What I am thankful for

As Thanksgiving is rapidly approaching I am quite thankful for where I am at in my life. Last year at this time I was looking for a job in accounting or a related business. As it got closer and closer to Labor Day this year I was willing to take on any form of labor. Although my most positive experiences in work were as a teacher and working in accounting; I just wanted a job. This is when I believe G-d put his hand out and guided me.

I went to the Verdugo Job Center in Glendale and signed up for job search assistance. After attending an orientation and a support group I met with a young woman named Deidra. I wemt to get help with my resume and how to better focus my job search. She gave me input that now seems so obvious to me, but until I met with Deidra I had not considered combining my two skill sets. The job counselors I had spoken with before encouraged me to either to apply for accounting jobs or start my own business. Deidra, instead, thought outside the box as they say. Her suggestion was for me to look at the EDD site and identify all the school that were training students in business. After I found the schools I contacted them and submitted my resume to many. Within a few weeks I had two interviews and was hired.

I love my job and it is an ideal position for me as it utilizes my skills. I am helping students learn about business and computer programs that will help them obtain jobs for themselves. I am happily paying it forward.

I am truly thankful to Deidra, family, friends and G-d who helped me through these difficult times and into a much better situation.

The Little Blog That Could

A little less than 2 months ago I decided to end this blog and start an advice blog. The two people I gave advice to really valued and utilized my advice. However, it is hard to have a daily advice column with that little response. In the meantime I have been busy looking for steady employment and continuing to settle in to my new home as well as spending valuable time with my fiancee. The solution to the advice column dilemma seems to be either finding a way to market it so others hear about it and write in or to not continue writing it. At this time I realize that I am no marketing genius nor do I wish to try and become one. So I am going to share my erratic thoughts here for myself and the readers whether there are 3, 3,000, or 3 million.

Recently I went on one of many interviews I have gone on. This was for a part time instructor position that I knew I would enjoy doing, but had no idea if I would get it. After one interview and a presentation in front of the other instructors and the administrator; they had me filling out paperwork such as a W4 that you only complete if you have the job. I asked them if it meant that I got the job and they indicated yes. It took all the control I have to refrain from screaming with job or jumping up and down. I am still looking for additional work as this is part time and at night, but most importantly it is steady work.

I believe strongly in the concepts in The Four Agreements and the concept that one's esteem needs to come from within. However, I couldn't help myself from feeling much better about myself due to the reinorcement and the fact I will have some place to go on every weekday. It feels good to provide a necessary skill to society.

Feelings are clearly not logical. Before and after getting the job I was the same person. The difference is having my personal confidence reinforced. I worked one day so far as a sub and as of tonight I will begin working every weekday or do I call it every weeknight? Either way it feels great to get back to work and know I am providing a necessary service to others and one that I am confident I can do well.

Advice to Self: Start an Advice Blog

I haven't written in a while mostly because I have been busy getting settled in to my new place and continuing my job search. One of the things that's been bothering me with this blog is that it does not seem to attract a large following. I have my small group of readers who I truly appreciate, but those are mainly people who happen to know me personally. The main problem is the fact that I chose to write about a variety of topics thus leading to my blog title "Erratic Thoughts". This has led me to wonder if I need to change my blog or open a new blog.

As I have been considering my new blog I have gone over a few different concepts. I thought about mental illness, but I already tried that and I found it a bit tedious and depressing at times. Another possibility is sports, but that is something I have become less and less interesting in plus there are many sportswriters out there. Entertainment is a possibility, but that involves having funds to go out to many events plus again in some ways my interests have lessened. As I continued to think of every kind of topic and shot them all down, I started to think about what do I most enjoy reading. Mystery novels are intriguing, but I am not planning on writing a novel at this time nor do I want to review them. I truly enjoy reading advice columns such as Dear Abby and Ask Amy. Wait a second! All the general advice columns I have read have been written by women. I have always been a good listener and one who many people have turned to for advice so this sounds like a thought. I don't claim to be an expert or a psychologist, but I have a lot of experiences and opinions. I figure this will be an interesting thing to do and hope to do it for fun and maybe help a few people in the meantime.

Don't Lose that Improv Feeling

If you can make it to a live improv comedy show I highly recommend The Groundlings on Melrose in West Hollywood, but if you can't make it there then check out these clips from the original Whose Line is it Anyway from the UK.



Over the last approximately 4 years I have been busy trying to find ways to make money and/or obtain gainful employment. Since I haven't been successful at finding anything with a consistent schedule I have chosen not to perform with any improv group. I performed for a little over 10 years with a very funny group from Orange County, CA called An Angry Mob. We performed very successful shows as headliners at The Original Comedy Store on Sunset as well as the one in La Jolla, The Coach House in San Juan Capistrano, and The Ice House in Pasadena as well as many other locations. The problem was that we might perform 3 shows in a week then over the next 6 months perform just another 3. It's a tough business out there especially when you book your gigs yourselves.

My cousin Sue passed away 3 1/2 years ago after battling a debilitating disease. It was very difficult watching a woman who loved to chat and laugh forced to communicate only in writing since she had to have a tracheotomy. Her best friend and I switched off being at her bedside over a 3 month period so she almost always had a daily visitor. I don't mention this to pat myself on the back, but rather to explain why words she said have such meaning. Due to family discord that did not directly involve us, we had not been close until the last two years of her life. During this time she became very supportive of me as a person and enjoyed attending the group's performances. She encouraged me to keep performing even if it was just once or twice a year. I lived in L.A. for about a year from 2006 to 2007 and took classes with the well renowned Groundlings. I enjoyed the opportunity to perform although I did not make out of the first level through any of my three attempts. This is greatly due to the fact that I enjoy being a quick wit rather than being able to create characters which The Groundlings are known for (Paul Reubens aka Pee Wee Herman was a Groundling, Phil Hartman, Lisa Kudrow, and many many more).

There is such a camraderie felt when one is part of a comedy troupe or merely an improv comedy performance. The energy on the stage when shows go well is electric and it bonds the entire group. Even when shows don't go that well, the group can be bonded by blaming the audience, lighting, or the fact the girl in front had makeup that looked like it was put on by monkeys on crack. Of course there is the occasional time when the group doesn't get along, but with the right group it is all worth it in the end.

My cousin's answering machine allowed us to hear her voice from beyond the grave. When anyone called, Sue's voice would say "You Know What to Do." This message took us through difficult decisions her best friend and I had to make. These included carrying out her wishes when some of those were not made clear by her even though she had a living will and made me the executor of her estate. I know that I will jump up on an improv state again and hopefully sooner rather than later. One of the motivating factors will be knowing that somewhere my cousin will be smiling and laughing louder than anyone in the crowd. In addition, her words and spirit will always resonate with me letting me know that I know what to do.

A Raphe by any other name

I just left my local 7 Eleven and instead of being given a standard salutation such as thanks or have a goodnight, the guy said "Thanks Bub." After all these years I am being called bub. It's bad enough that my name Raphael is pronounced "Ray-fee-ohl" which confuses the average bear and almost anyone else I have met, but now I have to deal with the indignity of being called inane names.

My nickname is Raphe (Rayf) which has turned into Roff by people that I have known for years. People I don't know will call me Ralph or Greg and I just stand there in awe. However, these are situations where I can give them the benefit of the doubt and figure that somehow they just haven't heard my name right or maybe just don't care.

Why would anyone think calling someone boss would be received positively? When I get my oil changed I don't want to be referred to as boss or bro. A simple sir would do or even Mr. Margolin.




I have a strange idea for people in customer service. If you can't think of a respectable name to call your customer then how about asking him/her what they would like to be called? This concept may be too much for your average individual, but it is one that I wish would be taken into account.

Someday I will walk up to the counter at the local Seven Eleven, place my product on the counter, and have over my money. I will receive my change and my item then as I saunter out the store I will hear those special words, "Thank you sir." My ears will perk up and I will be one happy dude.

20 years or so of Bipolar

It was in 1990 that I was officially diagnosed with bipolar disorder. I wasn't given a certificate or anything, but the doctor definitively gave me that diagnosis. I knew that I had some sort of condition years before, but this was when I became truly aware. Being diagnosed with a mental illness is not like being told you have strep throat and being given an antibiotic. You can't take a drug and in a few weeks be magically cured. With mental illness it is a life long process of doctors, medications, education and more.

The date that started my ten week stay in various psychiatric hospitals was August 11, 1990. Thankfully since I exited the last of the 3 hospitals on October 23, 1990 I have not had the need to return. Does this mean that life has been simple since then? Definitely not simple at all. There have been many romantic relationships over the years that have not lasted including a failed marriage. I became an elementary school teacher only to find out after 7 years of full time teaching that this really wasn't the career for me. Leaving teaching I decided to try my hand at working as a Realtor, but I found that I don't like banging on people's doors and need a more structured job. I worked as an independent contractor doing general accounting for a friend for a while, but as of late last year he no longer needed my services due to lessening of his client base. I am still on call with him, but he hasn't needed me for quite a while. In case you didn't know, the job market isn't exactly stellar right now so looking back maybe teaching wasn't so bad after all.

Many of my problems are not limited to someone with a mental illness. This is where sometimes it is hard identifying if am I experiencing a situation that is part of being bipolar and having a manic or depressive episode or am I just experiencing the challenges of life. Being elated over getting a job or sad for losing one are quite normal. If these feelings last excessively long this can be an issue. If I either decide that I can suddenly be elected King of the World or that I am completely unemployable then these are mental illness issues. Unfortunately things are usually not that clear and there are subtle nuances one must learn to identify when feelings are going a bit awry.

As you can see even after having knowledge of this condition for nearly 20 years I am still learning more and more about myself. One of the best things one can have when dealing with any mental illness is having an excellent support system. I have been blessed with having supportive friends and family over the years and now a very wonderful fiancee who is there whenever I need her. The challenges will continue, but I can confidently say that I can succeed and when it is all over I plan on being able to say that I did it my way!

Assumption assumption, what's your function?

As I have mentioned before the book The Four Agreements has had a very strong impact on my life. One of the agreements is to never make assumptions. I have worked to avoid assumptions since learning of this, but what is most interesting is to look back on my life and see how making assumptions affected me.

Much of my early years was spent going from one boyhood crush to another. Many times these crushes had no basis in reality. The young woman I was attracted to did not match what I envisioned of her in my brain as well as not being unreachable as I perceived.

