. My doctor says I have panic disorder and agoraphobia. I can hardly function, so I am going to take antidepressants and try exposure therapy. My doctor says a benzodiazepine would make the symptoms go away sooner. But I am worried they will make me too drowsy and they may be too hard for me to quit.

Manuel, age 43

I was having lunch with some friends and suddenly began to feel strange—like I couldn’t breathe and my heart was pounding. I didn’t know what was happening; I thought I was having a heart attack. Although the symptoms began to go away after about 10 minutes, I went to the emergency room, where they did some tests and didn’t find anything wrong. A week later, the same thing happened in the middle of the night. I went to see my doctor, and she suggested I may have had a panic attack. Since then, the attacks have been occurring at least once a week, and I have been diagnosed with panic disorder. Although each attack is still a horrible experience, I now know what is happening and that I will get through it. I have been going to therapy for several weeks and am learning how to deal with the symptoms of panic attacks. They are less frequent now and less intense. I think I can get through this without taking any medicine.

Annie, age 32

When I divorced my wife, Celia, I began to feel down and very anxious. As a contractor, I have to deal with people every day, and it seemed very hard to do my job when I felt so stressed out and depressed. I had my first panic attack when my dog got lost at a job. I knew he was probably fine and would soon come back, but with the stress of everything else it just seemed like more than I could handle. I felt awful; I was choking and had bad stomach cramps. Since then, I have had attacks like this nearly every day and a lot of the time I feel down in the dumps. I have been diagnosed with panic disorder and depression. I am going to therapy, and it seems to help a little, but I still have panic attacks and often feel like life is not worth living, and I feel anxious about interacting with people at all. At first I didn’t want to take any medicine. But after reading about it and talking it over with my doctor, I decided to start taking an antidepressant.

Louis, age 28

WHAT MATTERS MOST TO YOU:

What matters most to you?

Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.
Reasons to take medicines for panic disorderReasons not to take medicines for panic disorder
I am willing to take medicine for at least several months, or longer if I need to.I don’t want to take medicines if at all possible.

More importantEqually important More important
My panic disorder is not improving enough with counselling alone.I want to continue counselling, without medicine, at least for a while.

More importantEqually important More important
I think my symptoms may be worse than the possible side effects of the medicine.I think the side effects of the medicine would be worse than my symptoms.

More importantEqually important More important
My other important reasons:My other important reasons:

YOUR DECISION:

Where are you leaning now?

Now that you’ve thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.

Taking medicines NOT taking medicines

Leaning toward Undecided Leaning toward.

WHAT ELSE DO YOU NEED TO MAKE YOUR DECISION:

Check the facts

1. Taking medicine is the only way I can treat my panic disorder.
True
False

I’m not sure

2. There are two different kinds of medicines that I can take to help my panic disorder.
True
False

I’m not sure
Decide what’s next
1.
Do you understand the options available to you?
Yes No

2.
Are you clear about which benefits and side effects matter most to you?
Yes No

3.
Do you have enough support and advice from others to make a choice?
Yes No

Certainty
1. How sure do you feel right now about your decision?
Not sure at allSomewhat sure Very sure

2. Check what you need to do before you make this decision.
I’m ready to take action.
I want to discuss the options with others.
I want to learn more about my options.

3. Use the following space to list questions, concerns, and next steps.

Your Summary:

Here’s a record of your answers. You can use it to talk with your doctor or loved ones about your decision.
Your decision

Next steps

Finishing all the steps will help you make the best decision. You can skip steps if you want, but your summary page won’t be complete. Answer question >
Which way you’re leaning

Finishing all the steps will help you make the best decision. You can skip steps if you want, but your summary page won’t be complete. Answer question >

How sure you are

Finishing all the steps will help you make the best decision. You can skip steps if you want, but your summary page won’t be complete. Answer question >
Your knowledge of the facts

Getting ready to act

What matters to you…

Antidepressants should help you start to feel better within 1 to 3 weeks. But it can take as many as 6 to 8 weeks to see more improvement.

Talk with your doctor if:

You don’t notice any improvement by 3 weeks.
You have concerns or questions about your medicines.

The medicines may cause side effects, but these are usually mild. They may get better after a few weeks.
Benzodiazepines help relieve symptoms right away.

You may have to try more than one medicine to find one that works. Your doctor may have you switch to another medicine if the first one doesn’t help.

