Bipolar (Manic-Depressive) Disorder.
Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual
shifts in a person's mood, energy, and ability to function. Different from the normal ups and downs that everyone goes through,
the symptoms of bipolar disorder are severe. They can result in damaged relationships, poor job or school performance, and
even suicide. But there is good news: bipolar disorder can be treated, and people with this illness can lead full and productive
More than 2 million American adults,1 or about 1 percent of the population age 18 and older in any given year,2 have bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. However, some people
have their first symptoms during childhood, and some develop them late in life. It is often not recognized as an illness,
and people may suffer for years before it is properly diagnosed and treated. Like diabetes or heart disease, bipolar disorder
is a long-term illness that must be carefully managed throughout a person's life.
"Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis
of rational thought, and too often erodes the desire and will to live. It is an illness that is biological in its origins,
yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure,
yet one that brings in its wake almost unendurable suffering and, not infrequently, suicide."
"I am fortunate that I have not died from my illness, fortunate in having received the best
medical care available, and fortunate in having the friends, colleagues, and family that I do."
Kay Redfield Jamison, Ph.D., An Unquiet Mind, 1995, p. 6.
(Reprinted with permission
from Alfred A. Knopf, a division of Random House, Inc.)
What Are the Symptoms of Bipolar Disorder?
Bipolar disorder causes dramatic mood swings—from overly "high" and/or irritable to sad
and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go
along with these changes in mood. The periods of highs and lows are called episodes of mania and depression.
Signs and symptoms of mania (or a manic episode) include:
- Increased energy, activity, and restlessness
- Excessively "high," overly good, euphoric mood
- Extreme irritability
- Racing thoughts and talking very fast, jumping from one idea to another
- Distractibility, can't concentrate well
- Little sleep needed
- Unrealistic beliefs in one's abilities and powers
- Poor judgment
- Spending sprees
- A lasting period of behavior that is different from usual
- Increased sexual drive
- Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
- Provocative, intrusive, or aggressive behavior
- Denial that anything is wrong
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.
Signs and symptoms of depression (or a depressive episode) include:
- Lasting sad, anxious, or empty mood
- Feelings of hopelessness or pessimism
- Feelings of guilt, worthlessness, or helplessness
- Loss of interest or pleasure in activities once enjoyed, including sex
- Decreased energy, a feeling of fatigue or of being "slowed down"
- Difficulty concentrating, remembering, making decisions
- Restlessness or irritability
- Sleeping too much, or can't sleep
- Change in appetite and/or unintended weight loss or gain
- Chronic pain or other persistent bodily symptoms that are not caused by physical illness or
- Thoughts of death or suicide, or suicide attempts
A depressive episode is diagnosed if five or more of these symptoms last most of the day, nearly
every day, for a period of 2 weeks or longer.
A mild to moderate level of mania is called hypomania. Hypomania may feel
good to the person who experiences it and may even be associated with good functioning and enhanced productivity. Thus even
when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything
is wrong. Without proper treatment, however, hypomania can become severe mania in some people or can switch into depression.
Sometimes, severe episodes of mania or depression include symptoms of psychosis
(or psychotic symptoms). Common psychotic symptoms are hallucinations (hearing, seeing, or otherwise sensing the presence
of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained
by a person's usual cultural concepts). Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the
time. For example, delusions of grandiosity, such as believing one is the President or has special powers or wealth, may occur
during mania; delusions of guilt or worthlessness, such as believing that one is ruined and penniless or has committed some
terrible crime, may appear during depression. People with bipolar disorder who have these symptoms are sometimes incorrectly
diagnosed as having schizophrenia, another severe mental illness.
It may be helpful to think of the various mood states in bipolar disorder as a spectrum or
continuous range. At one end is severe depression, above which is moderate depression and then mild low mood, which many people
call "the blues" when it is short-lived but is termed "dysthymia" when it is chronic. Then there is normal or balanced mood,
above which comes hypomania (mild to moderate mania), and then severe mania.
In some people, however, symptoms of mania and depression may occur together in what is called
a mixed bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, significant change
in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling
Bipolar disorder may appear to be a problem other than mental illness—for instance, alcohol
or drug abuse, poor school or work performance, or strained interpersonal relationships. Such problems in fact may be signs
of an underlying mood disorder.
Diagnosis of Bipolar Disorder
Like other mental illnesses, bipolar disorder cannot yet be identified physiologically—for
example, through a blood test or a brain scan. Therefore, a diagnosis of bipolar disorder is made on the basis of symptoms,
course of illness, and, when available, family history. The diagnostic criteria for bipolar disorder are described in the
Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DSM-IV).3
- Descriptions offered by people with bipolar disorder give valuable insights into the various
mood states associated with the illness:
Depression: I doubt completely my ability to do anything well. It seems
as though my mind has slowed down and burned out to the point of being virtually useless…. [I am] haunt[ed]… with
the total, the desperate hopelessness of it all…. Others say, "It's only temporary, it will pass, you will get over
it," but of course they haven't any idea of how I feel, although they are certain they do. If I can't feel, move, think or
care, then what on earth is the point?
Hypomania: At first when I'm high, it's tremendous… ideas are
fast… like shooting stars you follow until brighter ones appear…. All shyness disappears, the right words and
gestures are suddenly there… uninteresting people, things become intensely interesting. Sensuality is pervasive, the
desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being,
omnipotence, euphoria… you can do anything… but, somewhere this changes.
Mania: The fast ideas become too fast and there are far too many…
overwhelming confusion replaces clarity… you stop keeping up with it—memory goes. Infectious humor ceases to amuse.
Your friends become frightened…. everything is now against the grain… you are irritable, angry, frightened, uncontrollable,
Some people with bipolar disorder become suicidal. Anyone who is thinking about committing
suicide needs immediate attention, preferably from a mental health professional or a physician. Anyone who talks about suicide
should be taken seriously. Risk for suicide appears to be higher earlier in the course of the illness. Therefore,
recognizing bipolar disorder early and learning how best to manage it may decrease the risk of death by suicide.