It was easy for me to put most women I liked on a pedestal. My self esteem was so low that nearly every young woman appeared to me to be better than me and thus beyond my reach. The best way I can demonstrate this is to bring out an example of my youth.

During my freshman year in high school I was threatened by a fellow student with muscles in one of his arms bigger than all of my muscles put together. He was upset because someone was using a computer generated device to call his girlfriend and somebody told him it sounded like me. It wasn't me and I actually didn't even know his girlfriend or what she looked like. Since I was being threatened by this tobacco chewing spitball spitting hulk of a youth I figured I might as well find out who I was accused of harassing. I inquired of a mutual acquaintance and I saw her from afar. Well, this started a crush/obsession that would last for years. Did she intrigue me because I talked with her and got to know all about her life, values, and beliefs? No, that would make too much sense, involve maturity, and require self esteem that I did not possess. It was based on how she looked and what I thought she was all about by watching her from a far.

She appeared to be the all American girl and down to Earth. I imagined us being a couple hanging out together, dancing at school dances, and walking on the beach hand in hand. I also didn't ask her out for my first three years of school due to the fact she was either attached or when she wasn't I didn't feel worthy of even approaching her for a date. Over time I did get to know her more, but it was still on a superficial level as my interest wasn't in whom she really was, but rather the person I created in my brain. I finally got the nerve in my senior year to ask her out. By this time I had managed to let everyone around her and myself know of my interest so it was truly the world's worst kept secret. I even remember yelling her name from across campus and then jumping under a table. This made me appear completely stable and a dream man I am sure. Something I didn't expect happened which is she actually said she would think about it. This to me was amazing, I was flying on air although it is very likely she didn't know how best to let me down and felt uncomfortable with this encounter. After a few days she let me know that she was turning down my offer. She was pleasant about it, but looking back I can't blame her one bit.

She was still in my mind when I attended my 5 year and 10 year reunion. I dated other women throughout those years, but every so often I would think of her and at the reunions I wanted to dance with her. This again was not to know her, but rather as some idea that it proved I was worthy. Two years after the 10 year reunion I was married and stayed married for around six years.

After my divorce I contacted the object of my obsession, but now with the knowledge that I was no better or worse than anyone else. The assumptions I had about others superiority to me were gone. We chatted for a while through email and decided to meet for lunch. In high school I would have viewed this "lunch date" as the start of our voyage onto marriage and lifelong happiness. Instead I no longer was making assumptions and we just had a pleasant lunch getting to actually know each other and build on our new friendship.

A few years later we saw each other at our 20 year high school reunion and finally got the dance I had so much longed for. This was not a romantic dance, but rather friends having fun together. What was most important to me was that I was free of assumptions of the past so I could enjoy this moment and not think beyond it in any way. I truly can see clearly now, my brain is on.

Do I take the bible literally?

Every year my family gets together for Passover. This is the holiday that is from Exodus in the bible which tells the story of Moses leading the Jews out of Egypt. During the Seder (the meal and reading during Passover) we read about how the Jews were kept as prisoners under Pharaoh's rule and the way they were able to finally convince the Pharaoh to let Moses's people go. This is a very brief synopsis of this holiday as there is much more to it, but I only wish to focus on this aspect of it.

According to the story that is read during Passover, there were 10 plagues that were put upon the the Pharaoh and his people. They are blood, frogs,lice, flies, cattle disease, boils, locusts, darkness, and slaying of the first born. This was not a good time to be one of Pharaoh's followers.

My concern and questions about this story is that this describes a God that would punish all members of a group for the actions of the few. History is filled with actions a country's leadership conducts that goes against the desires of many of the common people. The Passover story doesn't say these plagues are against only those that support the pharaoh, but really against all his people. This to me seems inherently unfair and not how the God I believe in would act. I believe in a loving god that has expectations for us all and if there is some sort of judgement day; judgement will be based on individual actions and not a country's leadership or lack thereof.

I do not claim to know more than others or have a clear cut answer here. I wish only to raise the question and hear others' perspectives. If someday I go to the pearly gates and am told that I was wrong then I will clearly accept that. I hope and desire that for now and the rest of my time on Earth that I will always feel comfortable with questioning the things I don't understand.

Liberal Republican or Conservative Democrat?

As I try to think of which party I belong in I am reminded of a fun 80's song by Eddie Murphy. It is a bit of a stretch to connect this to this post, but since this is my blog I am going to do it anyway.



I wish we didn't live in a two party system, but in the United States that is what we have. There are of course other parties, but unless one wants to be left out of voting for individual candidates during the primaries then it is necessary to choose a party. This is the time a difference can be made in regards to who is going to hold office in California. The districts are so gerrymandered that after the primary the contest is basically decided based on whether the district is Democratic or Republican.

So the question left for me to answer is whether I consider myself a liberal Republican or a conservative Democrat. I am pretty liberal when it comes to social issues such as gay marriage and legalizing marijuana. However, I am anti abortion which is socially conservative. Economically I believe in keeping a close eye on budgets and not spending any more then needs to be spent. I don't believe unions are nearly as necessary as they were in the early 20th century and may actually not be needed at all. At least when it comes to public employees there are serious issues. Of course it would be great if everyone could have an excellent retirement like with the public employee's and the teachers unions. In California the unions are so powerful that they can fight any legislation that tries to adjust their retirement many times under the auspices of doing what is best for children.

This leaves me back where I started which is trying to figure out where I fit in politically. It is not as important as I used to think. During college I was a member of the Young Democrats and I believed that someday I would run for political office. After I graduated and saw all the underhanded activities that are involved in politics I completely lost interest in being elected. One time when I was still considering running for office I had lunch with an elected official I knew. This individual proudly told me how he/she was able to find out details on a competitor by hiring a private investigator. After gathering some dirt he/she used the info to get the other candidate to drop out of the race. I was advised that with $300 I could find out whatever I wanted to about my competitors. Politics was much different than how I had naively thought and now I knew this was not meant for me.

I am currently registered as a Republican and after writing this post I feel I am going to stay that way for now. This is not a major decision as there are many contests that are non-partisan. Then there are many contests in which the incumbent is running unopposed. For the few where there is a choice of candidates I'll be voting for the most liberal of Republicans, but in this time of extreme politics I am probably going to be voting in the minority.

Why do I care so much about what other people do?

This video is from don Miguel Ruiz author of The Four Agreements and other books on Toltec wisdom. His books have helped me see my life more clearly.



When someone I am with comments with disdain about another person's choice of clothing, partner, or food I generally ask them "Why do you care?" Tonight I noticed that I am not good at practicing what I preach.

My friend Joe called me today because he had Angels baseball tickets (explanation given for my international readers and/or non sports enthusiasts) and asked me to accompany him. He actually didn't ask me to accompany him as that would have felt odd, but he did ask if I would go with him.


We drove to the stadium, parked across the street to save a few bucks and get some exercise, then proceeded to find our seat. From the time right before the game and throughout, a gentleman (not actually much of a gentleman, but trying to avoid calling names) started yelling to the players. Mind you we were in the right field bleachers five or so rows in front of the scoreboard so Bobby Abreu or any of the other outfielders could not be privy to this man's commentary. However, it was his prerogative to show his enthusiasm without using profanity which he did refrain from. I still found it unsettling that he felt these players could actually hear him from that far and if so that they were being affected by his taunts. He apparently was having a good time and the woman he was with seemed happy enough so why did this bother me so? I admit to occasionally saying words of encouragement to my favorite player, Ron Cey, like come on get a hit (I wasn't very original back then), but I didn't carry on a one sided conversation with him. It was more like a prayer or mantra or praying mantra (better than praying mantis), but why do I care?

Except for when he yelled so loud that I might have suffered ear damage or when he called a black player boy for not diving (doubt he would have yelled boy to a white player), this didn't need to affect me. However, I managed to get more and more annoyed as the game went on. He may have been bothered by the fact I sat there throughout and only let out an occasional modest cheer, but I doubt it. I like having a mellow experience and need to recognize that that is not what I will get at a ball game. If I want mellow I need to attend the symphony (except when they perform my favorite which is the 1812 overture by Tchaikofsky) or an Air Supply concert. Maybe, there is a bit of me that is jealous of his uninhibited boisterousnes, but I wish I was better at letting it slide off my back into a pool filled with marshmallow creme and coconut shavings.

Later on in the game which was 2 to 0 from the 3rd inning on and finished that way many people began to leave. This started from the 7th inning on and this was a close game! I can see if it was a blowout or something, but other than that, why come to a game and not follow through with it. You have made it almost to the end, why not see it to completion? Again, I realize that I am there for the experience of seeing a game live. As long as there are thousands of fans still there it still will have intensity and excitement. The people that stayed need my attention more then those that have abandoned their seats to be clogged in traffic with others who left early. I wish I knew a simple clear cut answer. I think I may need a personal paradigm shift to see things in a more positive light. I have had 40 or so years of practice at seeing the negatives of what's there; it will take more than one night of revelation to see the positiveness of each and every experience.

Why I am Anti-Abortion

The following is a song that I think of when I think of my daughter. The video is from youtube so I apologize for the misspelling of the word lose as loose.



I don't like the term pro life. Having people live is of course a positive thing, but more importantly I would rather people not have abortions. This opinion is coming from someone who as of 7 years ago considered himself pro choice. I have also always considered myself to be a social liberal. My philosophy on being a social liberal is that if what an individual is doing is not affecting another person then leave them alone. This includes but is not limited to supporting gay marriage and legalizing marijuana.

Let's start by identifying why I was pro choice. I believed that abortion was not a good thing, but it wasn't for me to say whether not another person should have one. However, I don't believe many people want to go through the physical and emotional pain of an abortion if it could be avoided. A former friend had told me about an abortion that she had over 30 years ago and she still imagined what the child would have looked and acted like. I can't imagine how difficult it is to live with this feeling.

What changed my mind? During the development of my only child there were a variety of reasons why it was an at risk pregnancy. This meant that from the early stages of her development before we even knew my daughter was a she we watched her in the womb via sonograms. As she grew and swam as I called it, I felt a connection right then with her. She was growing, but she was and is a person.

