Bipolar and Unstable Mood Disorders
Mood Disorders: Bipolar Type < xml="true" ns="urn:schemas-microsoft-com:office:office" prefix="o" namespace="">
Irritable, Excitable, Nasty Mood Swings!
1. Essential Feature of Mood Disorders: There is a disturbance of the predominant feeling state or mood, depressed , manic or mixed. In a Depressive Episode the mood is sad or there is a loss of interest or pleasure. The Manic Episode the mood is abnormally elevated, that is too good, too cheerful, or high, and expansive, that is growing, getting bigger. A critical problem is that is either state manic or depressed irritability can be the major or only finding, especially in children or adolescents. Also it may be a Mixed Episode, that is one may be sad, too cheerful, and irritable within a specific episode in a relatively short time. The irritability in a the manic state is more excitable, explosive, nasty, affecting others often more than self, where as in the depressed state it is more painful often to the self than others, more inwardly directed.
2. Essential Feature of Bipolar Mood Disorder: Bipolar means having two poles or opposite mood states. The manic or high energy state that show itself with an irritable, nasty, mean mood, changing or swinging to a normal, or a low energy sad, tired, depressed state or pole. The low energy state may show itself with physical problems like excessive sleep, headaches, etc, that force the brain to slow down and rest. The high energy pole may also show itself with an expansive, silly, too happy mood. When the mood changes have these two poles and cause significant impairment at home, school , socially or distress to self or others and are of sufficient duration, usually one week it then is classified as a disorder, a Bipolar Mood Disorder.
3. Critical Importance of Differentiating Causes of Depression: Depression is the most common expression of Bipolar Disorder. Greater than 30% of patients with bipolar disorder and incorrectly diagnosed with Unipolar depression , and nearly 50% with bipolar are diagnosed with some other disorder. Based on this misdiagnosis, antidepressants, other medications and treatments are used that initially may help some of the presenting symptoms, but in the long wrong worsen the problems, fuel episodes , and may actually make the bipolar process more resistant to the usual treatment. Also there is a delay in proper diagnosis and treatment.
4. A Diagnostic Warning: In any disorder one or a few symptoms, over a short period of time does not make the diagnosis. It is the totally picture including the presenting problems and their history, the individual persons and family history, and treatment response history of the individual person and family members. The initial diagnostic impression should be just that an impression, not a harder conclusion, and be provisional, needing to be modified and changed depending on history and response to treatment. A diagnosis is all of these things not just a label. People take labels very seriously because of what they mean, and what they think they mean, and because of their effects on long term functioning and personal and public perception.
5. Bipolar Disorder, Variability , Early & other Precursors: No other Diagnosis presents with such variability in its presentation and severity not only in deferent age groups but also within individual episodes, and even sub episodically. Variability and unpredictability is the rule and is somewhat diagnostic, especially in the younger person, and early in the course. There seems to be a core of excitability sometimes seen as early as infancy that shows itself with many possible severe and episodic precursors if not the initial symptoms, or episodes of a bipolar process. Some examples of these possible precursors are Infantile Colic, Severe Tantrums, Severe Separation Anxiety, Psychosomatic Symptoms and Disorders, Headaches, especially Migraines, Severe Sleep Disturbances, including nightmares, Eating Disturbances including Bulimic, Anorexic, type states, including severe increased appetite with or without severe weight gain, Panic Attacks. , School and Work Refusal, Avoidance, Absences, Unexplained and episodic Learning Problems and Work related problems, episodic Severe Relationship Problems, Nicotine, Drug and Alcohol Experimentation especially if at early age. If these are part of a Bipolar process or disorder, they may not respond adequately or at all to any intervention until the underlying process is treated with mood stabilizing medication. Especially if these symptom clusters, or problems come and go, and substitute for each other as representations of the underlying core of excitability that represent the bipolar process they will be either ignored as minor, or a stage, or treated as a separate diagnosis, with inadequate treatments. What helps in clarifying the underlying diagnosis, is family history, and that these representations don’t occur alone but with the core symptoms of a bipolar process, though at time subtle, hidden, or masked, but the core symptoms are there, in the individual, and in the family history.