WHAT CAN I EXPECT IF I DO NOT TAKE MEDICATIONS FOR PANIC DISORDER:

Some people use counselling, such as cognitive-behavioural therapy, to treat panic disorder. It can help you to:

• Deal with problems you are having right now.
• Learn how to deal with future anxiety and panic attacks.

Other treatments include support groups and exercises that help you relax, such as progressive muscle relaxation or meditation.

WHY MIGHT YOUR DOCTOR RECOMMEND TAKING MEDICATIONS:

Your doctor might advise you to take medicines if:

• You have not been able to control your symptoms with other treatment, such as counselling with cognitive-behavioral therapy.
• You have other problems linked to panic disorder that could benefit from medicine, such as depression or problems with drugs or alcohol.

The two types of medicines used most often are antidepressants and benzodiazepines. Some people use both.

Antidepressants. These include:

Selective serotonin reuptake inhibitors (SSRIs), such as citalopram, paroxetine, or sertraline. These are the most common medicines for panic disorder.

Tricyclic antidepressants (TCAs), such as clomipramine or imipramine.

Monoamine oxidase inhibitors (MAOIs), such as phenelzine or tranylcypromine.

Antidepressants with mixed neurotransmitter effects, such as venlafaxine.

Benzodiazepines, such as alprazolam or clonazepam. They are sometimes used for panic disorder. They may be used alone or with an antidepressant.
These drugs can help you feel better right away. They may also be used as a part of long-term treatment, either alone or with an antidepressant.

They may be especially helpful if you have agoraphobia .

They can be taken as needed. But they can cause addiction (dependence). Symptoms often come back when you stop taking them.

Panic Attacks and Panic Disorder

Topic Overview

What are panic attacks and panic disorder?

A panic attack is a sudden, intense fear or anxiety that may make you short of breath or dizzy or make your heart pound. You may feel out of control. Some people believe that they are having a heart attack or are about to die. An attack usually lasts from 5 to 20 minutes. But it may last even longer, up to a few hours. You have the most anxiety about 10 minutes after the attack starts. If these attacks happen often, they are called a panic disorder.
Panic attacks can be scary and so bad that they get in the way of your daily activities. Treatment can help most people have fewer symptoms or even stop the attacks.
More women than men get panic attacks.What causes panic attacks and panic disorder?

Experts aren’t sure what causes panic attacks and panic disorder. But the body has a natural response when you are stressed or in danger. It speeds up your heart, makes you breathe faster, and gives you a burst of energy. This is called the fight-or-flight response . It gets you ready to either cope with or run away from danger. A panic attack occurs when this response happens when there is no danger.
Panic attacks and panic disorder may be caused by an imbalance of brain chemicals or a family history of panic disorder. They sometimes happen with no clear cause.

Panic attacks may also be brought on by:

A health problem such as an overactive thyroid (hyperthyroidism ), or heart or breathing problems.

Depression or another mood disorder.
Heavy alcohol use.
Using too much nicotine or too much caffeine.
Taking certain medicines, such as those used to treat asthma and heart problems.
Using illegal drugs, such as marijuana or cocaine.
Living with high levels of stress for a long time.
You have a higher chance of getting panic disorder if you have a parent with depression or bipolar disorder.

What are the symptoms?

Symptoms of a panic attack may include:
A feeling of intense fear, terror, or anxiety.
Trouble breathing or very fast breathing.
Chest pain or tightness.
A heartbeat that races or isn’t regular.
Sweating.
Nausea or an upset stomach.
Dizziness and shaking.
Numbness or tingling.

Symptoms of panic disorder may include:

Repeated panic attacks when there is no reason for the fight-or-flight response.
Changing your daily activities because you worry that you will have another attack.
Some people have a fear of being in crowds, standing in line, or going into shopping malls. They are afraid of having another panic attack or of not being able to escape. This problem is called agoraphobia . It can be so bad for some people that they never leave their homes.
People who have panic disorder often have depression at the same time.

How are panic attacks and panic disorder diagnosed?

Your doctor will ask about your past health and do a physical examination. The examination may include listening to your heart, checking your blood pressure, and ordering blood tests to look for other causes of your problem.

How are they treated?

Treatments for panic attacks and panic disorder include counselling, especially cognitive-behavioural therapy (CBT). Medicines may also help. Treatment can help most people control or even stop attacks. But symptoms can come back, especially if you stop treatment too soon.