Signs and symptoms that may accompany suicidal feelings include:
- talking about feeling suicidal or wanting to die
- feeling hopeless, that nothing will ever change or get better
- feeling helpless, that nothing one does makes any difference
- feeling like a burden to family and friends
- abusing alcohol or drugs
- putting affairs in order (e.g., organizing finances or giving away possessions to prepare
for one's death)
- writing a suicide note
- putting oneself in harm's way, or in situations where there is a danger of being killed
If you are feeling suicidal or know someone who is:
- call a doctor, emergency room, or 911 right away to get immediate help
- make sure you, or the suicidal person, are not left alone
- make sure that access is prevented to large amounts of medication, weapons, or other items
that could be used for self-harm
While some suicide attempts are carefully planned over time, others are impulsive acts that
have not been well thought out; thus, the final point in the box above may be a valuable long-term strategy for people
with bipolar disorder. Either way, it is important to understand that suicidal feelings and actions are symptoms of an illness
that can be treated. With proper treatment, suicidal feelings can be overcome.
What Is the Course of Bipolar Disorder?
Episodes of mania and depression typically recur across the life span. Between episodes,
most people with bipolar disorder are free of symptoms, but as many as one-third of people have some residual symptoms. A
small percentage of people experience chronic unremitting symptoms despite treatment.4
The classic form of the illness, which involves recurrent episodes of mania and depression,
is called bipolar I disorder. Some people, however, never develop severe mania but instead experience milder
episodes of hypomania that alternate with depression; this form of the illness is called bipolar II disorder.
When four or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling
bipolar disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycling
tends to develop later in the course of illness and is more common among women than among men.
People with bipolar disorder can lead healthy and productive lives when the illness is effectively
treated (see below—"How Is Bipolar Disorder Treated?"). Without treatment, however, the natural course of bipolar disorder tends to worsen. Over time
a person may suffer more frequent (more rapid-cycling) and more severe manic and depressive episodes than those experienced
when the illness first appeared.5 But in most cases, proper treatment can help reduce the frequency and severity of episodes and can help people with
bipolar disorder maintain good quality of life.
Can Children and Adolescents Have Bipolar Disorder?
Both children and adolescents can develop bipolar disorder. It is more likely to affect the
children of parents who have the illness.
Unlike many adults with bipolar disorder, whose episodes tend to be more clearly defined, children
and young adolescents with the illness often experience very fast mood swings between depression and mania many times within
a day.6 Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated.
Mixed symptoms also are common in youths with bipolar disorder. Older adolescents who develop the illness may have more classic,
adult-type episodes and symptoms.
Bipolar disorder in children and adolescents can be hard to tell apart from other problems
that may occur in these age groups. For example, while irritability and aggressiveness can indicate bipolar disorder, they
also can be symptoms of attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, or other
types of mental disorders more common among adults such as major depression or schizophrenia. Drug abuse also may lead to
For any illness, however, effective treatment depends on appropriate diagnosis. Children
or adolescents with emotional and behavioral symptoms should be carefully evaluated by a mental health professional. Any
child or adolescent who has suicidal feelings, talks about suicide, or attempts suicide should be taken seriously and should
receive immediate help from a mental health specialist.
What Causes Bipolar Disorder?
Scientists are learning about the possible causes of bipolar disorder through several kinds
of studies. Most scientists now agree that there is no single cause for bipolar disorder—rather, many factors act together
to produce the illness.
Because bipolar disorder tends to run in families, researchers have been searching for
specific genes—the microscopic "building blocks" of DNA inside all cells that influence how the body and mind work and
grow—passed down through generations that may increase a person's chance of developing the illness. But genes are not
the whole story. Studies of identical twins, who share all the same genes, indicate that both genes and other factors play
a role in bipolar disorder. If bipolar disorder were caused entirely by genes, then the identical twin of someone with the
illness would always develop the illness, and research has shown that this is not the case. But if one twin has bipolar
disorder, the other twin is more likely to develop the illness than is another sibling.7
In addition, findings from gene research suggest that bipolar disorder, like other mental illnesses,
does not occur because of a single gene.8 It appears likely that many different genes act together, and in combination with other factors of the person or the
person's environment, to cause bipolar disorder. Finding these genes, each of which contributes only a small amount toward
the vulnerability to bipolar disorder, has been extremely difficult. But scientists expect that the advanced research tools
now being used will lead to these discoveries and to new and better treatments for bipolar disorder.
Brain-imaging studies are helping scientists learn what goes wrong in the brain to produce
bipolar disorder and other mental illnesses.9,10 New brain-imaging techniques allow researchers to take pictures of the living brain at work, to examine its structure
and activity, without the need for surgery or other invasive procedures. These techniques include magnetic resonance imaging
(MRI), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI). There is evidence from imaging
studies that the brains of people with bipolar disorder may differ from the brains of healthy individuals. As the differences
are more clearly identified and defined through research, scientists will gain a better understanding of the underlying causes
of the illness, and eventually may be able to predict which types of treatment will work most effectively.
How Is Bipolar Disorder Treated?
Most people with bipolar disorder—even those with the most severe forms—can achieve
substantial stabilization of their mood swings and related symptoms with proper treatment.11,12,13 Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost
always indicated. A strategy that combines medication and psychosocial treatment is optimal for managing the disorder over
In most cases, bipolar disorder is much better controlled if treatment is continuous than if
it is on and off. But even when there are no breaks in treatment, mood changes can occur and should be reported immediately
to your doctor. The doctor may be able to prevent a full-blown episode by making adjustments to the treatment plan. Working
closely with the doctor and communicating openly about treatment concerns and options can make a difference in treatment effectiveness.
In addition, keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events
may help people with bipolar disorder and their families to better understand the illness. This chart also can help the doctor
track and treat the illness most effectively.
Medications for bipolar disorder are prescribed by psychiatrists—medical doctors (M.D.)
with expertise in the diagnosis and treatment of mental disorders. While primary care physicians who do not specialize in
psychiatry also may prescribe these medications, it is recommended that people with bipolar disorder see a psychiatrist for
Medications known as "mood stabilizers" usually are prescribed to help control bipolar disorder.11 Several different types of mood stabilizers are available. In general, people with bipolar disorder continue treatment
with mood stabilizers for extended periods of time (years). Other medications are added when necessary, typically for shorter
periods, to treat episodes of mania or depression that break through despite the mood stabilizer.
- Lithium, the first mood-stabilizing medication approved by the U.S. Food and Drug Administration
(FDA) for treatment of mania, is often very effective in controlling mania and preventing the recurrence of both manic and
- Anticonvulsant medications, such as valproate (Depakote®) or carbamazepine (Tegretol®),
also can have mood-stabilizing effects and may be especially useful for difficult-to-treat bipolar episodes. Valproate was
FDA-approved in 1995 for treatment of mania.
- Newer anticonvulsant medications, including lamotrigine (Lamictal®), gabapentin
(Neurontin®), and topiramate (Topamax®), are being studied to determine how well they work in stabilizing
- Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect.
- Children and adolescents with bipolar disorder generally are treated with lithium, but valproate
and carbamazepine also are used. Researchers are evaluating the safety and efficacy of these and other psychotropic medications
in children and adolescents. There is some evidence that valproate may lead to adverse hormone changes in teenage girls
and polycystic ovary syndrome in women who began taking the medication before age 20.14 Therefore, young female patients taking valproate should be monitored carefully by a physician.
- Women with bipolar disorder who wish to conceive, or who become pregnant, face special challenges
due to the possible harmful effects of existing mood stabilizing medications on the developing fetus and the nursing infant.15 Therefore, the benefits and risks of all available treatment options should be discussed with a clinician skilled in
this area. New treatments with reduced risks during pregnancy and lactation are under study.
Treatment of Bipolar Depression
Research has shown that people with bipolar disorder are at risk of switching into mania or
hypomania, or of developing rapid cycling, during treatment with antidepressant medication.16 Therefore, "mood-stabilizing" medications generally are required, alone or in combination with antidepressants,
to protect people with bipolar disorder from this switch. Lithium and valproate are the most commonly used mood-stabilizing
drugs today. However, research studies continue to evaluate the potential mood-stabilizing effects of newer medications.
- Atypical antipsychotic medications, including clozapine (Clozaril®), olanzapine
(Zyprexa®), risperidone (Risperdal®), quetiapine (Seroquel®), and ziprasidone (Geodon®),
are being studied as possible treatments for bipolar disorder. Evidence suggests clozapine may be helpful as a mood stabilizer
for people who do not respond to lithium or anticonvulsants.17 Other research has supported the efficacy of olanzapine for acute mania, an indication that has recently received FDA
approval.18 Olanzapine may also help relieve psychotic depression.19
- If insomnia is a problem, a high-potency benzodiazepine medication such as clonazepam (Klonopin®)
or lorazepam (Ativan®) may be helpful to promote better sleep. However, since these medications may be habit-forming,
they are best prescribed on a short-term basis. Other types of sedative medications, such as zolpidem (Ambien®),
are sometimes used instead.
- Changes to the treatment plan may be needed at various times during the course of bipolar
disorder to manage the illness most effectively. A psychiatrist should guide any changes in type or dose of medication.
- Be sure to tell the psychiatrist about all other prescription drugs, over-the-counter medications,
or natural supplements you may be taking. This is important because certain medications and supplements taken together may
cause adverse reactions.
- To reduce the chance of relapse or of developing a new episode, it is important to stick to
the treatment plan. Talk to your doctor if you have any concerns about the medications.
People with bipolar disorder often have abnormal thyroid gland function.5 Because too much or too little thyroid hormone alone can lead to mood and energy changes, it is important that thyroid
levels are carefully monitored by a physician.
People with rapid cycling tend to have co-occurring thyroid problems and may need to take thyroid
pills in addition to their medications for bipolar disorder. Also, lithium treatment may cause low thyroid levels in some
people, resulting in the need for thyroid supplementation.
Medication Side Effects
Before starting a new medication for bipolar disorder, always talk with your psychiatrist and/or
pharmacist about possible side effects. Depending on the medication, side effects may include weight gain, nausea, tremor,
reduced sexual drive or performance, anxiety, hair loss, movement problems, or dry mouth. Be sure to tell the doctor about
all side effects you notice during treatment. He or she may be able to change the dose or offer a different medication to
relieve them. Your medication should not be changed or stopped without the psychiatrist's guidance.
As an addition to medication, psychosocial treatments—including certain forms of psychotherapy
(or "talk" therapy)—are helpful in providing support, education, and guidance to people with bipolar disorder and their
families. Studies have shown that psychosocial interventions can lead to increased mood stability, fewer hospitalizations,
and improved functioning in several areas.13 A licensed psychologist, social worker, or counselor typically provides these therapies and often works together with
the psychiatrist to monitor a patient's progress. The number, frequency, and type of sessions should be based on the treatment
needs of each person.
Psychosocial interventions commonly used for bipolar disorder are cognitive behavioral therapy,
psychoeducation, family therapy, and a newer technique, interpersonal and social rhythm therapy. NIMH researchers are studying
how these interventions compare to one another when added to medication treatment for bipolar disorder.
- Cognitive behavioral therapy helps people with bipolar disorder learn to change inappropriate
or negative thought patterns and behaviors associated with the illness.
- Psychoeducation involves teaching people with bipolar disorder about the illness and its treatment,
and how to recognize signs of relapse so that early intervention can be sought before a full-blown illness episode occurs.
Psychoeducation also may be helpful for family members.
- Family therapy uses strategies to reduce the level of distress within the family that may
either contribute to or result from the ill person's symptoms.
- Interpersonal and social rhythm therapy helps people with bipolar disorder both to improve
interpersonal relationships and to regularize their daily routines. Regular daily routines and sleep schedules may help protect
against manic episodes.
- As with medication, it is important to follow the treatment plan for any psychosocial intervention
to achieve the greatest benefit.
- In situations where medication, psychosocial treatment, and the combination of these interventions
prove ineffective, or work too slowly to relieve severe symptoms such as psychosis or suicidality, electroconvulsive therapy
(ECT) may be considered. ECT may also be considered to treat acute episodes when medical conditions, including pregnancy,
make the use of medications too risky. ECT is a highly effective treatment for severe depressive, manic, and/or mixed episodes.
The possibility of long-lasting memory problems, although a concern in the past, has been significantly reduced with modern
ECT techniques. However, the potential benefits and risks of ECT, and of available alternative interventions, should be carefully
reviewed and discussed with individuals considering this treatment and, where appropriate, with family or friends.20
- Herbal or natural supplements, such as St. John's wort (Hypericum perforatum), have
not been well studied, and little is known about their effects on bipolar disorder. Because the FDA does not regulate their
production, different brands of these supplements can contain different amounts of active ingredient. Before trying herbal
or natural supplements, it is important to discuss them with your doctor. There is evidence that St. John's wort can reduce
the effectiveness of certain medications.21 In addition, like prescription antidepressants, St. John's wort may cause a switch into mania in some individuals with
bipolar disorder, especially if no mood stabilizer is being taken.22
- Omega-3 fatty acids found in fish oil are being studied to determine their usefulness, alone
and when added to conventional medications, for long-term treatment of bipolar disorder.23
A Long-Term Illness That Can Be Effectively Treated
Even though episodes of mania and depression naturally come and go, it is important to understand
that bipolar disorder is a long-term illness that currently has no cure. Staying on treatment, even during well times, can
help keep the disease under control and reduce the chance of having recurrent, worsening episodes.
Do Other Illnesses Co-occur with Bipolar Disorder?
Alcohol and drug abuse are very common among people with bipolar disorder. Research findings
suggest that many factors may contribute to these substance abuse problems, including self-medication of symptoms, mood symptoms
either brought on or perpetuated by substance abuse, and risk factors that may influence the occurrence of both bipolar disorder
and substance use disorders.24 Treatment for co-occurring substance abuse, when present, is an important part of the overall treatment plan.
Anxiety disorders, such as post-traumatic stress disorder and obsessive-compulsive disorder,
also may be common in people with bipolar disorder.25,26 Co-occurring anxiety disorders may respond to the treatments used for bipolar disorder, or they may require separate
treatment. For more information on anxiety disorders, contact NIMH (see below).
How Can Individuals and Families Get Help for Bipolar Disorder?
Anyone with bipolar disorder should be under the care of a psychiatrist skilled in the diagnosis
and treatment of this disease. Other mental health professionals, such as psychologists, psychiatric social workers, and psychiatric
nurses, can assist in providing the person and family with additional approaches to treatment.
Help can be found at:
- University—or medical school—affiliated programs
- Hospital departments of psychiatry
- Private psychiatric offices and clinics
- Health maintenance organizations (HMOs)
- Offices of family physicians, internists, and pediatricians
- Public community mental health centers
People with bipolar disorder may need help to get help.
- Often people with bipolar disorder do not realize how impaired they are, or they blame their
problems on some cause other than mental illness.
- A person with bipolar disorder may need strong encouragement from family and friends to seek
treatment. Family physicians can play an important role in providing referral to a mental health professional.
- Sometimes a family member or friend may need to take the person with bipolar disorder for
proper mental health evaluation and treatment.
- A person who is in the midst of a severe episode may need to be hospitalized for his or her
own protection and for much-needed treatment. There may be times when the person must be hospitalized against his or her wishes.
- Ongoing encouragement and support are needed after a person obtains treatment, because it
may take a while to find the best treatment plan for each individual.
- In some cases, individuals with bipolar disorder may agree, when the disorder is under good
control, to a preferred course of action in the event of a future manic or depressive relapse.
- Like other serious illnesses, bipolar disorder is also hard on spouses, family members, friends,
- Family members of someone with bipolar disorder often have to cope with the person's serious
behavioral problems, such as wild spending sprees during mania or extreme withdrawal from others during depression, and the
lasting consequences of these behaviors.
- Many people with bipolar disorder benefit from joining support groups such as those sponsored
by the National Depressive and Manic Depressive Association (NDMDA), the National Alliance for the Mentally Ill (NAMI), and
the National Mental Health Association (NMHA). Families and friends can also benefit from support groups offered by these
organizations. For contact information, see the "For More Information" section at the back of this booklet.
What About Clinical Studies for Bipolar Disorder?
Some people with bipolar disorder receive medication and/or psychosocial therapy by volunteering
to participate in clinical studies (clinical trials). Clinical studies involve the scientific investigation of illness and
treatment of illness in humans. Clinical studies in mental health can yield information about the efficacy of a medication
or a combination of treatments, the usefulness of a behavioral intervention or type of psychotherapy, the reliability of a
diagnostic procedure, or the success of a prevention method. Clinical studies also guide scientists in learning how illness
develops, progresses, lessens, and affects both mind and body. Millions of Americans diagnosed with mental illness lead healthy,
productive lives because of information discovered through clinical studies. These studies are not always right for everyone,
however. It is important for each individual to consider carefully the possible risks and benefits of a clinical study before
making a decision to participate.
In recent years, NIMH has introduced a new generation of "real-world" clinical studies. They
are called "real-world" studies for several reasons. Unlike traditional clinical trials, they offer multiple different treatments
and treatment combinations. In addition, they aim to include large numbers of people with mental disorders living in communities
throughout the U.S. and receiving treatment across a wide variety of settings. Individuals with more than one mental disorder,
as well as those with co-occurring physical illnesses, are encouraged to consider participating in these new studies. The
main goal of the real-world studies is to improve treatment strategies and outcomes for all people with these disorders. In
addition to measuring improvement in illness symptoms, the studies will evaluate how treatments influence other important,
real-world issues such as quality of life, ability to work, and social functioning. They also will assess the cost-effectiveness
of different treatments and factors that affect how well people stay on their treatment plans.
The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) is seeking participants
for the largest-ever, "real-world" study of treatments for bipolar disorder. To learn more about STEP-BD or other clinical
studies, see the Clinical Trials page on the NIMH Web site http://www.nimh.nih.gov, visit the National Library of Medicine's clinical trials database http://www.clinicaltrials.gov, or contact NIMH.
||3 and older|
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|*Because of its potential for serious side effects affecting the liver,
Cylert should not ordinarily be considered as first-line drug therapy for ADHD.|
The U.S. Food and Drug Adminstration (FDA) recently approved a medication for ADHD that is
not a stimulant. The medication, Strattera®, or atomoxetine, works on the neurotransmitter norepinephrine, whereas the stimulants
primarily work on dopamine. Both of theses neurotransmitters are believed to play a role in ADHD. More studies will need to
be done to contrast Strattera with the medications already available, but the evidence to date indicates that over 70 percent
of children with ADHD given Strattera manifest significant improvement in their symptoms.
Some people get better results from one medication, some from another. It is important to work
with the prescribing physician to find the right medication and the right dosage. For many people, the stimulants dramatically
reduce their hyperactivity and impulsivity and improve their ability to focus, work, and learn. The medications may also improve
physical coordination, such as that needed in handwriting and in sports.
The stimulant drugs, when used with medical supervision, are usually considered quite
safe. Stimulants do not make the child feel "high," although some children say they feel different or funny. Such changes
are usually very minor. Although some parents worry that their child may become addicted to the medication, to date there
is no convincing evidence that stimulant medications, when used for treatment of ADHD, cause drug abuse or dependence. A review
of all long-term studies on stimulant medication and substance abuse, conducted by researchers at Massachusetts General Hospital
and Harvard Medical School, found that teenagers with ADHD who remained on their medication during the teen years had a lower
likelihood of substance use or abuse than did ADHD adolescents who were not taking medications.13
The stimulant drugs come in long- and short-term forms. The newer sustained-release stimulants
can be taken before school and are long-lasting so that the child does not need to go to the school nurse every day for a
pill. The doctor can discuss with the parents the child's needs and decide which preparation to use and whether the child
needs to take the medicine during school hours only or in the evening and on weekends too.
If the child does not show symptom improvement after taking a medication for a week, the doctor
may try adjusting the dosage. If there is still no improvement, the child may be switched to another medication. About one
out of ten children is not helped by a stimulant medication. Other types of medication may be used if stimulants don't work
or if the ADHD occurs with another disorder. Antidepressants and other medications can help control accompanying depression
Sometimes the doctor may prescribe for a young child a medication that has been approved by
the FDA for use in adults or older children. This use of the medication is called "off label." Many of the newer medications
that are proving helpful for child mental disorders are prescribed off label because only a few of them have been systematically
studied for safety and efficacy in children. Medications that have not undergone such testing are dispensed with the statement
that "safety and efficacy have not been established in pediatric patients."
Side Effects of the Medications.
Most side effects of the stimulant medications are minor and are usually related to the dosage
of the medication being taken. Higher doses produce more side effects. The most common side effects are decreased appetite,
insomnia, increased anxiety, and/or irritability. Some children report mild stomach aches or headaches.
Appetite seems to fluctuate, usually being low during the middle of the day and more normal
by suppertime. Adequate amounts of food that is nutritional should be available for the child, especially at peak appetite
If the child has difficulty falling asleep, several options may be tried—a lower dosage
of the stimulant, giving the stimulant earlier in the day, discontinuing the afternoon or evening dosage, or giving an adjunct
medication such as a low-dosage antidepressant or clonidine. A few children develop tics during treatment. These can often
be lessened by changing the medication dosage. A very few children cannot tolerate any stimulant, no matter how low the dosage.
In such cases, the child is often given an antidepressant instead of the stimulant.
When a child's schoolwork and behavior improve soon after starting medication, the child, parents,
and teachers tend to applaud the drug for causing the sudden changes. Unfortunately, when people see such immediate improvement,
they often think medication is all that's needed. But medications don't cure ADHD; they only control the symptoms on the day
they are taken. Although the medications help the child pay better attention and complete school work, they can't increase
knowledge or improve academic skills. The medications help the child to use those skills he or she already possesses.
Behavioral therapy, emotional counseling, and practical support will help ADHD children cope
with everyday problems and feel better about themselves.
Facts to Remember About Medication for ADHD.
- Medications for ADHD help many children focus and be more successful at school, home, and
play. Avoiding negative experiences now may actually help prevent addictions and other emotional problems later.
- About 80 percent of children who need medication for ADHD still need it as teenagers. Over
50 percent need medication as adults.
Medication for the Child with Both ADHD and Bipolar Disorder.
Since a child with bipolar disorder will probably be prescribed a mood stabilizer such as lithium
or Depakote®, the doctor will carefully consider whether the child should take one of the medications usually prescribed for
ADHD. If a stimulant medication is prescribed, it may be given in a lower dosage than usual.
The Family and the ADHD Child
Medication can help the ADHD child in everyday life. He or she may be better able to control
some of the behavior problems that have led to trouble with parents and siblings. But it takes time to undo the frustration,
blame, and anger that may have gone on for so long. Both parents and children may need special help to develop techniques
for managing the patterns of behavior. In such cases, mental health professionals can counsel the child and the family, helping
them to develop new skills, attitudes, and ways of relating to each other. In individual counseling, the therapist helps children
with ADHD learn to feel better about themselves. The therapist can also help them to identify and build on their strengths,
cope with daily problems, and control their attention and aggression. Sometimes only the child with ADHD needs counseling
support. But in many cases, because the problem affects the family as a whole, the entire family may need help. The therapist
assists the family in finding better ways to handle the disruptive behaviors and promote change. If the child is young, most
of the therapist's work is with the parents, teaching them techniques for coping with and improving their child's behavior.
Several intervention approaches are available. Knowing something about the various types of
interventions makes it easier for families to choose a therapist that is right for their needs.
Psychotherapy works to help people with ADHD to like and accept themselves
despite their disorder. It does not address the symptoms or underlying causes of the disorder. In psychotherapy, patients
talk with the therapist about upsetting thoughts and feelings, explore self-defeating patterns of behavior, and learn alternative
ways to handle their emotions. As they talk, the therapist tries to help them understand how they can change or better cope
with their disorder.
Behavioral therapy (BT) helps people develop more effective ways to
work on immediate issues. Rather than helping the child understand his or her feelings and actions, it helps directly in changing
their thinking and coping and thus may lead to changes in behavior. The support might be practical assistance, like help in
organizing tasks or schoolwork or dealing with emotionally charged events. Or the support might be in self-monitoring one's
own behavior and giving self-praise or rewards for acting in a desired way such as controlling anger or thinking before acting.
Social skills training can also help children learn new behaviors. In
social skills training, the therapist discusses and models appropriate behaviors important in developing and maintaining social
relationships, like waiting for a turn, sharing toys, asking for help, or responding to teasing, then gives children a chance
to practice. For example, a child might learn to "read" other people's facial expression and tone of voice in order to respond
appropriately. Social skills training helps the child to develop better ways to play and work with other children.
Support groups help parents connect with other people who have similar
problems and concerns with their ADHD children. Members of support groups often meet on a regular basis (such as monthly)
to hear lectures from experts on ADHD, share frustrations and successes, and obtain referrals to qualified specialists and
information about what works. There is strength in numbers, and sharing experiences with others who have similar problems
helps people know that they aren't alone. National organizations are listed at the end of this document.
Parenting skills training, offered by therapists or in special classes,
gives parents tools and techniques for managing their child's behavior. One such technique is the use of token or point systems
for immediately rewarding good behavior or work. Another is the use of "time-out" or isolation to a chair or bedroom when
the child becomes too unruly or out of control. During time-outs, the child is removed from the agitating situation and sits
alone quietly for a short time to calm down. Parents may also be taught to give the child "quality time" each day, in which
they share a pleasurable or relaxing activity. During this time together, the parent looks for opportunities to notice and
point out what the child does well, and praise his or her strengths and abilities.
This system of rewards and penalties can be an effective way to modify a child's behavior.
The parents (or teacher) identify a few desirable behaviors that they want to encourage in the child—such as asking
for a toy instead of grabbing it, or completing a simple task. The child is told exactly what is expected in order to earn
the reward. The child receives the reward when he performs the desired behavior and a mild penalty when he doesn't. A reward
can be small, perhaps a token that can be exchanged for special privileges, but it should be something the child wants and
is eager to earn. The penalty might be removal of a token or a brief time-out. Make an effort to find your child being
good. The goal, over time, is to help children learn to control their own behavior and to choose the more desired behavior.
The technique works well with all children, although children with ADHD may need more frequent rewards.
In addition, parents may learn to structure situations in ways that will allow their child
to succeed. This may include allowing only one or two playmates at a time, so that their child doesn't get overstimulated.
Or if their child has trouble completing tasks, they may learn to help the child divide a large task into small steps, then
praise the child as each step is completed. Regardless of the specific technique parents may use to modify their child's behavior,
some general principles appear to be useful for most children with ADHD. These include providing more frequent and immediate
feedback (including rewards and punishment), setting up more structure in advance of potential problem situations, and providing
greater supervision and encouragement to children with ADHD in relatively unrewarding or tedious situations.
Parents may also learn to use stress management methods, such as meditation, relaxation techniques,
and exercise, to increase their own tolerance for frustration so that they can respond more calmly to their child's behavior.
Some Simple Behavioral Interventions
Children with ADHD may need help in organizing. Therefore:
- Schedule. Have the same routine every day, from wake-up time to bedtime.
The schedule should include homework time and playtime (including outdoor recreation and indoor activities such as computer
games). Have the schedule on the refrigerator or a bulletin board in the kitchen. If a schedule change must be made, make
it as far in advance as possible.
- Organize needed everyday items. Have a place for everything and keep
everything in its place. This includes clothing, backpacks, and school supplies.
- Use homework and notebook organizers. Stress the importance of writing
down assignments and bringing home needed books.
Children with ADHD need consistent rules that they can understand and follow. If rules are
followed, give small rewards. Children with ADHD often receive, and expect, criticism. Look for good behavior and praise it.
Your ADHD Child and School
You are your child's best advocate. To be a good advocate
for your child, learn as much as you can about ADHD and how it affects your child at home, in school, and in social
If your child has shown symptoms of ADHD from an early age and has been evaluated, diagnosed, and treated
with either behavior modification or medication or a combination of both, when your child enters the school system, let his
or her teachers know. They will be better prepared to help the child come into this new world away from home.
If your child enters school and experiences difficulties that lead you to suspect that he or she has ADHD,
you can either seek the services of an outside professional or you can ask the local school district to conduct an evaluation.
Some parents prefer to go to a professional of their own choice. But it is the school's obligation to evaluate children that
they suspect have ADHD or some other disability that is affecting not only their academic work but their interactions with
classmates and teachers.
If you feel that your child has ADHD and isn't learning in school as he or she should, you should find out
just who in the school system you should contact. Your child's teacher should be able to help you with this information. Then
you can request—in writing—that the school system evaluate your child. The letter should include the date, your
and your child's names, and the reason for requesting an evaluation. Keep a copy of the letter in your own files.
Until the last few years, many school systems were reluctant to evaluate a child with ADHD. But recent laws
have made clear the school's obligation to the child suspected of having ADHD that is affecting adversely his or her performance
in school. If the school persists in refusing to evaluate your child, you can either get a private evaluation or enlist some
help in negotiating with the school. Help is often as close as a local parent group. Each state has a Parent Training and
Information (PTI) center as well as a Protection and Advocacy (P&A) agency. (For information on the law and on the PTI
and P&A, see the section on support groups and organizations at the end of this document.)
Once your child has been diagnosed with ADHD and qualifies for special education services, the school, working
with you, must assess the child's strengths and weaknesses and design an Individualized Educational Program (IEP). You should
be able periodically to review and approve your child's IEP. Each school year brings a new teacher and new schoolwork, a transition
that can be quite difficult for the child with ADHD. Your child needs lots of support and encouragement at this time.
Never forget the cardinal rule—you are your child's best advocate.
Your Teenager with ADHD
Your child with ADHD has successfully navigated the early school years and is beginning his or her journey
through middle school and high school. Although your child has been periodically evaluated through the years, this is a good
time to have a complete re-evaluation of your child's health.
The teen years are challenging for most children; for the child with ADHD these years are doubly hard. All
the adolescent problems—peer pressure, the fear of failure in both school and socially, low self-esteem—are harder
for the ADHD child to handle. The desire to be independent, to try new and forbidden things—alcohol, drugs, and sexual
activity—can lead to unforeseen consequences. The rules that once were, for the most part, followed, are often now flaunted.
Parents may not agree with each other on how the teenager's behavior should be handled.
Now, more than ever, rules should be straightforward and easy to understand. Communication between the adolescent
and parents can help the teenager to know the reasons for each rule. When a rule is set, it should be clear why the
rule is set. Sometimes it helps to have a chart, posted usually in the kitchen, that lists all household rules and all rules
for outside the home (social and school). Another chart could list household chores with space to check off a chore once it
When rules are broken—and they will be—respond to this inappropriate behavior as calmly and matter-of-factly
as possible. Use punishment sparingly. Even with teens, a time-out can work. Impulsivity and hot temper often accompany ADHD.
A short time alone can help.
As the teenager spends more time away from home, there will be demands for a later curfew and the use of
the car. Listen to your child's request, give reasons for your opinion and listen to his or her opinion, and negotiate. Communication,
negotiation, and compromise will prove helpful.
Your Teenager and the Car.
Teenagers, especially boys, begin talking about driving by the time they are 15. In some states, a learner's
permit is available at 15 and a driver's license at 16. Statistics show that 16-year-old drivers have more accidents per driving
mile than any other age. In the year 2000, 18 percent of those who died in speed-related crashes were youth ages 15 to 19.
Sixty-six percent of these youth were not wearing safety belts. Youth with ADHD, in their first 2 to 5 years of driving, have
nearly four times as many automobile accidents, are more likely to cause bodily injury in accidents, and have three times
as many citations for speeding as the young drivers without ADHD.14
Most states, after looking at the statistics for automobile accidents involving teenage drivers, have begun
to use a graduated driver licensing system (GDL). This system eases young drivers onto the roads by a slow progression of
exposure to more difficult driving experiences. The program, as developed by the National Highway Traffic Safety Administration
and the American Association of Motor Vehicle Administrators, consists of three stages: learner's permit, intermediate (provisional)
license, and full licensure. Drivers must demonstrate responsible driving behavior at each stage before advancing to the next
level. During the learner's permit stage, a licensed adult must be in the car at all times.15 This period of time will give the learner a chance to practice, practice, practice. The more your child drives, the
more efficient he or she will become. The sense of accomplishment the teenager with ADHD will feel when the coveted license
is finally in his or her hands will make all the time and effort involved worthwhile.
Note: The State Legislative Fact Sheets—Graduated Driver Licensing System can be found at web site
http://www.nhtsa.dot.gov/people/outreach/safesobr/21qp/html/fact_sheets/Graduated_Driver.html, or it can be ordered from NHTSA Headquarters, Traffic Safety Programs, ATTN: NTS-32, 400 Seventh Street, S.W.,
Washington, DC 20590; telephone 202-366-6948.
Attention Deficit Hyperactivity Disorder in Adults
Attention deficit hyperactivity disorder is a highly publicized childhood disorder that affects approximately
3 percent to 5 percent of all children. What is much less well known is the probability that, of children who have ADHD, many
will still have it as adults. Several studies done in recent years estimate that between 30 percent and 70 percent of children
with ADHD continue to exhibit symptoms in the adult years.16
The first studies on adults who were never diagnosed as children as having ADHD, but showed symptoms as adults,
were done in the late 1970s by Drs. Paul Wender, Frederick Reimherr, and David Wood. These symptomatic adults were retrospectively
diagnosed with ADHD after the researchers' interviews with their parents. The researchers developed clinical criteria for
the diagnosis of adult ADHD (the Utah Criteria), which combined past history of ADHD with current evidence of ADHD behaviors.17 Other diagnostic assessments are now available; among them are the widely used Conners Rating Scale and the Brown Attention
Deficit Disorder Scale.
Typically, adults with ADHD are unaware that they have this disorder—they often just feel that it's
impossible to get organized, to stick to a job, to keep an appointment. The everyday tasks of getting up, getting dressed
and ready for the day's work, getting to work on time, and being productive on the job can be major challenges for the ADHD
Diagnosing ADHD in an Adult.
Diagnosing an adult with ADHD is not easy. Many times, when a child is diagnosed with the disorder, a parent
will recognize that he or she has many of the same symptoms the child has and, for the first time, will begin to understand
some of the traits that have given him or her trouble for years—distractibility, impulsivity, restlessness. Other adults
will seek professional help for depression or anxiety and will find out that the root cause of some of their emotional problems
is ADHD. They may have a history of school failures or problems at work. Often they have been involved in frequent automobile
To be diagnosed with ADHD, an adult must have childhood-onset, persistent, and current symptoms.18 The accuracy of the diagnosis of adult ADHD is of utmost importance and should be made by a clinician with expertise
in the area of attention dysfunction. For an accurate diagnosis, a history of the patient's childhood behavior, together with
an interview with his life partner, a parent, close friend, or other close associate, will be needed. A physical examination
and psychological tests should also be given. Comorbidity with other conditions may exist such as specific learning disabilities,
anxiety, or affective disorders.
A correct diagnosis of ADHD can bring a sense of relief. The individual has brought into adulthood many negative
perceptions of himself that may have led to low esteem. Now he can begin to understand why he has some of his problems and
can begin to face them. This may mean, not only treatment for ADHD but also psychotherapy that can help him cope with the
anger he feels about the failure to diagnose the disorder when he was younger.
Treatment of ADHD in an Adult.
Medications. As with children, if adults take a medication for ADHD, they often start with
a stimulant medication. The stimulant medications affect the regulation of two neurotransmitters, norepinephrine and dopamine.
The newest medication approved for ADHD by the FDA, atomoxetine (Strattera®), has been tested in controlled studies in both
children and adults and has been found to be effective.19
Antidepressants are considered a second choice for treatment of adults with ADHD. The older antidepressants,
the tricyclics, are sometimes used because they, like the stimulants, affect norepinephrine and dopamine. Venlafaxine (Effexor®),
a newer antidepressant, is also used for its effect on norepinephrine. Bupropion (Wellbutrin®), an antidepressant with an
indirect effect on the neurotransmitter dopamine, has been useful in clinical trials on the treatment of ADHD in both children
and adults. It has the added attraction of being useful in reducing cigarette smoking.
In prescribing for an adult, special considerations are made. The adult may need less of the medication for
his weight. A medication may have a longer "half-life" in an adult. The adult may take other medications for physical problems
such as diabetes or high blood pressure. Often the adult is also taking a medication for anxiety or depression. All of these
variables must be taken into account before a medication is prescribed.
Education and psychotherapy. Although medication gives needed support, the individual must
succeed on his own. To help in this struggle, both "psychoeducation" and individual psychotherapy can be helpful. A professional
coach can help the ADHD adult learn how to organize his life by using "props"—a large calendar posted where it will
be seen in the morning, date books, lists, reminder notes, and have a special place for keys, bills, and the paperwork of
everyday life. Tasks can be organized into sections, so that completion of each part can give a sense of accomplishment. Above
all, ADHD adults should learn as much as they can about their disorder.
Psychotherapy can be a useful adjunct to medication and education. First, just remembering to keep an appointment
with the therapist is a step toward keeping to a routine. Therapy can help change a long-standing poor self-image by examining
the experiences that produced it. The therapist can encourage the ADHD patient to adjust to changes brought into his life
by treatment—the perceived loss of impulsivity and love of risk-taking, the new sensation of thinking before acting.
As the patient begins to have small successes in his new ability to bring organization out of the complexities of his or her
life, he or she can begin to appreciate the characteristics of ADHD that are positive—boundless energy, warmth, and
Fidgeting, interrupting conversations, losing things, forgetting the reason for a
trip to the grocery store - everyone acts this way once in a while. But a long and persistent history of restless, impulsive,
or inattentive behavior may be a sign of Adult ADD. This is especially true if these behaviors have existed since childhood
and result in problems at work, home, and/or in social settings.
If you think you might have Adult ADD, here are several
questions you might want to ask yourself. These are some of the questions that can help doctors and healthcare professionals
screen for Adult ADD.
Ask yourself these questions and think about how long you have experienced these symptoms and
how often they occur. If these symptoms are interfering with your success at home, at work, or with friends, and have your
whole life, you may want to talk to your doctor or healthcare professional about a clinical evaluation.
Multiple Personality Disorder (Dissociative Identity Disorder) is the existence within a
person of two or more distinct personalities. The different personalities are referred to as "alters". Alters may have experienced
a distinct personal history, self-image, and identity, including a separate name, as well as age. At least two of these personalities
recurrently take control of the person's behavior.
For me multiplicity is life, not a definition, but the purpose here is to help the non-multiple gain insight
about the inner world of the multiple, so below is the definition the majority of multiples themselves would give you.
Multiplicity, simply put, is about hiding, pain and survival, no more, no less. It is a desperate, completely
creative, and wonderful survival mechanism. For the child who endures repeated and inescapable abuse, it may be their only
escape. I consider myself to be blessed with MPD not cursed. It was a gift from God to me, to ensure my survival in a world
that was full of insanity and reason not to survive. That is not to say that being a multiple is a picnic, because it is not.
It certainly brings it share of difficulties for me in my life, but what I am saying is, at least I can do life and do it
with some degree of mental health because I survived an insane childhood with my sanity.
Individuals most likely to develop MPD share several common factors. They have endured repetitive, and often
life-threatening abuse during a developmental stage of childhood. The type of abuse can vary or be a combination of physical,
extreme emotional, sexual or Satanic Ritual Abuse. The multiple may have a biological predisposition for auto-hypnotic phenomena,
or in plain english, a high level of hypnotizablitiy.
To understand MPD, it is helpful to have a basic understanding of dissociation. Dissociation is the state
in which, a person becomes separated from reality. Picture dissociation as line with a continuum (see the illustration
below) from normal everyday experiences, to disorders that fall in the middle, such as Post Traumatic Stress, to those that
go to the far extreme, MPD.
Common examples of normal dissociation are highway hypnosis which at one time or another, most
have experienced. For instance, Have you ever been driving and suddenly wondered, "Did I stop for that last stoplight?" (My
pyschiatrist says he does this himself) or become so engrossed in a book that you are no longer aware of your surroundings?
Have you ever watched a movie and completely lost your sense of the present? Daydreaming is a common form of dissociation,
which I think everyone does or has done at sometime.
Dissociation is a common defense mechanism against childhood abuse. There is no adult onset of Multiple Personality.
Only children have the flexibility, to fracture off from the "core" personality and escape the traumatic and painful memory.
The common belief among most professionals is the personality splintered or fractured before the age of five.
Those with MPD have a dominant personality that determines the individual's behavior. Each personality has
a separate and consistent pattern of perceiving their environment, themselves and others. The internal world of an individual
who has MPD is structured, although each person's system is as unique as non-multiples are from one another. There are several
metaphors that MPD's use to describe how they function and what their internal world looks and acts like. Each multiple has
a specific way they see the inside of their mind, where the alters live when they are not in control of the body. Examples
include stages, tunnels, houses, and levels. These are their internal homes, where they go when they are not are not out,
in control of the body , or when they are hiding. It is helpful for a person with MPD to make a map or diagram of their internal
The alter's job is to protect the host personality from the memory of the trauma, therefore, it is not necessary
for all alters to look and act differently than the host. This task is accomplished for the co-conscious MPD, by means of
the dissociative barriers, or for the non-conscious MPD, walls of amnesia. I will elaborate on non conscious versus co-conscious
on the next page, but for now either form of MPD would produce typical types of alters. I have listed them below:
A depressed, exhausted host.
A strong, angry protector.
A scared, hurt child.
An internal persecutor who blames one or more of the alters for the abuse they have endured. (Sometimes patterened or named
after the actual abuser)
Multiples, as well as those who deal with them, come to recognize different alters as completely separate
people, rather than just different aspects of the same person. The different personalities usually have different names, ages,
gender, likes, dislikes. Certain alters may have physical or mental abilities that the others do not possess. Often there
is a difference in body language, speech and mannerisms. Some MPD's (myself included) have an alter that changes the color
of the eyes, while others have been known to have one alter with cancer, diabetes, etc., while all the other alters remain
healthy or have their own ailments. While most multiples have alters who are very similar to one another, the difference can
be so minute, that at times, even the MPD themselves might have a difficult time distinguishing the difference.
If you know someone who is multiple, remember that for them each of the alters are different people. One may
do or say something while in control of the body that another would not. Some alters have very specific jobs and you will
only see them when they are out to do whatever their job might be. You might like some of the alters better than others but
it is a general thought in the psychological community to try not to show partiality between the alters. Also, don't be afraid
to ask the MPD questions and learn about them, all of them. Most people who are multiple are more than willing to answer your
questions, and even welcome someone who takes the time to ask.