6. Bipolar Disorder and “The Suffering Well”: In its more outwardly dramatic loud presentation it get at least the attention it deserves, but in it more internally quiet presentation often only the individual person having the symptoms are aware of the intense emotional pain and suffering they endure. Some of these are “The Suffering Well”, people who on the surface are functioning well, at work, at school, socially, and even in their family, and even those closest to them are not fully aware of their emotional pain and suffering, which may have been ongoing for years. The bipolar “suffering well” person may be using great amount of energy controlling their mood symptoms, and be so good at it that their level of functioning is either minimally impaired or seeming non impaired. Many Bipolar people are intelligent, talented, hard working, and very very good at what they do and some are expertise, they are also personal, and can be good sales people, including selling themselves, and they use these attributes not only to control their mood and its symptoms, but have so much reserve, and function at such a high level, that as their bipolar symptoms get worse their functioning is little impaired, but they may be fooling others, but they are not fooling themselves, they know they are in pain, and slipping, and may be losing it, but the denial, shame, guilt built into any depressive process aid and abets them in not sharing with others even the ones they trust the most their private symptoms. When they are alone they are often miserable, they try hard not to be alone to avoid this misery, acutely aware of their sad , bad, and mad moods, not taking it out on themselves privately, the force of will they used to control the symptoms can no longer hold, so the symptoms flood in, the racing thoughts, shifting moods, the anger, irritability, rage, the self hatred, alternating with confusing false highs of mood, they are empty , lonely, feeling better off dead, the energy is low, they want to sleep, but they can’t, and they finally do, a restless sleep, and they awaken and it starts all over again, sometimes for years. When they finally do seek help it is for some of their symptoms only like the trouble sleeping or the constant anxiety, worry and tension they feel, that only work partially and for a short time. These are truly suffering people who still by most standards, except for perhaps their own, are doing well, sometimes surprisingly well.
7. Severity of Bipolar Symptoms based on GAF vs. Diagnostic Label: A diagnostic label in itself no matter what its connotation of how severe or major of a disorder it may represent, does not in reality address the severity of that disorder. There are people with any mental health problem that may have symptoms or clusters of symptoms that may represent a specific disorder. By definition for a symptom cluster or syndrome to qualify as a disorder there must be significant symptom severity leading to distress and or significant impairment of functioning. But what is significant? The Global Assessment of Functioning Scale is used to deal with these issues, and can be used to assess the severity of a disorder and the response to treatment. On the high end is a rating of 100 with superior functioning in all areas , and no symptoms, to 50 in the middle with severe symptoms and distress and/or serious impairment of functioning at home, school, family relationships, or impairment with judgment, thinking or mood, and as you approach zero, there is extreme severity of symptoms, with extremely impaired functioning in all areas with the end point of being dangerous to self or others with a clear expectation of death. In the example of the high functioning “Suffering Well”, bipolar person, their score for impairment may be very high, because there is little to no impairment, such a score may be 85 for example meaning doing so well that it normally would require no clinical attention, that is evaluation or treatment, however in rating symptom severity and distress, the hopelessly feeling near suicidal symptom would be rated perhaps 50 or serious severity, which would indicate an immediate need for clinical attention.
8. Critical Understanding- Changing Moods lead to Changing Symptoms: Failure to understand this principal leads too much diagnostic confusion and the wrong medication approaches. As we go over the symptoms of Depressive and Manic Episodes or states, they often represent two sides of the same coin, their presentation shifting and changing as they are mood driven. Being constantly aware of this and treating the cause, rather than the symptoms, is essential. A good example is the depression , in a rapid cycling person one part of the day they may be feeling worthless, hopeless , depressed, thinking of suicide, the mood shifts and now they are cheerful too happy, and feel they can live forever and do anything and everything, now their mind in racing, with poor concentration and they can’t sleep, in transition they go through a period of irritability, excitably, anger and panic.