Imagine you have a close family member who is in a comatose state where they are unable to communicate with you. You have been told by the doctors as long as they get the nutrients from the I.V.'s and are given proper care; they will come out of the coma and have a fruitful life. Besides the I.V.'s imagine there are additional tubes connected to your family member. Now let's imagine that for some reason you decide that you no longer want to take care of this family member. Rather than finding someone else to step in and help care for them you decide to pull out the I.V.'s and the tubes. Your family member dies and you are charged with murder. Lets switch the situation to a child in the womb. In my opinion, it is no different.

Notice that I have made a concerted effort to refer to the one having the abortion as a person and not a woman. I know that of course women are the ones who carry a child so they are the ones having the abortions. To me though this is not a woman's or man's issue. It is a human issue. It is every human's responsibility to make life as comfortable for a woman carrying an unwanted pregnancy to full term. This includes simplifying the adoption process as access to quality prenatal care. I believe also that a DNA system should be set up so all men's information is accessible regarding the child. This means that the man will be held responsible for his participation in bringing the child into the world and also this solves the problem of having some men identified as parents of children that aren't actually theirs. There are privacy issues here which need to be worked out, but it is important that both the man and the woman are given help as well as being responsible for their actions.

I know this is a volatile issue and I am just stating my opinion. I hope my writing will encourage others to look into this issue more deeply. I don't anticipate changing tons of people's minds, but do feel the responsibility to bring up issues that others will find intriguing.

Poll Position

Polls used to be conducted on a variety of items, but mainly for elections, products, and television shows. The costs of these polls were such that they occurred only when it was important enough and thus cost effective. The advent of the internet has changed all that. In some instances I know it has been beneficial to lessen the cost of conducting polls. Students at universities can illicit responses from a large enough group to make proper scientific conclusions at a fraction of the cost. The same goes for researchers working to identify causes of cancer, alzheimer's and other life destroying diseases. What bothers me is the other polls that occur all too often.

First off, I know I don't have to answer any of the annoying polls or read them for that matter so nobody tell me that. Just cause I can ignore something doesn't mean I can't state my position on the matter. There are now polls about whether you think Tiger Woods will be back soon or later, what the chance of a certain team winning is, who you think will be kicked off a show, etc. These to me are such nonsense! Who are the people that respond? Are they close friends of members of the team so they know who is secretly injured? I highly doubt it. Most the people are just regular individuals who by clicking a button give their worthless opinion on a subject. If 80% of the respondents think the Lakers will win the championship does that mean they will? Of course it doesn't.

Scientifically speaking most the surveys are not accurate because the sample is not randomly chosen; instead they consist of those individuals that have internet and go to the particular site and have the desire to respond to the given question. I have the ability to conduct polls on this blog. I did do one, but at the time my readership was low and the response was very little. Now, I don't foresee having any more polls because I can get an idea about what people think by reading the comments and not by a silly poll.

There are still important polls out there. The most important one being when we go to the polls to cast our votes. Also, it is important to take a small poll like asking everyone in the office what topping do they like on their pizza.

I am going to make sorted effort to not respond to any polls online unless they are for a really valid reason. Whether I like to put my toilet paper with the paper coming over or under does not seem like a good use of my time. I would like to get comments from you so I can find out what is your poll position.

Illegal Immigration

My great grandparents came to this country in the early twentieth century to avoid the pogroms in Russia. This is where the Russians were burning Jewish towns and killing the Jews. When they came to this country it was much easier to be able to go through the immigration process, but either way they did go through it. I believe our laws need to be adjusted so that they are reasonable and much more efficient, but I still believe in the concept of legal immigration.

Some people believe in the idea of no borders. This is a utopian idea that I believe is very dangerous in our time. If we open our country to allow anyone to come in and become a citizen we risk many consequences. An open border would allow terrorists or anyone else that wants to cause harm to our country and our people easy access to doing so. This also would make it tempting for other countries to open their jails and send their criminals to our country. It likely would also cause more harm to our social services including hospitals and schools. Hospitals could be serving foreigners that come over only to receive medical care and then head back to their country. The schools which are already challenged trying to educate the current student body would likely be inundated with students who come over for a short time and leave thus disrupting the flow of classrooms as well as putting extra strain on educators.
Another problem I find with illegal immigration is how illegals become basically second class citizens. Imagine that you are a worker who is in the country illegally and is dealing with poor working conditions. These could be things like unsafe work areas, sexual harassment, pay below the minimum wage, and more are situations that many illegals won't complain about for risk of being deported.

What are some solutions? Before I get into that there needs to be ground rules to discussions. The race card must be kept in the deck. It is unfortunate that right now according to stats on Wikipedia that 57% of illegal immigrants are from Mexico and another 24% from other Latin American countries. This makes it easy for immigrant activists to claim racism when illegal immigration is brought up. I am not naive so I understand that there are racists out there that use illegal immigration as a cover for their true feelings. However, from my experience there are many more of us that would like a reasonable immigration policy and we must allow for an intelligent discussion of it. My feelings on illegal immigrants is the same whether that immigrant is from Mexico or Russia or any other land. I hope this will be an issue we can discuss with intelligence because it is not going away any time soon.

Will I celebrate Easter in the future because it's fun?

My 5 1/2 year old daughter told me on Easter that she wanted me to celebrate Easter because it's fun. I am a Unitarian Universalist which is a liberal religion that includes peoples of Christian, Jewish faith, atheists, and others within it. This is a belief system I have been searching for my entire life and now I feel quite comfortable with it. I grew up being Jewish and still believe in the basic tenets of the religion thus I have continued to observe many of the holidays. My daughter's comment threw me for a bit of a loop.

I am a divorced father with one child who I share with my ex-wife. She lives with my ex and I see her every Tuesday and every other Sunday. The Sunday of my recent visit happened to be Easter. Since our family is Jewish we didn't celebrate Easter with Hannah as she was doing that with her mother and her family. Now from all I know from my ex throughout our marriage and since the divorce, she is merely a secular Christian. Hannah has never attended church with her mom nor with me except for an after church barbecue we attended to eat and play with friends. I remember being in school and dying eggs then I believe we would also hunt for hidden eggs. This was a fun activity and I didn't think twice about the religious history of it all. I would not expect my daughter to delve into that now either, but since I am an adult who has where does that leave me?

I wrote this post because I truly wasn't sure what I wanted to do. It wasn't until the end of the previous paragraph that I came to a conclusion. I can have fun and celebrate with my daughter like she wants me to. As she grows and asks questions about the holidays and what they mean then I can let her know how I see things and encourage her to make up her own mind. This is what works for me. I know whether my daughter is trying to gather acorns at Atlantis park, rocks at Balaeric, or Easter eggs anywhere; what matters is seeing that beaming smile on her lovely face.

Friends???

Recently I removed over 260 of my Facebook "friends" in order to reduce the list to the people I have contacted over the last year or so and am strongly connected to in one way or another. I didn't start out trying to get a large group of friends as some way of feeling good about myself. My friends list expanded mainly because I attempted to put on an all class reunion for my high school and it evolved into me adding those that I talked to about the reunion. The reunion didn't pan out, but I kept these "friends" still on my list. I must admit that at times seeing 338 people listed felt kind of cool, but then I thought who are all these people? Many of them I am sure are very nice, but I could not tell you one thing about them. It became tedious having to create groups so I could see what was happening with the people I really knew and thus truly wanted to know what they were doing. I can't tell you how much better it feels. It is like a little weight off my back. Pretty much nobody that is off my list commented on any of my postings as they probably have large lists themselves and I clearly was not a priority. This is completely fine as I don't need affirmation from near strangers to know that I am okay. I've got 76 true connections right now that I can better keep up with. Also, I have my parents, sister, fiancee, and my daughter who when she gives me a hug makes everything seem alright.

Freedom of Speech has a volume dial

Originally I planned on writing about the various political and religious comments on Facebook and how they bug me. I then realized how hypocritical that would be of me as I just proudly shared Anna Paquin's announcement that she is a bisexual. What this comes down to is that we all have freedom of speech as well as the freedom to not listen or pay attention. If my socially liberal views that I espouse continually bother a "friend" on Facebook, they have every right to remove me from their friends' list or hide all posts from me. This is true of me with regards to religion exclamations from enthusiastic Christians. I don't have the same views as them so that leaves me a few choices. I can continue to have them on my friends' list and ignore their writings, make comments on their status as to why I don't see things as they do, or remove them from my lists.



The first choice which is to ignore their writings on religion works for me if I am close to the person and the majority of their writings discuss other topics. However, if the majority of the discussion is of a religious or political nature then I move on to the next option. I respect everyone's right to their own religious belief and since I can't claim to have the answer of which if any religion has it right; I will not comment on a religious comment. This has led me to remove some "friends" who share mostly on their religion because it is not of interest to me and I have limited hours in my day. Lastly, I mentioned removing people from my list. This I have done mostly in cases where a person was constantly making what I perceive to be cynical comments on the state of the world. Every individual has the right to be a cynic, but I have the right to not want to hear more than the ones I already hear.

A discussion on the positive and negatives of a certain candidate or politician is interesting for me to read about. I get to see other points of view and learn a lot. However, reading someone call our president names like Obamanation or Obamarama or whatever does me no good and in my opinion is disrespectful. I didn't agree with much of President George W. Bush's policies, but see no reason to lower myself to the level of mocking his name. Doing so would truly be bush league.

The I'ds of March

On this last day of March it is only fitting to shrare some special I'ds thoughts. I have spent much of life thinking of what I should do in life and other times looking too far ahead to what I would do. Now, I try to follow the idea of living in the moment. This is challenging because there are some things that need to be planned for such as making sure to have money for rent, being free to pick up my daughter, and a nice evening with my fiancee. Otherwise the moment is a better place to be.

Yesterday I was approaching a left hand turn lane. From far away there appeared not to be enough room to move from my lane to the turn lane. However, as we arrived at the left turn lane, there was plenty of room to get into the lane. This is something minor, but it is an example of how worrying ahead of time doesn't really do any good.

I also don't like the word should. It is easy to say should about many things. I should have majored in human services, I should have studied harder, and I should have saved money better. However, this doesn't change what occurred. This lesson I have been passing on to my daughter. After a wonderful visit (all my visits with her are wonderful) she might see a park she likes or think of a fun game we didn't get to and out comes "We should have done that." I turn it around quickly by asking her if she enjoyed what we did that day. Thankfully she always says that yes she did. There, I tell her and we go back to the understanding that staying in the moment is key. It seems like she is getting a concept at 5 1/2 that it took me into my 30's to truly grasp. I guess she is a little ahead of the curve or I was quite far behind. It is probably a combination of both.

I wrote about silliness before and it comes to mind that how can you truly let yourself be silly if you are constantly focused on what should be happening or what you would rather be doing. Enjoy the moment and be silly, play a game, get work done, or whatever you like, but don't worry about what others think. This is just a waste of mental and sometimes physical energy.

Silliness

When I think of silliness I think of this:






One of the biggest gifts of parenting is silliness. My best times with my daughter are when we are goofy together. I love hearing her say "You are a silly daddy." I have to admit that I love hearing anything from her mouth except for the occasional whine about not getting her way.

I wasn't very good at being silly during my childhood. I was so concerned about what others thought of me and not getting into trouble that I took things way too seriously. This is due to a variety of reasons, but mostly I was just a very nervous child with way too low self esteem.

What is silliness to me? Well, let me start out with what is not. It's not about throwing a pie in someone's face or bonking them on the head like in The Three Stooges. These are silly, but not the kind of silly I enjoy. Silliness for me is getting on a jungle gym and pretending my daughter is driving us to Disneyland. She buckles me in and off we go. It is also when she bakes me a cake out of sand with rocks for candles for my "birthday" and she gets her other little friends to sing me happy birthday. This is of course after she puts the sand cake into the oven which is located in the open next to the nearest tree. More silliness occurs when we play soccer in which she is the coach and I am the kid. I have more fun being the kid with her then I ever was as a kid myself.

Life has struggles all around us, but what makes them worthwhile is knowing that we can be silly every once in a while. Maybe, we can be silly more often then that if we let ourselves be and let others, too. Whatever your belief system says; we are all unique. This uniqueness allows us to be silly in our own way. If you are around a group of young children some day, look at them and see how they act when given the opportunity to be creative and themselves. Their eyes sparkle if given an instrument, some paints, or just running around playing their own reindeer games.

Every time I get down and sad I think of my daughter's smile and the fact I am blessed with a constant reminder that it is okay to be silly. Unfortunately as a divorced parent I don't see her nearly as much as I wish I did, but I keep a rock in my pocket which reminds me that my silly girl is always with me. I could tell her to get serious, but that just seems silly.

It's the P-word...Politics!

This is the only kind of politics I enjoy now - http://www.youtube.com/watch?v=eabefjsJsAQ



I grew up in a family that was always involved in local politics. My mother worked for a local state senator, my father served on the planning commission, was a member of the local central committee, and ran for city council. I got into the picture too by being a member of the city's youth commission. When I was halfway through college I decided to major in political science because the field interested me so much. Now, I find myself despising politics and how those in politics act towards each other and those that they were elected to represent.

Before I began my studies in college level political science, I knew there were lots of underhanded dealings, but I was still overly idealistic. This has changed over the years and especially came to head during the 2003 recall of Governor Gray Davis in California. Early on in my political life I was a Democrat. Prior to 2003 I became a Republican which is still my party of choice. This is not a resounding endorsement, but rather the understanding that we are currently limited to a two party system.



Discussing the reasons why voters were drawn to recall Davis is unnecessary. What matters is identifying how this election made me see how hypocritical politicians and voters could be. This was just a few years after the Bush Gore elections and that was cited as a concern. There were 135 candidates on the ballot and some cited a fear that it would take a very long time to determine the winner. This was just a smoke screen. Gray Davis was still the governor so until it was determined if the recall was successful and who the new governor was, Davis would still be in office. This annoyed me, but what I read in the paper around this same time really made my blood boil. Whether I agreed with Democratic party policies or not, I always believed that they were sincere with regards to their values. These values included supporting immigrants and not discriminating against them or pretty much any minority group. Among the candidates were Arnold Schwarzenegger and Lieutenant Governor Cruz Bustamante. Constantly letters were sent into the paper mocking Schwarzenegger’s inability to pronounce the name of the state correctly. Bustamante also had an accent, but nothing was mentioned of his. If anyone dared to mock his accent there would be screams of racism from many on the Democratic side. This is just one example of hypocrisy in politics; unfortunately I have encountered many more prior and since then.

Haitian "orphans"

Start with this classic song released in 1979. Reunited by Peaches and Herb

Check out this story about the Haitian orphans who were recently reunited with their families.

http://www.cnn.com/2010/WORLD/americas/03/17/haiti.baptists.children/index.html?hpt=T2

There is a massive earthquake and thousands killed leaving many thousands of children orphaned. Let's rush in and help out. Well, of course we want to help out, but is rushing in always the best answer. Is it ever possible that some of those so called do gooders may have other not so wonderful purposes for doing what they do? I argue that this is not just possible, but likely in almost every situation in life. There are always some who are out to take advantage of a situation under the auspices of doing the better good. These are teachers or administrators who claim when requesting more funds that they are doing so for the good of the children. This may be true, but their motives must not cloud the analysis of the results produced.

What happened in Haiti? A massive earthquake hit a country that was ill prepared for the disaster let alone any disaster. Many people were killed and clearly with the large amount of deaths there are many orphaned children. Does this mean that every child is an orphan? Of course not and also there may be some children who think they are orphans, but in actuality have parents looking for them.

Part of the problem here is the instant satisfaction society that we have become. Voters in California were warned that if we tried to recall then Governor Davis, we were at risk for a long recount that would mean we might have to wait to know who are new governor would be for over a month like during the 2000 presidential recount. I believe that as long as we get the count eventually then however long it takes it is worth it. This is true for the "orphans" as well. As long as the "orphans" are getting enough food, shelter, and clothing while we determine if they have families then they should stay in their home country. When it is determined that they are actually orphans then they can be processed correctly. If it is determined they aren't orphans then we haven't done the tragic move of removing them from their families.

Our country has done a lot of wonderful things for this world. We have also made the mistake many times of pushing our values and desires on people rather than offering them support in strengthening their countries. There are no simple answers when we try to help another country out, but we need to keep in mind that we are there to help and not to take over. This is true for countries and families as well.

Wikipedia info on Bipolar Disorder

Some of you reading my blog may wonder what is a more exact definition of bipolar disorder so I have included the following for you all.

The following is from en.wikipedia.org/wiki/Bipolar_disorder

Bipolar disorder

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"Manic depression" redirects here. For other uses, see Manic depression (disambiguation).

Bipolar disorder
Classification and external resources
Many people involved with the arts, such as Vincent van Gogh, are believed to have suffered from bipolar disorder

Bipolar disorder or manic–depressive disorder (also referred to as bipolar affective disorder or manic depression) is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated mood. These moods are clinically referred to as mania or, if milder, hypomania. Individuals who experience manic episodes also commonly experience depressive episodes or symptoms, or mixed episodes in which features of both mania and depression are present at the same time.^[1] These episodes are usually separated by periods of "normal" mood, but in some individuals, depression and mania may rapidly alternate, known as rapid cycling. Extreme manic episodes can sometimes lead to psychotic symptoms such as delusions and hallucinations. The disorder has been subdivided into bipolar I, bipolar II, cyclothymia, and other types, based on the nature and severity of mood episodes experienced; the range is often described as the bipolar spectrum.
Data from the United States on lifetime prevalence varies, but indicates a rate of around 1% for Bipolar I, 0.5–1% for Bipolar II or cyclothymia, and 2–5% for subthreshold cases meeting some, but not all, criteria. The onset of full symptoms generally occurs in late adolescence or young adulthood. Diagnosis is based on the person's self-reported experiences, as well as observed behavior. Episodes of abnormality are associated with distress and disruption, and an elevated risk of suicide, especially during depressive episodes. In some cases it can be a devastating long-lasting disorder; in others it has also been associated with creativity, goal striving and positive achievements; there is significant evidence to suggest that many people with creative talents have also suffered from some form of bipolar disorder (for more information, see list of people affected by bipolar disorder). ^[2]
Genetic factors contribute substantially to the likelihood of developing bipolar disorder, and environmental factors are also implicated. Bipolar disorder is often treated with mood stabilizer medications, and sometimes other psychiatric drugs. Psychotherapy also has a role, often when there has been some recovery of stability. In serious cases in which there is a risk of harm to oneself or others involuntary commitment may be used; these cases generally involve severe manic episodes with dangerous behavior or depressive episodes with suicidal ideation. There are widespread problems with social stigma, stereotypes and prejudice against individuals with a diagnosis of bipolar disorder.^[3] People with bipolar disorder exhibiting psychotic symptoms can sometimes be misdiagnosed as having schizophrenia, another serious mental illness.^[4]
The current term "bipolar disorder" is of fairly recent origin and refers to the cycling between high and low episodes (poles). A relationship between mania and melancholia had long been observed, although the basis of the current conceptualisation can be traced back to French psychiatrists in the 1850s. The term "manic-depressive illness" or psychosis was coined by German psychiatrist Emil Kraepelin in the late nineteenth century, originally referring to all kinds of mood disorder. German psychiatrist Karl Leonhard split the classification again in 1957, employing the terms unipolar disorder (major depressive disorder) and bipolar disorder.

Signs and symptoms

Bipolar disorder is a condition in which people experience abnormally elevated (manic or hypomanic) and abnormally depressed states for periods of time in a way that interferes with functioning. Bipolar disorder has been estimated to afflict more than 5 million Americans—about 1 out of every 45 adults.^[5] It is equally prevalent in men and women, and is found across all cultures and ethnic groups.^[6] Not everyone's symptoms are the same, and there is no blood test to confirm the disorder. Researchers postulate that bipolar disorder may be caused by chemical imbalances in the brain. Bipolar disorder can appear to be unipolar depression. Diagnosing bipolar disorder is often difficult, even for mental health professionals. What distinguishes bipolar disorder from unipolar depression is that the affected person experiences states of mania and depression. Often bipolar is inconsistent among patients because some people feel depressed more often than not and experience little mania whereas others experience predominantly manic symptoms.

Depressive episode

Main article: Major depressive episode

Signs and symptoms of the depressive phase of bipolar disorder include persistent feelings of sadness, anxiety, guilt, anger, isolation, or hopelessness; disturbances in sleep and appetite; fatigue and loss of interest in usually enjoyable activities; problems concentrating; loneliness, self-loathing, apathy or indifference; depersonalization; loss of interest in sexual activity; shyness or social anxiety; irritability, chronic pain (with or without a known cause); lack of motivation; and morbid suicidal ideation.^[7] In severe cases, the individual may become psychotic, a condition also known as severe bipolar depression with psychotic features.

Manic episode

Main article: Mania

Mania is generally characterized by a distinct period of an elevated, expansive, or irritable mood state. People commonly experience an increase in energy and a decreased need for sleep. A person's speech may be pressured, with thoughts experienced as racing. Attention span is low and a person in a manic state may be easily distracted. Judgment may become impaired; sufferers may go on spending sprees or engage in behavior that is quite abnormal for them. They may indulge in substance abuse, particularly alcohol or other depressants, cocaine or other stimulants, or sleeping pills. Their behavior may become aggressive, intolerant or intrusive. People may feel out of control or unstoppable. People may feel they have been "chosen," are "on a special mission," or other grandiose or delusional ideas. Sexual drive may increase. At more extreme phases of bipolar I, a person in a manic state can begin to experience psychosis, or a break with reality, where thinking is affected along with mood.^[8] Many people in a manic state experience severe anxiety and are very irritable (to the point of rage), while others are euphoric and grandiose.
In order to be diagnosed with mania according to the Diagnostic and Statistical Manual of Mental Disorders (commonly referred to as the DSM) a person must experience this state of elevated or irritable mood, as well as other symptoms, for at least one week, less if hospitalization is required. According to the National Institute of Mental Health, "A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for 1 week or longer. If the mood is irritable, four additional symptoms must be present."^[9]

Hypomanic episode

Main article: Hypomanic episode

Hypomania is generally a mild to moderate level of mania, characterized by optimism, pressure of speech and activity, and decreased need for sleep. Some people have increased creativity while others demonstrate poor judgment and irritability. Others experience hypersexuality. These persons generally have increased energy and tend to become more active than usual. They do not, however, have delusions or hallucinations. Hypomania can be difficult to diagnose because it may masquerade as mere happiness, though it carries the same risks as mania.
Hypomania may feel good to the person who experiences it. Thus, even when family and friends learn to recognize the mood swings, the individual often will deny that anything is wrong.^[10] Mind you, what might be called a "hypomanic event", if it not accompanied by complementary depressive episodes ("downs", etcetera), is not typically deemed as problematic whatsoever. The "problem" arises when mood changes are uncontrollable and, more importantly, volatile or "mercurial". If unaccompanied by depressive counterpart episodes or otherwise general irritability, this behavior is typically called hyperthymia, or happiness, which is of course perfectly normal. Indeed, the most elementary definition of bipolar disorder is an often "violent" or "jarring" state of essentially uncontrollable oscillation between hyperthymia and dysthymia.

Mixed affective episode

Main article: Mixed state (psychiatry)

In the context of bipolar disorder, a mixed state is a condition during which symptoms of mania and clinical depression occur simultaneously (for example, agitation, anxiety, aggressiveness or belligerence, confusion, fatigue, impulsiveness, insomnia, irritability, morbid and/or suicidal ideation, panic, paranoia, persecutory delusions, pressured speech, racing thoughts, restlessness, and rage).^[11]

Associated features

Associated features are clinical phenomena that often accompany the disorder, but are not part of the diagnostic criteria for the disorder.

Cognitive functioning

Reviews have indicated that most individuals diagnosed with bipolar disorder but who are euthymic (not experiencing major depression or mania) do not show neuropsychological deficits on most tests.^[12] Meta-analyses have indicated, by averaging the variable findings of many studies, cognitive deficits on some measures of sustained attention, executive function and verbal memory, in terms of group averages. On some tests functioning is superior, however,^[12] and sub-threshold mood states and psychiatric medications may account for some deficits.^[13][14] A 2010 study found that "excellent performance" at school at age 15-16 was associated in males with a higher rate of developing bipolar disorder, but so was the poorest performance.^[15] A 2005 study of young adult males found that poor performance on visuospatial tasks was associated with a higher rate of developing bipolar disorder, but so was high performance in arithmetic reasoning.^[16]

Creativity

Main article: Creativity and mental illness

Bipolar disorder has been associated with people involved in the arts but it is an ongoing question as to whether many creative geniuses had bipolar disorder.^[17][18][19] Some studies have found a significant association between bipolar disorder and creativity, although it is unclear in which direction the cause lies or whether both conditions are caused by a third unknown factor; temperament has been hypothesized to be one such factor.^[20][21][22]

Goals

A series of authors have described mania or hypomania as being related to a high motivation to achieve, ambitious goal-setting, and sometimes high achievement. One study indicated that the pursuit of goals, encouraged by sometimes achieving them, can become emotionally dysregulated and involve the development of mania.^[23] Individuals may have low self-esteem and difficulties in social adjustment, however, and by definition there are periods of depression with difficulty in motivation and functioning.^[24]

Causes

The causes of bipolar disorder likely vary between individuals. Twin studies have been limited by relatively small sample sizes but have indicated a substantial genetic contribution, as well as environmental influence. For Bipolar I, the (probandwise) concordance rates in modern studies have been consistently put at around 40% in monozygotic twins (same genes), compared to 0 to 10% in dizygotic twins.^[25] A combination of bipolar I, II and cyclothymia produced concordance rates of 42% vs 11%, with a relatively lower ratio for bipolar II that likely reflects heterogeneity. The overall heritability of the bipolar spectrum has been put at 0.71.^[26] There is overlap with unipolar depression and if this is also counted in the co-twin the concordance with bipolar disorder rises to 67% (Mz) and 19% (Dz).^[27] The relatively low concordance between dizygotic twins brought up together suggests that shared family environmental effects are limited, although the ability to detect them has been limited by small sample sizes.^[26]

Genetic

Genetic studies have suggested many chromosomal regions and candidate genes appearing to relate to the development of bipolar disorder, but the results are not consistent and often not replicated.^[28] Although the first genetic linkage finding for mania was in 1969,^[29] the linkage studies have been inconsistent.^[30] (Genetic linkage studies may be followed by fine mapping searching for the phenomenon of linkage disequilibrium with a single gene, then DNA sequencing; using this approach causative DNA base pair changes have been reported for the genes P2RX7^[31] and TPH1^{[citation needed]}). Recent meta-analyses of linkage studies detected either no significant genome-wide findings or, using a different methodology, only two genome-wide significant peaks, on chromosome 6q and on 8q21. Genome-wide association studies have also not brought a consistent focus — each has identified new loci, while none of the previously identified loci were replicated.^[30] Findings did include a single-nucleotide polymorphism in DGKH;^[32] a locus in a gene-rich region of high linkage disequilibrium (LD) on chromosome 16p12;^[33] and a single-nucleotide polymorphism in MYO5B.^[34] A comparison of these studies, combined with a new study, suggested an association with ANK3 and CACNA1C, thought to be related to calcium and sodium voltage-gated ion channels.^[35] Diverse findings point strongly to heterogeneity, with different genes being implicated in different families.^[36] Numerous specific studies find various specific links.^{[37][38][39][40][41]} Advanced paternal age has been linked to a somewhat increased chance of bipolar disorder in offspring, consistent with a hypothesis of increased new genetic mutations.^[42] A review seeking to identify the more consistent findings suggested several genes related to serotonin (SLC6A4 and TPH2), dopamine (DRD4 and SLC6A3), glutamate (DAOA and DTNBP1), and cell growth and/or maintenance pathways (NRG1, DISC1 and BDNF), although noting a high risk of false positives in the published literature. It was also suggested that individual genes are likely to have only a small effect and to be involved in some aspect related to the disorder (and a broad range of "normal" human behavior) rather than the disorder per se.^[43]

Childhood precursors

Some limited long-term studies indicate that children who later receive a diagnosis of bipolar disorder may show subtle early traits such as subthreshold cyclical mood abnormalities, full major depressive episodes, and possibly ADHD with mood fluctuation. There may be hypersensitivity and irritability. There is some disagreement whether the experiences are necessarily fluctuating or may be chronic.^[44] A history of stimulant use in childhood is found in high numbers of bipolar patients and has been found to cause an earlier onset of bipolar disorder and a worse clinical course, independent of attention deficit hyperactivity disorder.^[45][46][47]

Life events and experiences

Evidence suggests that environmental factors play a significant role in the development and course of bipolar disorder, and that individual psychosocial variables may interact with genetic dispositions.^[43] There is fairly consistent evidence from prospective studies that recent life events and interpersonal relationships contribute to the likelihood of onsets and recurrences of bipolar mood episodes, as they do for onsets and recurrences of unipolar depression.^[48] There have been repeated findings that between a third and a half of adults diagnosed with bipolar disorder report traumatic/abusive experiences in childhood, which is associated on average with earlier onset, a worse course, and more co-occurring disorders such as PTSD.^[49] The total number of reported stressful events in childhood is higher in those with an adult diagnosis of bipolar spectrum disorder compared to those without, particularly events stemming from a harsh environment rather than from the child's own behavior.^[50] Early experiences of adversity and conflict are likely to make subsequent developmental challenges in adolescence more difficult, and are likely a potentiating factor in those at risk of developing bipolar disorder.^[44]

Neural processes

Hyperintensities (bright areas on MRI scans above) are 2.5 times more likely to occur in bipolar disorder

Researchers hypothesize that abnormalities in the structure and/or function of certain brain circuits could underlie bipolar and other mood disorders. Some studies have found anatomical differences in areas such as the amygdala,^[51] prefrontal cortex^[52] and hippocampus. However, despite 25 years of research involving more than 7,000 MRI scans, studies continue to report conflicting findings and there remains considerable debate over the neuroscientific findings. Two fairly consistent abnormalities found in a meta-analysis of 98 MRI or CT neuroimaging studies were that groups with bipolar disorder had lateral ventricles which were on average 17% larger than control groups, and were 2.5 times more likely to have deep white matter hyperintensities. Given the size of the meta-analysis, it was concluded that the relatively small number of significant findings was perhaps surprising, and that there may be genuinely limited structural change in bipolar disorder, or perhaps heterogeneity has obscured other differences. In addition, it was noted that averaged associations found at the level of multiple studies may not exist for an individual.^[53]
The "kindling" theory asserts that people who are genetically predisposed toward bipolar disorder can experience a series of stressful events,^[54] each of which lowers the threshold at which mood changes occur. Eventually, a mood episode can start (and become recurrent) by itself. There is evidence of hypothalamic-pituitary-adrenal axis (HPA axis) abnormalities in bipolar disorder due to stress.^[55]
Recent research in Japan hypothesizes that dysfunctional mitochondria in the brain may play a role ^[56]
Other recent research implicates issues with a sodium ATPase pump,^[57] causing cyclical periods of poor neuron firing (depression) and hyper sensitive neuron firing (mania). This may only apply for type one, but type two apparently results from a large confluence of factors.^{[citation needed]}

Melatonin activity

It has been suggested that a hypersensitivity of the melatonin receptors in the eye could be a reliable indicator of bipolar disorder, in studies called a trait marker, as it is not dependent on state (mood, time, etc). In small studies, patients diagnosed as bipolar reliably showed a melatonin-receptor hypersensitivity to light during sleep, causing a rapid drop in sleeptime melatonin levels compared to controls.^[58] Another study showed that drug-free, recovered, bipolar patients exhibited no hypersensitivity to light.^[59] It has also been shown in humans that valproic acid, a mood stabilizer, increases transcription of melatonin receptors^[60] and decreases eye melatonin-receptor sensitivity in healthy volunteers^[61] while low-dose lithium, another mood stabilizer, in healthy volunteers, decreases sensitivity to light when sleeping, but doesn't alter melatonin synthesis.^[62] The extent to which melatonin alterations may be a cause or effect of bipolar disorder are not fully known.

Psychological processes

Psychological studies of bipolar disorder have examined the development of a wide range of both the core symptoms of psychomotor activation and related clusterings of depression/anxiety, increased hedonic tone, irritability/aggression and sometimes psychosis. The existing evidence has been described as patchy in terms of quality but converging in a consistent manner. The findings suggest that the period leading up to mania is often characterized by depression and anxiety at first, with isolated sub-clinical symptoms of mania such as increased energy and racing thoughts. The latter increase and lead to increased activity levels, the more so if there is disruption in circadian rhythms or goal attainment events. There is some indication that once mania has begun to develop, social stressors, including criticism from significant others, can further contribute. There are also indications that individuals may hold certain beliefs about themselves, their internal states, and their social world (including striving to meet high standards despite it causing distress) that may make them vulnerable during changing mood states in the face of relevant life events. In addition, subtle frontal-temporal and subcortical difficulties in some individuals, related to planning, emotional regulation and attentional control, may play a role. Symptoms are often subthreshold and likely continuous with normal experience. Once (hypo)mania has developed, there is an overall increase in activation levels and impulsivity. Negative social reactions or advice may be taken less notice of, and a person may be more caught up in their own thoughts and interpretations, often along a theme of feeling criticised. There is some suggestion that the mood variation in bipolar disorder may not be cyclical as often assumed, nor completely random, but results from a complex interaction between internal and external variables unfolding over time; there is mixed evidence as to whether relevant life events are found more often in early than later episodes.^[12] Many sufferers report inexplicably varied cyclical patterns, however.^[63]

Diagnosis

Diagnosis is based on the self-reported experiences of an individual as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a psychiatrist, nurse, social worker, clinical psychologist or other clinician in a clinical assessment. There are lists of criteria for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms. Assessment is usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to oneself or others. The most widely used criteria for diagnosing bipolar disorder are from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR, and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, currently the ICD-10. The latter criteria are typically used in Europe and other regions while the DSM criteria are used in the USA and other regions, as well as prevailing in research studies.
An initial assessment may include a physical exam by a physician. Although there are no biological tests which confirm bipolar disorder, tests may be carried out to exclude medical illnesses such as hypo- or hyperthyroidism, metabolic disturbance, a systemic infection or chronic disease, and syphilis or HIV infection. An EEG may be used to exclude epilepsy, and a CT scan of the head to exclude brain lesions. Investigations are not generally repeated for relapse unless there is a specific medical indication.
There are several other mental disorders which may involve similar symptoms to bipolar disorder. These include schizophrenia,^[64] schizoaffective disorder, drug intoxication, brief drug-induced psychosis, schizophreniform disorder and borderline personality disorder. Both borderline personality and bipolar disorder can involve what are referred to as "mood swings". In bipolar disorder, the term refers to the cyclic episodes of elevated and depressed mood which generally last weeks or months. The term in borderline personality refers to the marked lability and reactivity of mood, known as emotional dysregulation, due to response to external psychosocial and intrapsychic stressors; these may arise or subside suddenly and dramatically and last for seconds, minutes, hours or days. A bipolar depression is generally more pervasive with sleep, appetite disturbance and nonreactive mood, whereas the mood in dysthymia of borderline personality remains markedly reactive and sleep disturbance not acute.^[65] Some hold that borderline personality disorder represents a subthreshold form of mood disorder,^[66][67] while others maintain the distinctness, though noting they often coexist.^[68][69]

Clinical scales

The Bipolar Spectrum Diagnostic Scale (BSDS)^[70] was developed by Ronald Pies, MD and was later refined and tested by S. Nassir Ghaemi, MD, MPH and colleagues. The BSDS arose from Pies's experience as a psychopharmacology consultant, where he was frequently called on to manage cases of "treatment-resistant depression." There are 19 question items and two sections on the English version of the BSDS. The scale was validated in its original version and demonstrated a high sensitivity.^[71]

Criteria and subtypes

There is no clear consensus as to how many types of bipolar disorder exist.^[72] In DSM-IV-TR and ICD-10, bipolar disorder is conceptualized as a spectrum of disorders occurring on a continuum. The DSM-IV-TR lists three specific subtypes:^[73]

Bipolar I disorder

One or more manic episodes. Subcategories specify whether there has been more than one episode, and the type of the most recent episode.^[74] A depressive or hypomanic episode is not required for diagnosis, but it frequently occurs.

Bipolar II disorder

No manic episodes, but one or more hypomanic episodes and one or more major depressive episode.^[75] However, a Bipolar II diagnosis is not a guarantee that they will not eventually suffer from such an episode in the future.^{[citation needed]} Hypomanic episodes do not go to the full extremes of mania (i.e., do not usually cause severe social or occupational impairment, and are without psychosis), and this can make Bipolar II more difficult to diagnose, since the hypomanic episodes may simply appear as a period of successful high productivity and is reported less frequently than a distressing, crippling depression.

Cyclothymia

A history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes.^[76] There is a low-grade cycling of mood which appears to the observer as a personality trait, and interferes with functioning.

Bipolar Disorder NOS (Not Otherwise Specified) is a catchall category, diagnosed when the disorder does not fall within a specific subtype.^[77] It can still significantly impair and adversely affect the quality of life of the patient.
The Bipolar I and II categories have specifiers that indicate the presentation and course of the disorder. For example, the "with full interepisode recovery" specifier applies if there was full remission between the two most recent episodes.^[78]

Rapid cycling

Most people who meet criteria for bipolar disorder experience a number of episodes, on average 0.4 to 0.7 per year, lasting three to six months.^[79][80]
Rapid cycling, however, is a coarse specifier that may be applied to any of the above subtypes. It is defined as having four or more episodes per year and is found in a significant fraction of individuals with bipolar disorder. The definition of rapid cycling most frequently cited in the literature (including the DSM) is that of Dunner and Fieve: at least four major depressive, manic, hypomanic or mixed episodes are required to have occurred during a 12-month period.^[81] There are references that describe very rapid (ultra-rapid) or extremely rapid^[82] (ultra-ultra or ultradian) cycling. One definition of ultra-ultra rapid cycling is defining distinct shifts in mood within a 24-to-48-hour period.

Challenges

The experiences and behaviors involved in bipolar disorder are often not understood by individuals or recognized by mental health professionals, so diagnosis may sometimes be delayed for 10 years or more.^[83] That treatment lag is apparently not decreasing, even though there is now increased public awareness of this mental health condition in popular magazines and health websites. Despite this increased focus, individuals are still commonly misdiagnosed.^[84] An individual may appear simply depressed when they are seen by a health professional. This can result in misdiagnosis of Major Depressive Disorder and harmful treatments. Screening tools such as the Hypomanic Check List Questionnaire (HCL-32)^[85] have been developed to assist the quite often difficult detection of Bipolar II disorders.
However, there is also a long-standing issue in the research literature as to whether a categorical classificatory divide between unipolar and bipolar depression is actually valid, or whether it is more accurate to talk of a continuum involving dimensions of depression and mania.^[86][87]
It has been noted that the bipolar disorder diagnosis is officially characterised in historical terms such that, technically, anyone with a history of (hypo)mania and depression has bipolar disorder whatever their current or future functioning and vulnerability. This has been described as "an ethical and methodological issue", as it means no one can be considered as being recovered (only "in remission") from bipolar disorder according to the official criteria. This is considered especially problematic given that brief hypomanic episodes are widespread among people generally and not necessarily associated with dysfunction.^[12]
Flux is the fundamental nature of bipolar disorder.^[88] Individuals with the illness have continual changes in energy, mood, thought, sleep, and activity. The diagnostic subtypes of bipolar disorder are thus static descriptions—snapshots, perhaps—of an illness in continual flux, with a great diversity of symptoms and varying degrees of severity. Individuals may stay in one subtype, or change into another, over the course of their illness.^[89] The DSM-V, to be published in 2013, will likely include further and more accurate sub-typing (Akiskal and Ghaemi, 2006).
The diagnosis of bipolar disorder can be complicated by coexisting psychiatric conditions such as obsessive-compulsive disorder, social phobia, panic disorder, or attention-deficit/hyperactivity disorder. Substance abuse may predate the appearance of bipolar symptoms, further complicating the diagnosis. A careful longitudinal analysis of symptoms and episodes, enriched if possible by discussions with friends and family members, is crucial to establishing a valid treatment plan where these comorbidities exist.^[90]
The diagnosis of bipolar disorder in children is particularly challenging, and controversial. Some who show some bipolar symptoms tend to have a rapid-cycling or mixed-cycling pattern that may not meet DSM-IV criteria.^[91] In addition, it can be difficult to distinguish between age-appropriate restlessness, the fidgeting of children with ADHD, and the purposeful busy activity of mania.^[92] Further complicating the diagnosis, is that abused or traumatized children can seem to have bipolar disorder when they are actually reacting to horrors in their lives.^[93]
In the elderly, recognition and treatment of bipolar disorder may be complicated by the presence of dementia or the side effects of medications being taken for other conditions.^[94] As yet there is very little evidence-based research to guide management of bipolar in the elderly as opposed to adults in general.

Management

Main article: Treatment of bipolar disorder

There are a number of pharmacological and psychotherapeutic techniques used to treat Bipolar Disorder. Individuals may use self-help and pursue a personal recovery journey.
Hospitalization may be required especially with the manic episodes present in bipolar I. This can be voluntary or (if mental health legislation allows and varying state-to-state regulations in the USA) involuntary (called civil or involuntary commitment). Long-term inpatient stays are now less common due to deinstitutionalization, although can still occur.^[95] Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or Assertive Community Treatment team, supported employment and patient-led support groups, intensive outpatient programs. These are sometimes referred to partial-inpatient programs.^[96]

Psychosocial

Psychotherapy is aimed at alleviating core symptoms, recognizing episode triggers, reducing negative expressed emotion in relationships, recognizing prodromal symptoms before full-blown recurrence, and, practicing the factors that lead to maintenance of remission^[97] Cognitive behavioural therapy, family-focused therapy, and psychoeducation have the most evidence for efficacy in regard to relapse prevention, while interpersonal and social rhythm therapy and cognitive-behavioural therapy appear the most effective in regard to residual depressive symptoms. Most studies have been based only on bipolar I, however, and treatment during the acute phase can be a particular challenge.^[98] Some clinicians emphasize the need to talk with individuals experiencing mania, to develop a therapeutic alliance in support of recovery.^[99]

Medication

Sodium valproate is a common mood stabilizer

The mainstay of treatment is a mood stabilizer medication such as lithium carbonate or lamotrigine.^[100][101] Lamotrigine has been found to be best for preventing depressions, while lithium is the only drug proven to reduce suicide in bipolar patients. These two drugs comprise several unrelated compounds which have been shown to be effective in preventing relapses of manic, or in the one case, depressive episodes. The first known and "gold standard" mood stabilizer is lithium,^[102] while almost as widely used is sodium valproate,^[103] also used as an anticonvulsant. Other anticonvulsants used in bipolar disorder include carbamazepine, reportedly more effective in rapid cycling bipolar disorder, and lamotrigine, which is the first anticonvulsant shown to be of benefit in bipolar depression.^[104]
Treatment of the agitation in acute manic episodes has often required the use of atypical antipsychotic medications, such as quetiapine, olanzapine and chlorpromazine. More recently, olanzapine and quetiapine have been approved as effective monotherapy for the maintenance of bipolar disorder.^[105] A head-to-head randomized control trial in 2005 has also shown olanzapine monotherapy to be as effective and safe as lithium in prophylaxis.^[106]
The use of antidepressants in bipolar disorder has been debated, with some studies reporting a worse outcome with their use triggering manic, hypomanic or mixed episodes, especially if no mood stabiliser is used. However, most mood stabilizers are of limited effectiveness in depressive episodes. Rapid cycling can be induced or made worse by antidepressants, unless there is adjunctive treatment with a mood stabilizer.^[107][108] One large-scale study found that depression in bipolar disorder responds no better to an antidepressant with mood stabilizer than it does to a mood stabilizer alone.^[109] Recent research indicates that triacetyluridine may help improve symptoms of bipolar disorder.^[110]Clinical studies have shown that Omega 3 fatty acids may have beneficial effects on bipolar disorder.^[111]
Also, topiramate is an anticonvulsant often prescribed as a mood stabilizer. It is an off-label use when used to treat bipolar disorder. Unfortunately, its usefulness is likely minimal and side effects, such as significant cognitive impairment, undermine its efficacy (Kushner, et al. 2006 Bipolar Disorders 8; Chengappa, et al. 2006 J Clin Psych; 6).
When medication causes a reduction in symptoms or complete remission, it is important for someone with a bipolar disorder to understand they should continue to take the medicine. This can be complicated, as effective treatment may result in the reduction of manic symptoms and/or the medicine can be mood blunting or sedative, resulting in the person feeling they are stifled or that the medicine isn't working. Either way, relapse is likely to occur if the medicine is discontinued.

Prognosis

For many individuals with bipolar disorder a good prognosis results from good treatment, which, in turn, results from an accurate diagnosis. Because bipolar disorder can have a high rate of both under-diagnosis and misdiagnosis^{[citation needed]}, it is often difficult for individuals with the condition to receive timely and competent treatment.
Bipolar disorder can be a severely disabling medical condition. However, many individuals with bipolar disorder can live full and satisfying lives. Quite often, medication is needed to enable this. Persons with bipolar disorder may have periods of normal or near normal functioning between episodes.^[112]
Ultimately one's prognosis depends on many factors, several of which are within the control of the individual. Such factors may include: the right medicines, with the right dose of each; comprehensive knowledge of the disease and its effects; a positive relationship with a competent medical doctor and therapist; and good physical health, which includes exercise, nutrition, and a regulated stress level.
There are obviously other factors that lead to a good prognosis as well, such as being very aware of small changes in one's energy, mood, sleep and eating behaviors, as well as having a plan in conjunction with one's doctor for how to manage subtle changes that might indicate the beginning of a mood swing. Some people find that keeping a log of their moods can assist them in predicting changes.^[113]

Functioning

A recent 20-year prospective study on bipolar I and II found that functioning varied over time along a spectrum from good to fair to poor. During periods of major depression or mania (in BPI), functioning was on average poor, with depression being more persistently associated with disability than mania. Functioning between episodes was on average good — more or less normal. Subthreshold symptoms were generally still substantially impairing, however, except for hypomania (below or above threshold) which was associated with improved functioning.^[114]
Another study confirmed the seriousness of the disorder as "the standardized all-cause mortality ratio among patients with BD is increased approximately two-fold." Bipolar disorder is currently regarded "as possibly the most costly category of mental disorders in the United States." Episodes of abnormality are associated with distress and disruption, and an elevated risk of suicide, especially during depressive episodes.^[115]

Recovery

A naturalistic study from first admission for mania or mixed episode (representing the hospitalized and therefore most severe cases) found that 50% achieved syndromal recovery (no longer meeting criteria for the diagnosis) within six weeks and 98% within two years. 72% achieved symptomatic recovery (no symptoms at all) and 43% achieved functional recovery (regaining of prior occupational and residential status). However, 40% went on to experience a new episode of mania or depression within 2 years of syndromal recovery, and 19% switched phases without recovery.^[116] Many therapists treat individuals with Bipolar I and II by helping them identify the return of symptoms, and actions that will prevent symptoms from getting worse.^[117]

Recurrence

The following behaviors can lead to depressive or manic recurrence:^{[citation needed]}

• Discontinuing or lowering one's dose of medication.
• Being under- or over-medicated. Generally, taking a lower dosage of a mood stabilizer can lead to relapse into mania. Taking a lower dosage of an antidepressant may cause the patient to relapse into depression, while higher doses can cause destabilization into mixed-states or mania.
• An inconsistent sleep schedule can aggravate symptoms. Too much sleep can be an indicator that depression is returning. It has been found that too little sleep can lead to mixed states/mania.
• Caffeine can cause destabilization of mood toward irritability, dysphoria, and mania. Anecdotal evidence seems to suggest that lower dosages of caffeine can have effects ranging from anti-depressant to mania-inducing.
• Inadequate stress management and poor lifestyle choices. If unmedicated, excessive stress can cause the individual to relapse. Medication raises the stress threshold somewhat, but too much stress still causes relapse.
• Often bipolar individuals are subject to self-medication, the most common drugs being alcohol, diazepam/sleeping tablets and marijuana. Studies show that tobacco smoking induces a calming effect on most bipolar people, and a very high percentage suffering from the prolonged use.^[118]

Recurrence can be managed by the sufferer with the help of a close friend, based on the occurrence of idiosyncratic prodromal events.^[119] This theorizes that a close friend could notice which moods, activities, behaviours, thinking processes, or thoughts typically occur at the outset of bipolar episodes. They can then take planned steps to slow or reverse the onset of illness, or take action to prevent the episode from being damaging.^[120]

Morbidity

According to an article in Psychiatric Times by McIntyre et al.,

"Mortality studies have documented an increase in all-cause mortality in patients with BD (Bipolar Disorder). A newly established and rapidly growing database indicates that mortality due to chronic medical disorders (eg, cardiovascular disease) is the single largest cause of premature and excess deaths in BD. The standardized mortality ratio from suicide in BD is estimated to be approximately 18 to 25, further emphasizing the lethality of the disorder."^[121]

Most people with bipolar disorder never attempt suicide or complete it. The annual average suicide rate in males and females with diagnosed bipolar disorder is 0.4%. This is 10 to more than 20 times that of the general population.^[122]
Bipolar disorder can cause suicidal ideation that leads to suicidal, especially during mixed states such as dysphoric mania and agitated depression.^[123] Persons suffering from Bipolar II have high rates of suicide compared to persons suffering from other mental health conditions, including Major Depression. Major Depressive episodes are part of the Bipolar II experience, and there is evidence that sufferers of this disorder spend proportionally much more of their life in the depressive phase of the illness than their counterparts with Bipolar I Disorder (Akiskal & Kessler, 2007^[which?]).

Epidemiology

Disability-adjusted life year for bipolar disorder per 100,000 inhabitants in 2002.

     no data      less than 180      180–186      186–190      190–195      195–200      200–205      205–210      210–215      215–220      220–225      225–230      230–235

The lifetime prevalence of bipolar disorder type I, which includes at least a lifetime manic episode, has generally been estimated at 2%.^[124] A reanalysis of data from the National Epidemiological Catchment Area survey in the United States, however, suggested that 0.8 percent experience a manic episode at least once (the diagnostic threshold for bipolar I) and 0.5 a hypomanic episode (the diagnostic threshold for bipolar II or cyclothymia). Including sub-threshold diagnostic criteria, such as one or two symptoms over a short time-period, an additional 5.1 percent of the population, adding up to a total of 6.4 percent, were classed as having a bipolar spectrum disorder.^[125] A more recent analysis of data from a second US National Comorbidity Survey found that 1% met lifetime prevalence criteria for bipolar 1, 1.1% for bipolar II, and 2.4% for subthreshold symptoms.^[126] There are conceptual and methodological limitations and variations in the findings. Prevalence studies of bipolar disorder are typically carried out by lay interviewers who follow fully structured/fixed interview schemes; responses to single items from such interviews may suffer limited validity. In addition, diagnosis and prevalence rates are dependent on whether a categorical or spectrum approach is used. Concerns have arisen about the potential for both underdiagnosis and overdiagnosis.^[127]
Late adolescence and early adulthood are peak years for the onset of bipolar disorder.^[128][129] These are critical periods in a young adult's social and vocational development, and they can be severely disrupted.
Major depressive disorder and bipolar disorder are currently classified as separate disorders. Some researchers increasingly view them as part of an overlapping spectrum that also includes anxiety and psychosis. According to Hagop Akiskal, M.D., at the one end of the spectrum is bipolar type schizoaffective disorder, and at the other end is recurrent unipolar depression, with the anxiety disorders present across the spectrum. Also included in this view is premenstrual dysphoric disorder, postpartum depression, and postpartum psychosis. This view helps to explain why many people who have the illness do not have first-degree relatives with clear-cut "bipolar disorder", but who have family members with a history of these other disorders.

Children

Main article: Bipolar disorder in children

In professional classifications such as the American Psychiatric Association's Diagnostic and Statistical Manual (DSM) ^[130] or the World Health Organization's International Classification of Diseases (ICD)^[131] bipolar disorder is classified with adult onset disorders. However, as far back as the 1920s, Kraepelin ^[132] showed in a retrospective study of 900 manic-depressive adults that 0.4% had onset of symptoms before the age of ten. In a cohort of bipolar disordered adults, Loranger and Levine ^[133] retrospectively evaluated 200 adult bipolar patients and found that 0.5% had onset between the ages of five and nine. In a study of 898 adults with bipolar disorder, Goodwin and Jamison ^[134] found that 0.3% had onset before age 10. This literature supported the existence of childhood onset mania, but also indicated that it may be rare.
This idea was supported by a review of 28 papers by Anthony and Scott^[135], which suggested that childhood bipolar disorder was uncommon. In these papers, only three of 60 cases (5%) of purported childhood bipolar disorder met their criteria for bipolar disorder. However, Anthony and Scott's criteria differed from those currently in use, so the applicability of this work to current views of bipolar disorder is uncertain.
Population and community studies using DSM criteria show that about 1% of youth may have bipolar disorder ^[136][137]. Studies in clinics using these criteria show that up to 20% of youth referred to psychiatric clinics have bipolar disorder ^{[138][139][140]}. Many of these children required hospitalization due to the severity of their disorder ^[141][142]
Because of these diagnostic uncertainties, the validity of an early-onset form of bipolar disorder had been debated in the late 20th century. However, since that time, systematic reviews of diagnostic, genetic, neurobiological, treatment and longitudinal research studies ^{[143][144][145][146]} have concluded that this disorder can be validly diagnosed in children and adolescents. This consensus of the scientific community is also seen in the appearance of practice parameters for the disorder from the American Academy of Child and Adolescent Psychiatry^[147]
Findings indicate that the number of American [children] and [adolescents] treated for bipolar disorder increased 40-fold from 1994 to 2003, and continues to increase. The data suggest that doctors had been more aggressively applying the diagnosis to children, rather than that the incidence of the disorder has increased. The study calculated the number of psychiatric visits increased from 20,000 in 1994 to 800,000 in 2003, or 1% of the [population] under age 20.^[148]
The reasons for this increase in diagnosis are unclear. On the one hand, the recent consensus from the scientific community (see above) will have educated clinicians about the nature of the disorder and the methods for diagnosis and treatment in children. That, in turn, should increase the rate of diagnosis. On the other hand, assumptions regarding behavior, particularly in regard to the differential diagnosis of bipolar disorder, ADHD, and conduct disorder in children and adolescents, may also play a role.
Another factor is that the "consensus" regarding the diagnosis in the pediatric age group seems to apply only to the USA. The British National Institute on Health and Clinical Excellence (NICE) guidelines on bipolar disorder in 2006 ^[149] specifically described the broadened criteria used in the USA to diagnose bipolar disorder in children as suitable "only for research" and "were not convinced that evidence currently exists to support the everyday clinical use of (pediatric bipolar phenotype) diagnoses" which increase the "risk that medicines may be used to inappropriately treat a bipolar diathesis that does not exist."(p526). A 2002 German survey ^[150] of 251 child and adolescent psychiatrists (average 15 years clinical experience) found only 8% had ever diagnosed a pre-pubertal case of bipolar disorder in their careers. A similar survey of 199 child & adolescent psychiatrists (av 15 years clinical experience) in Australia and New Zealand ^[151] also found much lower rates of diagnosis than in the USA and a consensus that bipolar disorder was overdiagnosed in children and youth in the USA. Concerns about overdiagnosis in the USA have also been expressed by American child & adolescent psychiatrists ^{[152][153][154][155]} and a series of essays in the book "Bipolar children: Cutting-edge controversy, insights and research" ^[156] highlight several controversies and suggest the science still lacks consensus with regard to bipolar disorder diagnosis in the pediatric age group.
Although accurately diagnosing all disorders in children is important, for bipolar disorder, it is critical. On the one hand, the antipsychotic drugs sometimes prescribed for the treatment of bipolar disorder may increase risk to health including heart problems, diabetes, liver failure, and death.^[157] On the other hand, bipolar disorder is a very disabling disorder which leads to many impairments in children, including cognitive impairment^{[158][159][160]}, psychiatric hospitalization^{[139][140][161][162][163]}, psychosis ^{[139][140][162][163]} and suicide.^[164] Thus, physicians, parents and patients need to weight the potential risks and benefits when treating this disorder.^[165]

Older age

There is a relative lack of knowledge about bipolar disorder in late life. There is evidence that it becomes less prevalent with age but nevertheless accounts for a similar percentage of psychiatric admissions; that older bipolar patients had first experienced symptoms at a later age; that later onset of mania is associated with more neurologic impairment; that substance abuse is considerably less common in older groups; and that there is probably a greater degree of variation in presentation and course, for instance individuals may develop new-onset mania associated with vascular changes, or become manic only after recurrent depressive episodes, or may have been diagnosed with bipolar disorder at an early age and still meet criteria. There is also some weak evidence that mania is less intense and there is a higher prevalence of mixed episodes, although there may be a reduced response to treatment. Overall there are likely more similarities than differences from younger adults.^[166]

History

Main article: History of bipolar disorder

Varying moods and energy levels have been a part of the human experience since time immemorial. The words "melancholia" (an old word for depression) and "mania" have their etymologies in Ancient Greek. The word melancholia is derived from melas/μελας, meaning "black", and chole/χολη, meaning "bile" or "gall",^[167] indicative of the term's origins in pre-Hippocratic humoral theories. Within the humoral theories, mania was viewed as arising from an excess of yellow bile, or a mixture of black and yellow bile. The linguistic origins of mania, however, are not so clear-cut. Several etymologies are proposed by the Roman physician Caelius Aurelianus, including the Greek word ‘ania’, meaning to produce great mental anguish, and ‘manos’, meaning relaxed or loose, which would contextually approximate to an excessive relaxing of the mind or soul (Angst and Marneros 2001). There are at least five other candidates, and part of the confusion surrounding the exact etymology of the word mania is its varied usage in the pre-Hippocratic poetry and mythologies (Angst and Marneros 2001).

Society and culture

Cultural references

See also: List of people affected by bipolar disorder

Kay Redfield Jamison is a clinical psychologist and Professor of Psychiatry at the Johns Hopkins University School of Medicine, who profiled her own bipolar disorder in her 1995 memoir An Unquiet Mind,^[168] and argued for a connection between bipolar disorder and artistic creativity in her 1993 book, Touched with Fire.^[169]
Several films portrayed characters with traits suggestive of the diagnosis which have been the subject of discussion by psychiatrists and film experts alike. The 1993 film Mr. Jones is a notable example, with Richard Gere playing a person who swings from a manic episode into a depressive phase and back again, spending time in a psychiatric hospital and displaying many of the features of the syndrome.^[170] Allie Fox, the character played by Harrison Ford in the 1986 movie The Mosquito Coast, displays some features including recklessness, grandiosity, increased goal-directed activity and mood lability, as well as some paranoia.^[171]
In the progressive metal band Dream Theater song Six Degrees of Inner Turbulence from the album of the same name, the lyrics of the first movement, About to Crash, describes a girl with bipolar disorder.
Tom Wilkinson portrayed a manic depressive lawyer in Tony Gilroy's film Michael Clayton. Matt Damon portrays a manic depressive whistleblower and FBI informant in the Steven Soderbergh film The Informant!. In the film, Mark Whitacre, the character played by Matt Damon, displays bizarre behavior including recklessness and grandiosity.
Next to Normal, a rock musical debuted off-Broadway in 2008 before going on to play in Arlington, VA and eventually, in April 2009, on Broadway. Its story concerns a mother who struggles with worsening bipolar disorder and the effect that her illness has on her family.
In the Australian TV drama Stingers, Gary Sweet played the role of Detective Luke Harris from season six, portraying him as having bipolar disorder and showing how his paranoia interfered with his work. As research for the role Sweet visited a psychiatrist to learn about manic depressive illness. He said that he left the sessions convinced he had the condition.
TV specials, for example the BBC's The Secret Life of the Manic Depressive,^[172] MTV's True Life: I'm Bipolar, talk shows, and public radio shows, and the greater willingness of public figures to discuss their own bipolar disorder, have focused on psychiatric conditions thereby raising public awareness.
On April 7, 2009, the nighttime drama 90210 on the CW network, aired a special episode where one of the characters, Silver, was diagnosed with bipolar disorder. A PSA aired after the episode, directing teens and young adults with questions or concerns about mood disorders to the Child and Adolescent Bipolar Foundation website for information, and to chat with other teens ^[173].
Recently Stacey Slater from the popular BBC soap EastEnders has begun to show signs of bipolar disorder; her mother Jean Slater also has bipolar disorder.^[174]
In Law & Order: Special Victims Unit, Elliot Stabler's daughter, Kathleen Stabler, is diagnosed with bipolar disorder. It is later revealed that his mother, Bernadette, also suffered the same disorder, but chose not to take medication for it.