Early treatment of panic attacks is very important. It can prevent other problems related to panic disorder. These problems include depression , anxiety disorders , and substance abuse .

Omega-3 Fatty Acids for Bipolar Disorder:
Topic Overview

Omega-3 fatty acids are found in marine or plant sources, such as fish oil and flaxseed oil. A few studies suggest that adding omega-3 fatty acids to medicine (such as lithium) can help reduce the depressive symptoms of bipolar disorder in some people. Omega-3 fatty acids don’t seem to have any effect on the manic symptoms of bipolar disorder. And omega-3 fatty acids alone are not a good treatment for bipolar disorder. They are not a replacement for medicine or other therapy used to treat bipolar disorder. 1, 2
There are few, if any, negative side effects of taking omega-3 fatty acids. Loose stools were reported most often. Researchers think that omega-3 fatty acids help support the membranes of brain cells, making it easier for them to send signals to one another, which may reduce the likelihood of depressive symptoms.

Bipolar Disorder: Preventing Manic Episodes
Introduction

The more you know about bipolar disorder, the better you will be able to cope with this lifelong illness. There are many steps that you can take—or help a loved one take—to recognize and better manage manic episodes.
Learn the warning signs of a manic episode and get early treatment to avoid disruption in your life.
At the same time each day, record your mood and any symptoms.
Take medicines as instructed by your doctor to help reduce the number of manic episodes.
To help prevent a manic episode, avoid triggers such as caffeine, alcohol or drug use, and stress.
Exercise, eat a balanced diet, get a good night’s sleep, and keep a consistent schedule. This can help reduce minor mood swings that can lead to more severe episodes of mania.
Have an action plan in place so that if you do have a manic episode, those who support you can follow the plan and keep you safe.

How do I manage a manic episode?

Know the warning signs

Learn to recognize your early warning signs. One of the most important ways to avoid a manic episode is to identify early signs and seek treatment.
Common early warning signs of a manic episode include:
Needing less sleep.
Being more active.
Feeling unusually happy, irritable, or energetic.
Making unrealistic plans or focusing intensely on a goal.
Being easily distracted and having racing thoughts.
Having unrealistic feelings of self-importance.
Becoming more talkative.

The best way to manage bipolar disorder is to prevent manic episodes. Although that is not always possible, you can identify and try to avoid the triggers that may lead to a mood swing. One of the most important aspects of managing your illness is to stay on a routine, particularly keeping a stable sleep pattern.

Managing a manic episode

Maintain a stable sleep pattern. Go to bed about the same time each night, and wake up around the same time each morning. Too much or too little sleep or changes in your normal sleep patterns can alter the chemicals in your body. And this can trigger mood changes or make your symptoms worse.
Stay on a daily routine. Plan your day around a fairly predictable routine. For example, eat meals at regular times, and make exercise or other physical activity a part of your daily schedule. You might also practice meditation or another relaxation technique each night before bed.

Set realistic goals. Having unrealistic goals can set you up for disappointment and frustration, which can trigger a manic episode. Do the best you can to manage your illness. But expect and be prepared for occasional setbacks.
Do not use alcohol or illegal drugs. It may be tempting to use alcohol or drugs to help you get through a manic episode. But this can make symptoms worse. Even one drink can interfere with sleep, mood, or medicines used to treat bipolar disorder.

Get help from family and friends. You may need help from your family or friends during a manic episode, especially if you have trouble telling the difference between what is real and what is not real (psychosis). Having a plan in place before any mood changes occur will help your support network help you make good decisions.
Reduce stress at home and at work. Try to keep regular hours at work or at school. Doing a good job is important, but avoiding a depressive or manic mood episode is more important. If stress at work, school, or home is a problem, counselling may help improve the situation and decrease stress.

Keep track of your mood every day. After you know your early warning signs, check your mood daily to see whether you may be heading for a mood swing. Write down your symptoms in a journal. Or record them on a chart or a calendar. When you see a pattern or warning signs of a mood swing, seek treatment.
Continue treatment. It can be tempting to stop treatment during a manic episode because the symptoms feel good. But it is important to continue treatment as prescribed to avoid taking risks or having unpleasant consequences from a manic episode. If you have concerns about treatment or the side effects of medicines, talk with your doctor. Do not adjust the medicines on your own.

Mood-Stabilizing Medicines for Bipolar Disorder and Schizophrenia: