Category Archives: Mental Health

Generalized Anxiety Disorder: What is it exactly?

Generalized Anxiety Disorder: An Overview

Generalized anxiety disorder is a form of anxiety that is chronic, lasts for at least six months and is not accompanied by obsessions, phobias or panic attacks. A person with generalized anxiety disorder experiences constant worry and anxiety without all the comorbid symptoms of other anxiety disorders. To be given a diagnosis of this anxiety disorder, you must be focused on two or more specific, stressful life experiences such as significant concern related to work, finances, relationships or other issues most days for a minimum of six months. Individuals with generalized anxiety disorder often spend a lot of time worrying and tend to have several or many significant concerns. However, it is very difficult to manage any control over your worries and anxiety when you have this disorder. Also, the worries tend to be significantly out of proportion to the actual threat involved.

If you have generalized anxiety disorder, you will most often have at least three of the following six symptoms, most days for a minimum of six months:

• Irritability
• difficulty concentrating
• difficulties with sleep
• being fatigued easily
• feeling restless
• tension in the muscles

Another important aspect of generalized anxiety disorder is that you will experience a significant level of distress and impairment in daily activities related to work, school and social experiences.

Most often, before a physician will diagnose you as having this anxiety disorder he/she will have ruled out most possible medical causes of chronic anxiety such as thyroid problems, drug-induced anxiety and hyperventilation. Generalized anxiety disorder also often occurs at the same time as depression. A competent psychologist or mental health clinician will quickly try to distinguish whether the anxiety should be treated as the primary or secondary disorder. It is often difficult to tell which came first.

This anxiety disorder can develop at any age. Among children and adolescents, the focus of worries will tend to be related to school or performance in sports. The source of concern among adults can be related to a variety of circumstances. It is believed that generalized anxiety disorder affects approximately 4% of the population in the United States and may be slightly more common among women (55% to 60%) than men.

Generalized anxiety disorder is not usually associated with any specific phobias. However, Aaron Beck M.D., has suggested that the disorder may be related to some “basic fears” of a broad-based nature. They may include:

• fear of being unable to cope
• fear of failure
• fear of disease and death
• fear of abandonment or rejection
• fear of losing control

Generalized anxiety disorder may be exacerbated by any circumstance that increases your perception of danger or seems threatening. The underlying cause is unknown although it is believed to be related to some combination of heredity and experiences in childhood such as excessive expectations of parents, fears of abandonment or rejection by others.

Treatment for Generalized Anxiety Disorder:

Cognitive Behavioral Therapy

Often some form of cognitive behavioral therapy is used to treat generalized anxiety disorder. Utilizing this type of psychotherapy involves identifying themes of worry and fearful self-talk which is then challenged and replaced by more positive, constructive thoughts. More realistic, positive thoughts are used to replace counterproductive thoughts which are then practiced and internalized over time. Cognitive behavioral therapy may also utilize guided imagery to replace negative with more positive themes of mental imagery.


Medications may be recommended for generalized anxiety disorder in moderate to severe cases. These medications may involve the use of both anxiety medications and antidepressants. Frequently, the anxiety medication Buspar may be used. At other times SSRI antidepressants may be used such as Luvox, Zoloft, Paxil or Serzone either alone or in conjunction with| Buspar.

Relaxation Training

Relaxation training for generalized anxiety disorder usually involves some type of deep breathing and relaxation techniques to reduce the generalized worry and feeling of anxiety. Also, a consistent exercise program may also be included.


Problem-solving usually takes the form of systematically working through and solving issues in our lives that seem to be a focus of worries. The focus becomes on solutions as opposed to the worries themselves. If there is no practical solution to a problem, the focus then becomes on ways to cope with the situation rather than continuing to worry about it. Sometimes, we may need to learn to accept things that we cannot change.


Distraction can also be used at times to help cope with worries that are not amenable to treatment with cognitive behavioral therapy or problem-solving. Distraction may involve diverting your attention to other activities such as listening to music, talking on the telephone, exercising, cooking, reading or solving puzzles.

Personality and Lifestyle Changes

Intervention along these lines tend to focus on the use of methods usually described to assist with panic disorder such as increased downtime, stress management, regular exercise, and eliminating stimulants and sweets from your diet. It may also involve resolving problems with others, changing attitudes toward perfectionism, a need to please others or an excessive need to feel in control.

By Paul Susic Ph.D. Licensed Psychologist

Prozac Medication: The Benefits, Side Effects and Dosages

Prozac Medication: An Overview

Prozac is a medication used to treat depression, obsessive-compulsive disorder, bulimia, and frequently severe symptoms of premenstrual syndrome. Prozac is within the drug classification referred to as selective serotonin reuptake inhibitors (SSRI’s), which is believed to help maintain a elevated level of the neurotransmitter serotonin in the brain.

Serotonin is a neurotransmitter in the brain which is believed to affect moods. This neurotransmitter is usually quickly reabsorbed after its initial release from neurons in the brain. It is believed that excess serotonin between the neurons is blocked by medications such as Prozac from being taken back up into the releasing neurons resulting in increased levels of serotonin in the brain.

Prozac is most often prescribed to treat depression of the moderate to severe variety which interferes with daily functioning and most often is referred to as major depression. The symptoms of major depression include low mood and low energy, changes in sleeping habits and appetite, decreased sex drive, feelings of guilt or worthlessness, difficulty concentrating, slowed thinking, and suicidal thoughts. However, Prozac can be taken for a variety of other mental health disorders including obsessive-compulsive disorder, premenstrual dysphoric disorder as well as others. It is most often prescribed for adolescents, adults and the elderly but may occasionally be prescribed for children.

Prozac Medication for Obsessive- Compulsive Disorders:

In addition to being used for the treatment of depression, Prozac is also used to treat obsessive-compulsive disorder. Obsessions are thoughts that won’t go away, and compulsions are repetitive behaviors and actions which are done to relieve anxiety often associated with the obsessions. Prozac is used at times to also treat bulimia which is a binge eating disorder which involves deliberate vomiting and has also been used to treat other eating disorders including obesity.

Premenstrual Dysphoric Disorder:

Under the brand name Serafem which includes the active ingredients in Prozac, this depression medication is sometimes prescribed for premenstrual dysphoric disorder (PMDD), which is often referred to as premenstrual syndrome (PMS) including mood changes such as anxiety, depression, persistent anger, irritability, and mood swings. There are various physical problems associated with PMDD, including bloating, breast tenderness, headache and joint muscle pain. Symptoms usually tend to begin about 1 to 2 weeks before a woman’s premenstrual period. They are frequently severe enough to interfere with a woman’s daily activities, functioning and relationships.

Prozac Medication: Precautions

You should always be open and honest with your doctor when your taking Prozac. Always give a complete medical history, including liver problems, kidney disease, seizures, heart problems, allergies and history of diabetes. This depression medication has been known to make individuals dizzy or drowsy, making it necessary to be cautious when engaging in activities that require alertness such as driving or using heavy machinery. Alcohol should be limited when on this medication. Caution is also advised if you have diabetes, alcohol dependence or liver disease. Also, caution should be taken when this medication is being used by the elderly as they are more sensitive to the effects of the drug. This drug should only be used if necessary if an individual is pregnant as the medication passes into the breast milk. Because of the possible risk to the infant, breast-feeding while on this medication is not recommended. Consultation with your physician about the benefits and risks of Prozac used during pregnancy and breast-feeding is imperative. Obviously, you should never share your Prozac with others.

Important Facts About This Depression Medication

It has been noted that there can be some very serious and at times even fatal reactions to occur when Prozac is taken at the same time as some other antidepressants such as the MAO inhibitors. Also, you need to be careful when taking high doses of Prozac over a prolonged period of time. If you are taking any other medications for depression or any other prescription or nonprescription drugs you need to notify your physician before beginning on Prozac.

Prozac Side Effects:

Although the Prozac side effects seem to be less than some of the earlier generation antidepressant medications such as desipramine, amitriptyline and nortriptyline, there are still side effects that you need to be aware of. Some of the more common side effects of Prozac are sweating, dry mouth, drowsiness, headache, insomnia and nausea. Some of the side effects that are less likely but at times even more severe are loss of appetite and unusual weight loss, uncontrollable movements such as tremors, decreased interest in sex, flu-like symptoms, and either unusual or severe mood changes. Even less likely but even more potentially serious Prozac side effects include trouble swallowing, vision changes, white spots and swelling on the mouth and tongue, painful and/or prolonged erection and changes in sexual ability. The most severe side effects associated with Prozac are irregular and fast heartbeat, and fainting. Allergic reactions to Prozac are relatively rare but may include itching, rash, swelling, trouble breathing and dizziness. If you notice any reactions after beginning treatment with Prozac, you need to notify your pharmacist or physician immediately. A more complete listing of Prozac side effects follows.

The Most Common Prozac Side Effects:

Abnormal vision, abnormal ejaculation, abnormal dreams, increased anxiety, reduced sex drive, dry mouth, dizziness, flushing, flulike symptoms, headache, gas, impotence, itching, insomnia, loss of appetite, nervousness, nausea, sinusitis, rash, sleepiness, sweating, sore throat, upset stomach, tremors, yawning, vomiting, weakness

Less Common Prozac Side Effects:

Agitation, abnormal taste, weight gain, sleep disorders, bleeding problems, confusion, chills, weight gain, ringing in the ears, palpitations, loss of memory, increased appetite, high blood pressure, frequent urination, ear pain, emotional instability

There have been other very rare side effects reported while taking Prozac. If you develop any unexplained or new symptoms after initiating treatment with this depression medication you need to contact your physician immediately.

Drug Interactions:

In addition to the Prozac side effects mentioned above, there are also concerns for negative food and drug interactions when taking this antidepressant medication. As mentioned previously, Prozac should never be taken at the same time as you are taking MAO inhibitors. This can cause a very serious medication interaction. Also, when Prozac is taken with other medications the effect may be increased, decreased or altered in other ways. You should always check with your doctor when Prozac is taken with the following medications:

Alprazolam (Xanax)
Carbamazepine (Tegretol)
Clozapine (Clozaril)
Diazepam (Valium)
Digitoxin (Crystodigin)
Drugs that impair brain function, such as sleep aids and narcotic painkillers
Flecainide (Tambocor)
Haloperidol (Haldol)
Lithium (Eskalith)
Other antidepressants (Elavil)
Phenytoin (Dilantin)
Pimozide (Orap)
Vinblastine (Velban)
Warfarin (Coumadin)

Special Warnings if You are Pregnant or Breast-feeding:

Prozac has not been adequately studied for its effects on pregnancy. If you are pregnant or plan to become pregnant in the near future, you need to talk with your physician as soon as possible to determine whether you should continue taking this depression medication. Prozac is known to appear in breast milk, so breast-feeding is obviously discouraged when taking this drug.

Prozac Dosage:

It is most common for your Prozac dosage to be taken once or twice a day and should be taken exactly as prescribed by your physician. It needs to be taken regularly to be effective. If it is possible, you should take your Prozac dosage at the same time every day.

Some patients have found that it can take as much as four weeks to feel any significant effects and get some relief from their depression. Doctors will also commonly maintain the treatment regimen for about nine months after the first initial three-month treatment trial. Some individuals who experience obsessive-compulsive disorder may not feel the full effects for as much as five weeks.

The Recommended Prozac Dosage:

The most common starting dosage of Prozac is 20 mg daily taken in the morning. Your physician may increase your dose after several weeks if there has been no improvement in symptoms. Elderly people with kidney and liver disease, and any other individual taking other medications may have their dosage adjusted by their doctor.

When taking a dosage of Prozac over 20 mg, the doctor may ask you to take it once a day in the morning or may ask that you to take two smaller doses in the morning and also at noontime.

The usual Prozac dosage for depression ranges between 20 mg and 60 mg. For obsessive-compulsive disorder, the usual dosage of Prozac ranges from 20 mg to 60 mg per day, although at times a maximum of 80 mg may be prescribed. The usual dosage of Prozac for bulimia nervosa is 60 mg taken in the morning. As with other disorders, the doctor may start at a lower dosage and increase to this level over a period of time. The most common Prozac dosage for premenstrual dysphoric disorder is 20 mg per day.

For some individuals who have been treated successfully with the daily form of Prozac, their doctor may switch them to a long acting form sometimes referred to as Prozac weekly. Your physician may ask you to skip your daily doses for seven days and then take your first weekly capsule.

If you miss your dose of Prozac you should take it as soon as you remember. If a significant time has passed however, you should skip that dosage and resume your normal dosage schedule.

Over dosage of Prozac:

Prozac like all medications, needs to be taken as recommended. Dosages more than the recommended amount can be dangerous and even fatal. Also, combining Prozac with certain other medications or drugs may cause symptoms of over dosage. If you suspect an overdose, you need to contact your doctor or go to an emergency room immediately.

The most common symptoms of Prozac over dosage include rapid heartbeat, nausea, seizures, vomiting and sleepiness. Some of the less common symptoms of Prozac over dosage include stupor, sweating, rigid muscles, low blood pressure, mania, coma, delirium, fainting, high fever and irregular heartbeat.

By Paul Susic Ph.D. Licensed Psychologist

Cognitive Behavioral Therapy for Depression, Anxiety and Insomnia?

Cognitive Behavioral Therapy: History

Cognitive behavioral therapy was founded by the psychiatrist Aaron Beck M.D. in the 1960’s. As he was conducting research on psychoanalysis he noticed that an internal dialogue seemed to be taking place as patients thought through and discussed their problems. Beck is considered to be the founding father of cognitive behavioral therapy. Albert Ellis Ph.D. on the other hand, was a psychologist who was the original creator of the conventional cognitive therapies and some of the basic principles underlying cognitive behavioral therapy.

Albert Ellis Ph.D. and Rational Emotive Therapy

In the mid-1950’s, Albert Ellis Ph.D. began to recognize some very important principles associated with thinking and behaviors, which he then applied to his brand of psychotherapy referred to as rational emotive therapy. He discovered that people would develop strong beliefs which would affect their emotional reactions and functioning. He recognized that certain beliefs could be very irrational resulting in individuals becoming depressed, anxious or contributing to other self-destructive behaviors.

When he began to formulate his ideas in about 1955, the role of thinking or cognition had not been addressed in any significant way by the field of psychology. He developed the therapeutic modality of rational emotive therapy in reaction to the inadequate explanations and techniques of behaviorism and psychoanalysis. He concluded that the inadequacy of psychoanalysis and behaviorism resulted from a deficiency in conceptualizations of emotional disturbance and personality. He concluded that by ignoring the role of thinking or cognition in emotional disturbance, both therapeutic models failed to explain the development and maintenance of dysfunctional thinking patterns.

Aaron Beck M.D. and Cognitive Behavioral Therapy

Following upon the therapeutic model of Albert Ellis Ph.D. and his rational emotive therapy, Aaron Beck M.D. also began recognizing the importance of thinking or cognition in individual’s distress and dysfunction in their daily lives. He began to see that the connection between feelings, emotions and thoughts were crucial in understanding reactions and behaviors.

He also began to recognize that patients were not always aware of their emotions and thoughts and were very incapable of identifying how their thoughts affect their behaviors. He began to recognize that when an individual is upset for example, their thought process is generally negative, destructive and frequently impractical. It became very apparent to Dr. Beck that individual’s thoughts played a huge role in understanding and being able to overcome life’s challenges.

As he continued to develop his therapeutic model, Dr. Beck began to consider that these skewed thinking processes were actually the result of what he considered to be automatic, involuntary thoughts, and that people have a tendency to accept them as true without considering any other alternatives. His cognitive behavioral therapy model began to emphasize the transformation of automatic thoughts by questioning their validity and whether they were an actual reflection of reality. He began to recognize that as an individual considers the existence of and then reduces or alters their destructive, self-critical or catastrophic thoughts, their sense of despair, worry, or depression would gradually decrease, and they would begin to live a more positive and satisfying life.

Literally thousands of studies have confirmed the effectiveness and validity of cognitive behavioral therapy. Many studies have suggested that cognitive behavioral therapy is more effective than medication alone in treating such conditions as insomnia and depression. It now seems to be the treatment model of choice for most psychologists, psychiatrists and other mental health clinicians. Part of its beauty is that it seems to be a very common-sense approach to treatment and can be used for almost any maladjusted behavior, where thoughts and ideas play a crucial role in the development and maintenance of dysfunctional patterns of thought and behavior.

An Overview of Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a relatively short-term psychotherapy model. It is a practical, results oriented approach to coping with a multitude of dysfunctional disorders including anxiety, depression, posttraumatic stress disorder, panic attacks, obsessive-compulsive disorder, social phobia, bipolar disorder, substance abuse, schizophrenia, eating disorders and anger issues as well as many others. Its goal is to help people to change the way they think and feel about specific situations in life as well as to change their resulting reactions and behaviors.

The therapy involves altering an individual’s attitudes and behavioral patterns by focusing on their thoughts, underlying beliefs, attitudes, and visual imagery. Cognitive behavioral therapy combines cognitive and behavioral psychotherapies and places an emphasis on the meaning ascribed to experiences and thought processes that can often be traced back to earlier childhood experiences. The behavioral aspect of therapy focuses on the connection between the challenges and obstacles faced as well as the actions and thoughts related to them. Negative and unpleasant thoughts can often lead to emotional distress and various other psychological issues. CBT attempts to help people to gain a better awareness of their negative interpretations and the behavioral patterns which arise from their skewed thinking processes. This therapeutic model frequently helps to develop alternative ways of processing thoughts and assists in developing new, more functional thoughts and behavioral patterns to mitigate psychological trauma and distress.

Three Models of Cognitive Therapy

The book Cognitive Behavioral Therapy by George Muntau has identified three major approaches to cognitive behavioral therapy. They are rational emotive therapy, Beck’s cognitive therapy and stress inoculation therapy.

Rational Emotive Behavior Therapy

Like cognitive behavioral therapy, rational emotive therapy also attempts to remediate maladaptive thoughts and behavioral patterns. It utilizes the process of discussion and persuasion to alter relevant thinking processes.

Beck’s Cognitive Therapy

As previously mentioned, Dr. Beck’s cognitive behavioral model originally developed for treating depression, is now used for a multitude of psychological disorders such as eating disorders, anxiety disorders, insomnia and even has been used in such specialties as sports psychology. The focus is on making the connection between maladaptive thinking patterns, feelings, and the resultant reactions and behaviors. Patients are trained to recognize and utilize automatic thoughts to alter thinking patterns and remediate their emotional distress.

Stress Inoculation Therapy

Stress inoculation therapy utilizes self-guided training to assist the patient in developing and utilizing self-transformational statements and affirmations. It is almost a “pep-talk” approach to altering thoughts and the resulting behaviors.

Cognitive Behavioral Therapy: Conclusion

Cognitive behavioral therapy is currently the model used by the majority of clinicians in providing psychotherapy for a whole variety of mental health disorders including depression, anxiety, insomnia and eating disorders as well as many others. It focuses on a common-sense approach to recognizing and dealing with dysfunctional thoughts which underlie distressful feelings and dysfunctional behavioral patterns. Current studies have found cognitive behavioral therapy to be just as effective as medications alone and to have superiority over medications in reducing the rate of relapse of various psychological disorders. Frequently, cognitive behavioral therapy is used in addition to medications for the optimal remediation of psychological disorders.

By Paul Susic Ph.D. Licensed Psychologist

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Help Wanted: Psychologists in Metropolitan St. Louis Missouri

Part-time and Full-time Psychologists Wanted in the St. Louis Metropolitan Area:

An excellent opportunity and exceptional pay for doctoral level psychologists in St. Louis city, St. Louis county, St. Charles County and the surrounding metropolitan area is now available. Senior Care Psychological Consulting is looking for psychologists to provide services in office, long-term care facilities and homes. Hours are very flexible including part-time and full-time opportunities to provide counseling, assessment and/or psychological testing services to geriatric patients and individuals with long-term chronic medical and mental health concerns. Experienced individuals are preferred but we will train individuals with the right personality and aptitude.


Senior Care Psychological Consulting provides excellent compensation, paid twice monthly without your having to wait on billing cycles or having to assume the risk of nonpayment. The average hourly rates are between $70-$114 per hour. This is a wonderful opportunity for a doctoral level psychologist who is interested in learning or continuing their experience in working with geriatrics and individuals with long-term medical and mental health disability. If you’re interested you may contact Paul Susic Ph.D. Licensed Psychologist at (636) 300-9922 or you may email me at for more information or to express your interest. Senior Care Psychological Consulting is an equal opportunity employer.

Paul Susic Ph.D. Licensed Psychologist
Clinical Director
Senior Care Psychological Consulting

Senior Care Psychological Consulting:

Senior Care Psychological Consulting in St. Charles, Missouri

The Only Strictly Doctoral Psychology Practice in St. Louis, Missouri

Senior Care Psychological Consulting is the premier provider of doctoral level geropsychology services for the metropolitan St. Louis, Missouri area. Senior Care Psychological Consulting is a specialty geriatric psychology practice providing psychological assessment, mental health counseling services, psychological testing, neuropsychological evaluation and disability evaluation to the elderly and chronic mentally ill in an office-based practice in St. Charles, Missouri. We also provide in- home services as well as providing services in nursing homes and other long term care facilities throughout the metropolitan St. Louis, Missouri area.

Paul Susic Ph.D. Licensed Psychologist and Senior Care Psychological Consulting

Senior Care Psychological was founded by Paul Susic Ph.D Licensed Psychologist who has been providing mental health services to the senior community for well over two decades. Paul developed one of the first exclusively geriatric psychiatric Partial Hospital programs in the St. Louis area, which he managed for approximately five years as the Program Manager at the former Incarnate Word Hospital. He also created and developed a whole continuum of outpatient mental health services which he also managed at Incarnate Word Hospital. He later was promoted to Director of the Department of Psychiatry of Incarnate Word Hospital, which he left in December, 1999 to begin a full-time geropsychology practice.

Paul Susic and Senior Care Psychological Counseling have continued their commitment to providing high-quality psychological assessment and mental health counseling services to the senior community. Senior Care specializes in providing psychological counseling and assessment services, psychological testing and neuropsychological evaluation in- home, in nursing homes and long-term care facilities throughout the metropolitan St. Louis area and also in an office based practice in St. Charles, Missouri. All services are provided under the direction of Dr.Susic who is the Clinical Director. Mental health assessments, testing as well as assessments for cognitive (memory) functioning and need for long-term placement are also available at senior care.

Please feel free to call and ask for Paul Susic Ph.D. Licensed Psychologist, and he will be pleased to assist you in any way possible. He may be reached at his office at (636) 300-9922 for local calls, or or he may also be reached by e-mail at

Senior Care Psychological Consulting 500 Huber Park Ct. Suite 205, Weldon Spring, MO 63304

Information and webpage by Paul Susic Ph.D. Licensed Psychologist

Senior Care Psychological Consulting:

Specific Phobia Disorder Treatment Information You Need to Know

Specific Phobia Disorder Treatment and Information: An Overview

Specific phobia disorder can be a very uncomfortable condition at the very least and absolutely disabling at its very worst. However, there are ways to cope with specific phobia disorder to prevent it from undermining an individual’s entire life. It is obviously imperative to have a good understanding of the condition as well as a recognition of when treatment is necessary. Specific phobia disorder involves a fear and avoidance of very specific circumstances or situations. It is very different from panic attacks and agoraphobia in various ways including that there are no spontaneous panic attacks or fear of panic attacks as you would experience in agoraphobia. It is also very different from social phobia in that there is no fear of embarrassment or humiliation in social situations. Direct exposure to the feared object can cause a panic reaction however. Often the fear and avoidance are significant enough to interfere with an individual’s daily functioning including working and social relationships, and frequently cause a tremendous feeling of distress. Frequently, individuals recognize the irrationality of their fear and response, but it continues to cause a considerable level of difficulty in their lives. Although there are many types of specific phobias some of the more common ones follow:

Dental or doctor phobias. Frequently these will begin with a fear of pain related to either dental or medical procedures conducted in the physician or dentist office. Later this may be generalized to anything related to or in memory of doctors or dentists. Unfortunately, this fear may cause some people to not seek medical or dental services when necessary.

Airplane phobia. Usually this phobic disorder is related to a fear of an airplane crashing. Often fears of the cabin depressurizing and not being able to breathe are part of the imagined scenario. A more contemporary version of this phobia is a fear of hijacking or a bombing of the plane Many individuals with this phobia will have an actual panic attack while flying. Some experts have concluded that approximately 10% of the population in the United States will not fly at all while an additional 20% will fly but experience tremendous anxiety.

Illness phobia. This phobic reaction is in relation to a fear of getting a specific medical condition such as cancer or having a heart attack. People with an illness phobia tend to seek constant reassurance from doctors and medical personnel and will avoid any reminder of the dreaded disease if possible. Illness phobia is also very different from hypochondriasis in that with a specific illness phobia people tend to focus on one specific illness as opposed to imagining the development of a variety of diseases or medical conditions.

Elevator phobia. This phobic reaction is usually in relation to fears of elevator cables breaking and the elevator crashing to the floor or being stopped and trapped inside. This fear frequently can cause an individual to have a panic attack although they have not previously had any history of panic disorder.

Animal phobias. The fear associated with this phobia is usually in relation to a variety of animals including rats, spiders, snakes, bats, dogs, and various other animals. This phobic disorder frequently begins in childhood where often the initial fears are considered to be rational or normal. It is only when they continue into adulthood and begin to undermine or interfere with an individual’s daily functioning that they actually develop to the point of becoming a specific phobia disorder.

Acrophobia. This phobia is often referred to as a “fear of heights”. Acrophobia can be related to a multitude of circumstances such as fear of being on the upper floors of a tall building, on top of a mountain, or even bridges. Individuals who experience this type of specific phobia disorder often say that they experience (1) dizziness or vertigo for (2) a feeling of being drawn toward the edge or an urge to jump.

Thunder and/or lightning phobias. This phobic disorder almost always starts in childhood. It is when it actually persists beyond the adolescent years that it is then defined as a specific phobia.
Specific phobias are very common and are believed to affect approximately 10% of the population. Because they do not always result in severe impairment in daily functioning, a significant amount of people who experience these fears and avoidant reactions do not seek treatment. Specific phobias seem to occur equally between men and women. Animal phobias however seem to be more common among women and illness phobia seems to be more common among men.

Development of Specific Phobia Disorder:

Specific phobias in general are usually fears about specific objects and circumstances experienced in childhood that were never really outgrown. However, in some circumstances they can be fears that are developed following the experience of a traumatic event such as an accident, illness or violent experience. Unfortunately, another precipitating factor which may lead to the possible development of a specific phobia may be the modeling of others. For example, repeated exposure to a parent who has a specific phobia can result in children developing it also.

Specific Phobia Disorder Treatment:

Specific phobia disorder treatment can be different from the usual treatment of panic disorders in that specific phobias do not generally involve spontaneous panic attacks. Therefore, they don’t often include treatments such as panic control therapy, interoceptive desensitization and medication.

Cognitive therapy. One of the more common treatments for specific phobia includes cognitive therapy which helps to recognize, challenge and replace some of the specific thoughts that perpetuate the fearful reactions and avoidance behavior. Fearful thoughts such as “What if I panic when I’m trapped on an airplane?” Can be replaced with thoughts such as “Although I’m on the plane for two hours, I will be off soon.”, or “I can get my mind on something else like reading or watching a movie.” These coping statements are usually rehearsed until they are internalized and often are accompanied with deep breathing or relaxation techniques.

Incremental exposure. This type of specific phobia treatment involves exposing the individual to the feared object or experience in incremental steps. An example of this may be when a fear of flying is incrementally approached through the use of imaginary flying experiences such as looking at pictures of people flying or even watching planes take off and land. Also, an individual may take a very short flight at first rather than a longer one. Initially they may even have a support person to accompany this individual, and eventually they may then take the flight on their own.

Relaxation training. Deep breathing and muscle relaxation can be practiced on a regular basis to reduce the general level of experienced anxiety. Relaxation training can be used to help with anticipatory anxiety as well as deep breathing while actually confronting the specific object or circumstance.

Some phobic objects and circumstances are not amenable to real-life desensitization such as earthquakes or other natural disasters. In these circumstances cognitive therapy would be used along with exposure to imaginary experiences of these natural disasters such as looking at pictures or watching movies associated with these feared catastrophes.

Specific phobia disorder conclusion:

It is always important to understand that specific phobia disorder is relatively benign initially, especially if it begins as a childhood fear. Although it has been found at times to last for many years and even decades, it will usually not get worse and sometimes will diminish over time. Fortunately, this disorder is not usually associated with other psychiatric disorders or mental health problems. People with specific phobia disorder often function at a high level in other aspects of their lives.

By Paul Susic Ph.D. Licensed Psychologist

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Bipolar I Disorder: Most Recent Episode Manic Diagnosis

Bipolar I Disorder: Most Recent Episode Manic Diagnosis: Most Essential Features

In order to have a bipolar I disorder diagnosis, it is absolutely essential to have at least one episode of mania. This manic episode will need to last at least a week, almost every day with symptoms present most of the time. During this period of mania, you will experience a high level of energy along with an elevated, irritable or expansive mood. Many individuals also experience an increased level of goal-directed behaviors. These behaviors need to be much more pronounced than normal, usual behaviors. If the mood is only irritable you may experience the following symptoms: the need for sleep; pressured speech or abnormally talkative; flight of ideas and racing thoughts; inflated sense of self-esteem or grandiosity; difficulty concentrating and easily distracted; major increase in psychomotor agitation or goal-directed activity associated with work, social, sexually related and possibly a significant increase in behaviors that could be riskier and result in severe negative consequences.

Additionally, individuals experiencing bipolar I disorder frequently also have histories of major depressive and hypomanic episodes, but it is not essential. Although many people believe that bipolar I disorder involves rapid mood swings, frequently that does not occur. Changes from mania to depression or hypomania could go on for weeks, months or longer. They may resolve to be followed by additional episodes at a later point in time.


Bipolar I Disorder: Most Recent Episode Manic-Special Considerations:

Bipolar I most recent episode manic have some special concerns in that it can be an extremely dangerous mood at times. Some research has found that as many as 25% to 50% of individuals who have a diagnosis of bipolar I disorder eventually attempt suicide.

Individuals experiencing a manic episode often become involved in very risky behavior. Some of these experiences can even be life-threatening. Clinicians working with patients having bipolar I mood episodes need to be very aware of the risks involved in that they need to make it a part of their work with clients to make risk assessments and have crisis planning.

The healthcare costs associated with bipolar I disorder are very high. Some research has found that bipolar I disorder results in three times higher cost than among other individuals because of the increased level of hospitalization, visits to doctors and the expense of medications.

Bipolar I Disorder: Most Recent Episode Manic-Psychological Treatment and Medications

Bipolar I disorder requires lifelong management of symptoms. Fortunately, there are effective treatments that can help you or your loved ones to have a relatively normal life. Medications are available to stabilize mood and psychosocial treatments are available. Research has found that some of the more effective treatments include the combination of medications along with psychological interventions. Some of the more effective psychological interventions for the treatment of bipolar I disorder include cognitive behavioral therapy, psychoeducation, family-focused therapy, and interpersonal social rhythm therapy.

The specific criteria for bipolar I disorder most recent episode manic follow:

Basic Bipolar I Disorder Diagnosis Criteria

A. Criteria have been met for at least one manic episode.
B. The occurrence of the manic and major depressive episode or episodes is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other schizophrenia spectrum and other psychotic disorders.

Manic Episode;

A. A distinct period of abnormal and persistent, elevated, expansive or irritable mood, and abnormal and persistent increased goal directed activity or energy. This must last for at least a week and be present most of the day, nearly every day.

B. During this period of mood disturbance with increased energy or activity, three (or more) of the following symptoms (except for if the mood is only irritable) and are to a significant degree and must be a noticeable change from your usual behavior.

1. Inflated self-esteem or sense of grandiosity.
2. A decreased need for sleep such as feeling rested after only three hours of sleep.
3. More talkative than usual or a sense of pressure when talking.
4. Racing thoughts and flight of ideas.
5. Easily distracted.
6. Increase in goal-directed activity socially, at work or school, or sexually, or psychomotor agitation.
7. Excessive involvement in negative or high-risk situations such as engaging in unrestrained buying sprees, uninhibited sexual indiscretions, or foolish business investments.

C. The disturbance must be severe enough to cause significant impairment in social or occupational functioning, or to result in hospitalization to prevent harm to yourself or others, or if there are psychotic features present.

D. The episode cannot be attributed to the physiological effects of a substance such as a specific drug of abuse, a medication or other treatment or another medical condition.
Note: A full manic episode that emerged during antidepressant treatment or electroconvulsive therapy. Manic symptoms significantly at a level beyond the actual physiological effect of that treatment may be sufficient evidence for a manic episode and therefore of a bipolar one diagnosis.

Note: Criteria A-D above constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.

Coding for Specific Bipolar I Diagnoses:

The diagnostic code for bipolar I diagnosis are 296. _ _ (F31. _ _). The specific diagnosis and the related coding is based upon the current or most recent episode only. Mental health clinicians also need to consider and specify the severity, whether psychotic features are present, whether the client is in partial or full remission.

Some information adapted by Paul Susic Ph.D. Licensed Psychologist from the Diagnostic And Statistical Manual of Mental Disorders Fifth Edition DSM-5

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Treatment for Depression: Psychotherapy and Psychological Treatments

Treatment for Depression: An Introduction

Treatments for depression have come a long way in the last couple of decades with many advancements in psychotherapy and psychological treatments that have been empirically supported by research. Research into cognitive behavioral therapy, behavior therapy and interpersonal therapy have now been conclusively found to be effective. Evidence has also been found to support the use of cognitive therapy and reminiscence therapy among senior adults. A review of each of the main specific therapeutic modalities follows below.

Treatment for Depression: Cognitive Behavioral Therapy

Cognitive behavioral therapy was originally developed by Aaron Beck M.D. in the late 1960’s. It has easily become the most popular treatment modality for depression, anxiety disorders and a multitude of other mental health conditions. Cognitive behavioral therapy focuses on the connection between thoughts, moods and behaviors and utilizes primarily the thoughts as the main intervention point to modify moods and ultimately behaviors. It recognizes the negative bias that many people develop that results in biased information processing and dysfunctional beliefs that lead to and maintain depression. The main goal is to identify and change the dysfunctional or maladaptive thinking which is believed to then consequently change the individual’s affect and behaviors.

Cognitive behavioral therapy is traditionally provided within a structured format that facilitates learning experiences, monitoring thoughts, development of more adaptive coping skills and Socratic questioning of maladaptive thinking. A full course of cognitive behavioral therapy may involve 14 to 16 sessions along with booster sessions whenever necessary. There has been significant evidence over the last several decades recognizing the effectiveness of cognitive behavioral therapy in treating depression. Various outcome studies have found it to be at least as effective as pharmacotherapy and may be more effective than depression medications alone in assisting with preventing relapse of depressive symptoms. A more recent field of cognitive behavioral therapy has also had an increased interest and attention in that it has integrated the concept of mindfulness as well into the traditional cognitive behavioral model, in an attempt to reduce the incidence of relapse.

Behavior Therapy Treatment of Depression:

Behavior therapy focuses on the use of reinforcement and extinction of behaviors that are found to be either positive or negative. Behavior therapies focus on increasing the quality as well as the frequency of pleasant experiences which are then expected to result in improvements in an individual’s mood. A structured treatment program that was developed utilizing this theoretical perspective is the Coping With Depression course. This course uses the format of a psychoeducational group which usually consists of 12 sessions over approximately eight weeks, and then uses skills training to improve social skills. The objective is then to increase activities that are pleasant as well as to teach individuals how to relax. Some recent evidence has found that the use of this Coping With Depression course is at least as effective as antidepressant medications in treating depression in the short-term and possibly even over the long-term.

Interpersonal Therapy for Depression:

An interpersonal therapy model for depression was developed by Klarman, Wiseman and Associates in the 1980’s. The basis for Interpersonal therapy is the Interpersonal model of depression which considers depression to be the result of or to be exacerbated by interpersonal difficulties between people. As a result, interpersonal therapy focuses on remediating these interpersonal problems. Interventions may focus on role transitions, or disputes, interpersonal deficits and skills and even grief issues which have been denied, delayed or may be inadequately completed.

Interpersonal therapy is also provided within a structured format and utilizes a progression through three phases: (1) the diagnosis and identification of specific areas of interpersonal difficulties as well as an explanation of the course of therapy; (2) focus on resolution of the specific problematic areas or difficulties and (3) termination of therapy. This type of therapy has been utilized in a modified format among several specific populations such as adolescents and the elderly and has been used for other mental health disorders as well. Interpersonal therapy has been demonstrated to be effective for both the acute and maintenance phases of depression.

Learned Helplessness Treatment Model for Depression:

Significant research has also recognized the importance of the learned helplessness model for the development and maintenance of depression. Learned helplessness is based upon a model by Martin Seligman Ph.D. in the early 1960’s in which he recognized that there was a connection between an individual’s sense of control over their environment and depression. He found that an individual’s inability to have a sense of control over adverse circumstances in their environment resulted in a sense of helplessness and ultimately depression. He believed this perspective and consequent depressed mood was basically a learned experience. This model recognizes the need for increasing an individual’s sense of control over their environment, reducing feelings of helplessness, hopelessness and depression.

Treatment for Depression: Conclusion

Research and my (Paul Susic Ph.D. Licensed Psychologist) clinical experience has found over the last several decades that optimal treatment for depression may include both psychotherapy and/or psychological treatments along with medications for the most effective treatment of major depressive disorder. Although medications frequently are prescribed as a front-line treatment for depression, this physiological focus is often not ideal. Medications alone have been found to have higher relapse risks of additional episodes than psychotherapy alone. In most cases it seems that the most effective approach may be to attempt to remediate the depression with psychotherapy and then add medication as necessary rather than trying medication and then adding psychotherapy as an adjunct treatment.

By Paul Susic Ph.D. Licensed Psychologist

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Are there effective psychosocial treatments for bipolar disorder?

Psychosocial treatments and psychotherapy for bipolar disorder: An overview

Psychosocial treatments are continuing to take a more prominent role in assisting in the mood stability of individuals with bipolar disorder. As an adjunct to pharmacotherapy (medication management of symptoms), family focused treatment strategies and cognitive behavioral therapy have been used to assist in successfully reducing relapse and intervening directly for bipolar depression and hypomanic episodes.

Psychosocial treatments for bipolar disorder are beginning to be recognized more often than in the past by experts as an adjunctive treatment to pharmacotherapy for the treatment and management of bipolar symptoms. Keck et al. (2004) recently found that experts are more consistently recommending psychotherapy and psychosocial interventions for the stages of bipolar disorder when patients are most receptive to interventions, such as when they are in an acute stage or in the maintenance phases of depressive and hypomanic episodes. However, these conclusions were not found when patients were experiencing acute manic or psychotic episodes. Psychological treatments and psychotherapy have also been recommended for the treatment of comorbid conditions such as when the patient has additional medical conditions such as eating or substance use disorders, or anxiety. It has been recommended as a first choice option when the use of medications is limited by comorbid medical conditions such as liver disease, renal conditions, obesity, pregnancy or heart disease.

Bipolar Disorder Psychosocial Treatments:

Some psychosocial treatments and psychotherapeutic interventions have demonstrated effectiveness for relapse prevention and in the earlier stages when the initial symptoms of bipolar disorder begin to occur. Cognitive behavioral therapy designed to treat existing symptoms and prevent relapse, individual cognitive behavioral therapy to treat bipolar depression, psychoeducational interventions and family-oriented interventions to assist in medication compliance and facilitating social support systems have demonstrated some effectiveness. Specific interpersonal related therapy along with interventions to assist with balancing sleep, awake, routine and activity cycles have been studied, although their effectiveness has not been proven at the present time.

The most effective psychosocial treatments seem to focus on some of the same basic principles: (1) Psychoeducation that helps patients to understand the role of medication compliance, and a basic understanding of their disorder as well as factors that aggravate the disorder such as issues related to sleep, regulating lifestyle and stress management; (2) communication and problem-solving training to reduce individual and family stress; (3) improving an understanding of early detection and intervention strategies such as increasing psychotherapy sessions, review of medications and increased family support and assistance. These interventions may be combined with additional cognitive behavioral strategies such as cognitive-restructuring, thought and activity monitoring, and other treatment interventions within an individual, family or group setting.

Cognitive Behavioral Therapy for Bipolar Disorder:

Typical cognitive behavioral therapy may include interventions for depression, balancing sleep and wake cycles and routine management, as well as monitoring of moods with a focus on the early detection of symptoms and initiating intervention. Lam and associates (2003) studied cognitive behavioral treatments and found some strong protective effects associated with the treatments, including a 43.8% relapse rate for individuals participating in cognitive behavioral therapy compared with a 75% rate for individuals from a control group who did not. Additional benefits were also identified in that the actual time spent in manic or depressive episodes was reduced significantly, and fewer days were spent hospitalized for the disorder.

Miklowitz (2003) found similar success with family interventions. In studies on family focused treatments that focus on psychoeducation for both bipolar patients and their families, along with assisting with communication and problem-solving have been found to be similarly effective. Interventions also included role-playing interventions and rehearsals both within and between sessions. Psychoeducational interventions included discussing risk and protective factors for mood episodes, along with rehearsal and relapse prevention efforts in the early stages of the bipolar episodes. The study by Miklowitz et al. (2003) found that in 21 sessions over a period of nine months of family focused treatments combined with medications, reduced both depression and manic symptoms as well as offered protection against relapse of bipolar episodes. These were compared to alternative interventions which focused on medication treatment along with two sessions of home-based family psychoeducation and crisis intervention over a period of nine months.

In another trial study by Rea et al. (2003), it was found that patients undergoing family focused therapy along with medication management had significantly longer delays in hospitalization and less relapse when compared to individuals undergoing only individual therapy consisting of medication compliance, psychoeducation, family support and problem-solving. Following the delivery of the active psychosocial treatments for a year, the rates of rehospitalization in the family focused therapy experience were only 12% as compared to 60% among the individuals receiving strictly individual therapy.

Summary of Psychosocial and Psychotherapeutic Interventions for Bipolar Disorder:

As reviewed in this article, several psychotherapeutic and psychosocial interventions have been found to be effective as an adjunct to the use of medications for the maintenance and early intervention to reduce the symptoms of bipolar disorder. The common principles involved in utilization of psychosocial treatments and psychotherapy for bipolar disorder focuses on the core belief that effective treatment needs to be a comprehensive, psychoeducational, cognitive behavioral, skill-based program, incorporating the family and social system which is oriented toward the long-term management of this chronic mental health condition.


Keck, D. A., Perlis, R.H., Otto, M.W., Carpenter, D., Docherty, J.P. & Ross, R. (2004). Expert Consensus Guideline Series: Treatment of bipolar disorder. A Postgraduate Medicine Special Report: December, 1-108.

Lam, D. H., Watkins, E. R., Hayward, P., Bright, J., Wright, K., Kerr, et all. (2003). A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: Outcome of the first year. Archives of General Psychiatry, 60, 145-152.

Miklowitz, D. J., George, E. L., Richards, J. A., Simoneau, T. L., & Sudduth, R. L. (2003). A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Archives of General Psychiatry, 60, 904-912.

Rea, M. M., Thompson, M. C., Miklowitz, D. J., Goldstein, M. J., Hwang, S., & Mintz, J. (2003). Family-focused treatment versus individual treatment for bipolar disorder: Results of a randomized clinical trial, Journal of Consulting and Clinical Psychology, 71, 482-492.

By Paul Susic Ph.D. Licensed Psychologist

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Bipolar Disorder Medication: Treatments of Choice?

Bipolar Disorder Medication Treatments: Overview

Bipolar disorder medication has been the treatment of choice for several decades now to control the severe and sometimes disabling symptoms of bipolar disorder. Doctors have been prescribing lithium and other mood stabilizers as well as anticonvulsant medications and atypical antipsychotics as the primary treatment for bipolar disorder along with the use of antidepressants and antianxiety medications, to help manage acute episodes as well as for the longer term management and to assist in managing future episodes.

Bipolar disorder medication treatments still rely upon the use of mood stabilizers such as lithium for the acute treatment of both manic and depressive episodes. Lithium has been used now for many decades to manage these moods and to prevent cycling into the other mood state. Doctors also have been known to use the anticonvulsants, antipsychotic medications, antidepressants, antianxiety and even sleep medications to manage the intense manic and depressive episodes as well as some of the associated problems, such as when the bipolar patient has a high level of anxiety or difficulty sleeping.

Mood stabilizers such as Lithium are used to prevent and treat the manic highs and the depressive lows. These medications are used to manage the symptoms so they do not interfere with school, work and with personal relationships. The main mood stabilizing medications are:

Divalproex sodium (Depakote)
Carbamazepine (Tegretol)
Lamotrigine (Lamictal)
Valproic acid (Depakene)

Some of these medications are also chategorized as anticonvulsants such as valproic acid, lamotrigine and carbamazepine.

Other medications used to treat bipolar disorder include the atypical antipsychotic medications. These include
Aripiprazole (Abilify)
Risperidone (Risperdal)
Quetiapine fumarate (Seroquel)
Olanzapine (Zyprexa)
Ziprasidone (Geodon)
Loxapine (Loxitand or loxapine inhaler (Adasuve)
Asenapine (Saphris)
Cariprazine (Vraylar)
Lurasidone (Latuda)

If an individual is experiencing insomnia or sleep difficulties in relation to their bipolar symptoms, they may receive prescriptions for antianxiety medications such as benzodiazepines. Some of the more common benzodiazepines include:

Alprazolam (Xanax)
Lorazepam (Ativan)
Diazepam (Valium)
Clonazepam (Klonopin)

Or frequently some of the newer sleep medication such as zaleplon (Sonata) and eszopiclone (Lunesta} will be prescribed as they are believed to cause fewer problems with thinking and memory then the antianxiety medicines, benzodiazepines.

Frequently, the doctor will prescribe the mood stabilizing medication lithium initially, but may also start a medication to also assist with the bipolar depression such as:

Fluoxetine (Prozac) which is combined with olanzapine (Zyprexa) to form a medication referred to as Symbyax
Quetiapine fumarate (Seroquel)
Lurasidone (Latuda) which may be taken either alone or with valproic acid or lithium.

Bipolar disorder medication treatments and depression:

Due to the predominance of depressive symptoms in bipolar disorder, antidepressants are often combined with mood stabilizers. However, there are significant concerns that the use of antidepressants can trigger manic episodes. These concerns have usually been related to the older antidepressants referred to as tricyclics rather than some of the newer serotonin reuptake inhibitors such as Paxil, Prozac and Zoloft. This risk was identified in a study by Gijsman, Geddes, Rendell, Nolen and Goodwin in 2004 in which it was found that there was a significant risk of the emergence of a manic conversion from depression among patients with a mood or anxiety disorder treated with tricyclic antidepressants, rather than when patients were treated with the SSRI’s. Also, even higher conversion rates from depression to manic episodes were found among younger antidepressant users.

Benzodiazepines and bipolar disorder:

Benzodiazepines have been used at times to reduce agitation and comorbid anxiety as an adjunctive medication treatment for bipolar disorder. However, the actual efficacy of these medicines has not been adequately studied at the present time when used in addition to the mood stabilizing medications.

Normal course of medication treatment for bipolar disorder:

Although mood stabilizers, antidepressants and other adjunctive medications have been used for the treatment of bipolar disorder for many years, the normal course of bipolar disorder continues to be one of relapse of episodes of mania/ hypomania and depression. Studies (Gitlin, Swenson, Heller, and Hammond, 1995) have found one-year relapse rates as high as 40% even while being treated with mood stabilizers. Medication compliance continues to be a major issue with patients with bipolar disorder, with one study (Keck et al., 1998) finding inadequate medication use among approximately one half to two thirds of the patients within one year of initial treatment. Discontinuing the use of medications and the related relapse of bipolar symptoms with these patients is very problematic, especially when these medications have been stopped abruptly. Psychological treatments have been successfully utilized to promote medication compliance and to improve the symptom course of bipolar disorder patients. Overall, psychosocial interventions and psychotherapy have been found to improve the management of long-term bipolar symptoms and assist in relapse prevention.


Gijsman, H.M., Geddes, J.R., Rendell, J.M., Nolen W.A. and Goodwin, G.M. (2004). Antidepressants for bipolar depression: a systematic review of randomized, controlled trials. American Journal of Psychiatry, 161, 1537-1547.

Gitlin, M.J., Swenson, J., Heller, T.L. and Hammen, C. (1995). Relapse and impairment in bipolar disorder. American Journal of Psychiatry, 152, 1635-1640.

Keck, P.E., McElroy, S.L., Strakowski, S.M., West, S.A., Sax, K.W., Hawkins et al (1998). Twelve-month outcome of patients with bipolar disorder following hospitalization for a manic or mixed episode. American Journal of Psychiatry, 155, 646-652.

By Paul Susic Ph.D. Licensed Psychologist