9. Critical Treatment Rule-Treat the Cause not the Symptoms: In the above example, What does one treat the depression, the racing thoughts, the poor concentration. the anger, the panic? If this happens over weeks or months, and one only has part of the history and the picture, this adds to the confusion, one may respond to and treat the problem symptoms rather than the disorder, with disastrous results. Getting only part of the history could result in miss diagnosis like, Major Depression, Panic Disorder, ADHD, or just treating the symptoms like the sleep difficulty , rather than seeing all these changing symptoms as manifestation of a Bipolar Disorder with Mixed Episodes and Rapid Cycling. In this case a mood stabilizing medication is the treatment of choice and address all the symptoms and the underlying cause, where as other medications treating the symptoms would only work temporarily if at all and would eventually escalate all the symptoms and lead to psychosis and suicide, truly catastrophic outcome.
10. Comparison of Symptoms of Depression and Mania: There are 9 symptoms of a depressive episode, and at least 5 must be present in a two week period. They are depressed mood, insomnia, decreased pleasure, guilt, decreased energy, poor concentration, appetite decrease, mind and body being fast or slow, suicide thoughts. There are 7 symptoms for mania and 3 must be present if mood is elevated, or 4 if irritable, over a one week period. They are distractibility, insomnia, grandiosity, flight of ideas, increased goal directed activities, more talkative than usual, thoughtlessness or impulsivity. Episodes are often mixed, especially in children and teens episodes and also may be rapid cycling, that is switching between high energy manic, excitable states, to low energy depressed states in hours or even minutes, so seeing the symptoms side by side, and their variations in mixed episodes is necessary to correctly make the diagnosis, and to appreciate the complex mixed ever changing nature that is confusing diagnostically and therapeutically. The criterion needed to make the diagnosis of Bipolar Disorder are discussed below starting with mood and ending with suicide ideas. Keep in mind that many episodes are mixed , and rapid cycling, which means both poles or both side of the same coin can be seen within a very short time. One needs diagnostically and therapeutically to the whole picture, not just to one pole, or symptom cluster in isolation.
11. Mood: In the manic, high energy state, the mood is too good, cheerful, or high, with a catchy infectious quality. The people who know the person best will tell you it is too much. Irritability and short fuse is very common, with lability, that is there is much changeability between high and low states within the present episode. During the depressed episode the person feels sad, empty, and in children especially irritability. “Down in the dumps,” “blah,” “I don’t care “ are used to describe the mood. Sometimes the depressed mood has to be inferred from appearance, demeanor, relatedness. Many time excessive concern and complaints about physical symptoms like headaches, other pains, stomach and intestinal distress, sleep difficulties are the presenting complaint and are the mood equivalent.
12. Sleep: Problems with sleep are always present nearly every day, though because of the episodic nature of mood problems especially Bipolar Episodes, may not be initially apparent or complained of, though in others it is the only or chief complaint for seeking evaluation and treatment. In Depressive Episodes waking up in the middle of the night or waking up too early is considered a cardinal biological marker. Others present with a pattern of excessive non restful sleep. In the Manic phase there is a decreased need for sleep, sometimes going on for days, and the person may wake up much earlier than usual, feeling full of energy, or at least not tired. Often trouble falling asleep is the problem, in Mania caused by excessive physical and mental energy and racing thoughts, “I can’t shut down my mind.” In Depression the problem falling asleep may be due to excessive worry and preoccupation with depressive and anxious thoughts, about the past, present and the future.
13. Interest and Pleasure: In depression there is a marked decrease in interest and or pleasure in all, or most activities, nearly every day, even those that were previously pleasurable. There is a not caring anymore attitude, and social withdrawal. In mania there is an increase in interest, and as the mood becomes expansive and indiscriminate enthusiasm for activities at work , school, and socially. Rather than isolation and withdrawal there is excessive involvement in pleasurable activities.
14. Self Evaluation: In depression there is severe negative self evaluation, with feelings of worthlessness, too much inappropriate guilt, feeling defective with self blame. In mania there is inflated self evaluation, from uncritical self-confidence to the point of grandiosity, even delusion ,that is thoughts not based on reality. Based on this inflated self image the person believes they are right, they should be in control, be the boss, knowing better than others like their bosses, teachers, their parents.
15. Physical Energy: In depression there is fatigue, tiredness, and loss of energy nearly every day, that is not associated with physical exertion. In mania there is increase of energy, to the point of over activity, restlessness, pacing, more talkative than usual or pressure to keep talking.
16. Concentration: In depression there is decreased ability to concentrate and think, with almost compulsive indecisiveness, associated with slowed thinking, depressed mood, lack of energy, poor motivation, and excessive worry. In mania there distractibility based on racing thoughts, and changing moods.
17. Appetite: Appetite changes can be severe in either direction, in depression or manic states, often the person looses their appetite, or starts craving carbohydrates, and has increased appetite, with corresponding weight gain or loss.
18. Psychomotor Changes: Psychomotor refers to the mind the psyche that is thoughts and feelings, and the motor, or movement of body. In mania there tends to be a consistent increase motor and thinking activity, the person feels speeded up and is speeded up , with a subjective sense that thoughts are racing, called flight of ideas, observable too rapid speech, that goes off on tangents, at times can get illogical and hard to follow. In depression the body- mind , that is psychomotor changes can go either way, and in different combinations, like mind feels slow, but body is fast, or mind is fast and body is slow, or both can be fast or slow. These changes in depression cause more subjective distress then in mania's consistent psychomotor agitation, for example, mind is fast, and wants to do things, but the simultaneous slow body give one lack of energy and one physical literally can’t get out of bed or a chair, to do what the mind wants or the opposite, slow mind fast body, where you have the physical energy but your mind because of poor concentration and slow thinking won’t allow you to do, what you physically feel capable of doing. The person when primarily depressed in almost constant conflict and distress over these changes, where as in the manic state, there may be little distress, until there is a switch from one state to another , high to low, and then when the person realizes this, there may be great conflict, distress and turmoil. These transition stages can be very emotionally painful and confusing in the bipolar process.
19. Suicide Ideas: Every mood disordered person no matter how mild , needs to be screened for suicide. Every depression as it gets worse makes one feel more and more worthless, negative and thoughts of being better off dead, enter one’s mind. This is an expected symptom of severe depression, and lower grade depression that are chronic, that is they have lasted a long time. Many suicides and attempts could be prevented if the person suffering from depression knew there was help or more help for them, and if those who knew them openly discussed the thinking process involved in suicide often and in detail. There are many exceptions, especially those so hopeless, and or psychotic, they tell no one, and those who complete suicide impulsively out of extreme excruciating despair , confusion, panic and terror, especially those with rapidly cycling mixed bipolar, with or without psychotic symptoms. This is the most important reason to treat any mood disorder especially bipolar disorder adequately, and all of its symptoms, and I mean all symptoms, and to adequately and completely treat all , and again I mean all of its associated disorders. Though there are some excellent screening tools, they are no substitute for adequate treatment and adequate exploration with the mood disordered person, and their family, and those who know them, their thoughts about dying and suicide. These two things offer best hope for preventing suicide, adequate exploration of ideas of death and suicide, and adequate treatment.
20. Progression of Ideas about Dying and Suicide: There is a progression from, feeling better off dead, to thinking maybe one should die, to having actually suicide ideas, that is one will do something to bring about one death. Then there is more thinking and thought about, actually contemplating how one may do it, what means, and actual suicide plan. Then there is more thinking and worsening of the depression until one develops suicide intent, the actual motivation, the wish to carry out the plan. Then there must be means, what you need to do it, and opportunity to do it, and actually preparing first in one’s mind, and then in reality to carry ,or to be ready to carry out the plan. In most cases all of this thinking occurs, and may be more complex than is portrayed here, because in a prolong depression, there is much over thinking to the point of obsession, and doubt along the way. Anywhere along this way the successful suicide could have been prevented if someone intervened with, support, education, therapy, and medication to offer symptom relief and hope. In many suicides the person including a child or teen has been thinking about it for weeks, months if not years, often giving many hints along the way, for people to pick up and offer help.
21. Suicide Prevention-Adequate Treatment and Exploration of Suicide Thinking: To summarize many suicides and suicide attempts can be prevented by adequate historical exploration often and in detail, of the victims thoughts as they progress, from thoughts about death and dying, to suicide thoughts, suicide intent, and suicide plan, with means and opportunity, all must be present at a minimum for the suicide to be successful. Other factors and some may beyond our control may also be operative, also need exploration. This is too big, complex, important and serious job for the professionals alone, but also friends, family, anyone who knows the individual, and suspects suicide must question and explore this topic. This can be life saving. We must be like homicide detectives, trying to prevent another homicide, but in reverse, actually suicide detectives trying to prevent suicide, by meticulous, detailed, investigating and exploration, questioning all involved, not just the potential victim. Questioning thoughts about death, dying, and suicide ideation, intent, and plan, and the means, planning, and opportunity , to hopefully intervene in time, and halting the progression, from feeling, to thought , to intent, to action. The second and equally important thrust must be adequate treatment, and here again the professional should not be alone, but needs the help of the individual, their family, anyone who knows them and can be helpful, like teachers, co workers, neighbors, friends, to assess the adequacy of treatment response, in its totality, not just distress, but how this distress shows itself, in impairment at home, school, work, socially and in leisure time. Adequate treatment should offer the hope, and the profession needs and often to tell the mood disordered person there is hope, for more and more symptom relief, and hope for preventing relapses, and re occurrences, and hope of treating painful and impairing symptoms of associated disorders, and the professional will keep trying over and over again, and not give up until there adequate treatment is in place, and it is working, and will continue to work,. All this needs to be conveyed over and over again to the mood disordered person and their support system, this information sharing and the hope it instills is as necessary and essential , as is the adequate treatment if a suicide is to be prevented.
22. Other Diagnoses to be Ruled Out: Among the most common are, [A.] Medical conditions, such as thyroid problems, multiple sclerosis, and others must be ruled out by history, laboratory studies, and physical examination.,[B.] substance induced disorders e.g. alcohol, cocaine, marijuana , inhalants, etc, must be ruled out , [C.] general medications prescribed and over the counter medications, including health foods, supplements, must be considered, [D.] psychiatric medications and treatments are in a class by themselves, as a rule outs, especially antidepressants or stimulants, or any substance or treatment such as light therapy, ECT, and others used for mental treatments,[E.] major depressions with a very irritable mood, and sever psychomotor agitation, no true mania or hypomania will be present, [F.], ADHD, Attention Deficit Hyperactivity Disorder which by definition has no significant mood disturbance, and has continuous rather than episodic symptoms.
23. Medication Treatment of Choice: Medication treatment is based on addressing the core of excitability that is causing the unstable moods leading to the high energy good feeling /excitable irritable state, the mania, and the switch to the low energy, bad feeling , which may also be irritable , the depressive ,pole, or episode. It is not either or, either treating the up or the down, which is a process, but treating that process. Medications of choice to treat this core excitability process with its changing moods, and the other symptom clusters that are associated with it are classified as mood stabilization medication. Mood stabilizing medications will treat both poles, and stop the switching by treating the core excitability, and should be treatment of choice in any kind of episode, manic, mixed, or depressed. Usually the mood stabilizing medication will treat also other symptoms , symptom cluster, partial syndromes, and disorders associated with the bipolar process. Good examples of this are severe sleep problems, and associated sleep issues like nightmares, bedwetting, sleep walking, migraine headaches, panic attacks, various fears and phobias, some obsessions and compulsions, psychosomatic manifestations like skin problems, gastrointestinal problems like upset stomach [GERD], constipation/diarrhea [IBS], ADHD type symptoms, some psychotic symptoms like voices and visions, eating problems like severe carbohydrate cravings, waking up and eating, binge eating, some body distortion problems,[ i.e. too fat], sensory sensitivities like to bright lights, sounds, textures, to name just some.
24. The Importance of Treating the Bipolar Process First and Adequately: Not using mood stabilizers as the first line treatment, and using other medications in other classes first to treat symptoms or problems is a common mistake. For example treating [A.] a symptom i.e. sleep with sleeping pill, [B.] a symptom clusters i.e., and ADHD cluster with stimulants, [C.] a syndrome i.e. panic attacks with an anti-panic antidepressant ,[D.] a partial disorder i.e. a depressive episode with and antidepressant , can have at least two bad outcomes. Firstly one is not addressing the underlying disorder the bipolar process which is fueling the symptoms that are of concern and are attempting to be treated, thus by not addressing their cause one is not only not giving good symptomatic treatment but also the total picture is not being treated and everything will get worse. Secondly many of the symptomatic treatments will only temporarily work if at all, and when they do work, only for a short time, and then the medication is increased to the point of either unacceptable side effects, or until it apparent that the things are not getting better, but everything is getting worse, because some of these medication can actually fuel the underlying process.
25. Serious Outcomes due to Inadequate Treatment: Don’t chase and treat symptoms but their cause. Not treating the cause can have very serious outcomes, including, lack of any symptom relief, worsening of the bipolar process with increased mood swings at both poles, with more intensity and frequency, being harder and harder to treat, each fueling the next episode, cycling being increased, with an increase of impulsive and wreck less high risk behaviors, eventually the development of psychotic symptoms, and the person becoming more and more dangerous to self and others, with homicidal and suicidal behaviors.
26. Definition of Adequate Medication Treatment: Needless suffering will occur at the minimum with serious out comes discussed above if Bipolar Disorder is not treated adequately. Adequate medication treatment occurs when the right medication or multiple medications, at the right doses, with no or minimum negative effects to ensure compliance, are used for a sufficient length of time, to accomplish reasonable total symptom relief, prevent re occurrences and relapses, or at the minimum reduce the frequency, intensity and duration of episodes, and to prevent complications and bad out comes.
27. Common Problems and Errors in Medication Management: Many of the problems would not occur if the principles of medication management that have been outlined elsewhere were followed.[ see in my series “Principles of Medication Management”] Common areas and errors are as follows [A.] High End Responders: not using any one medication to its optimal dose balancing good against any negative effects. There are people who need much larger than the usual dose who are not challenged with higher and higher dose because of some arbitrary maximum recommended dose, or some lab study indicating the maximum dose is achieved, though they are showing no signs or symptoms that the dosage they are taking is doing anything negative. In fact it often clear with these people that they are making improvement as the dose is escalated . [B.] Low End Responders: On the other end of the spectrum are people who respond to much lower doses than expected, and that even when put on the lowest usual dose they start developing negative effects. These people need to challenged with very small doses and go very slowly. Often a liquid preparation is used or needs to compounded by a pharmacy to start real low and go very slow. In both of these cases the low end and high end responder, the optimal dose is based more on the individual’s brain chemistry rather than more usual factors such as age, weight, mildness or severity of symptoms. [C.] Micro Diagnosis of All Problematic Symptoms: not being aware of through micro diagnosis that is looking for less and less troubling yet significant and problematic symptoms and problems that may be medication responsive and not treating all the symptoms of not only the primary disorder but of adjunctive problems adequately, [D.] Negative Effects of Medication: or side effect are often a problem in initial and long term management. The medication must be adjusted, fine tuned and or changed to ensure compliance and symptom relief. [E.] Support to Ensure Adequate Duration of Treatment: Even with all other problem areas and issues helped and resolved, still much support , education and supportive therapy is needed so that a sufficient duration of treatment can occur, for symptom relief, prevent relapses, and to treat and prevent complications.
28. Adequate Duration of Treatment: Bipolar Disorder varies in severity form mild forms with very few episodes, requiring medication only for the episodes, to a lifelong relapsing disorder requiring multiple hospitalizations and lifelong use of medication. The initial treatment for an episode is based on the same model a neurologist may use in treating a seizure disorder. There are some similarities between seizure disorder and mood disorders, among them is sharing some medications in common, certain anticonvulsants that are also mood stabilizers, Depakote, i.e. valproic acid, and Tegretal or carbamazapine, and Lamictal which also is an excellent antidepressant. The neurologist will treat a seizure disorder very aggressively with the goal of eliminating all seizures if possible for at least one year. After the person is seizure free for one year only then depending on other factors such as severity of seizures and other complicating diagnoses or other problems, will the medications used be slowly tapered to zero if the person remains seizure free. Then the person is followed with cautious watchfulness and if seizures re occur the medication is restarted. If certain seizures are not treated adequately they can result in status epilepticus, which can result in death. If certain Bipolar Disorders are not treated adequately they can lead to death though completed suicide. Each time a person has an episode of a seizure it is more likely that another episode will occur, and each episode fuels another, sometimes called kindling, and each successive episodes last longer, is more intense and harder to treat ,and in some cases becomes more and more resistant to medications that worked previously. Each seizure also may be causing electrical , brain chemistry, physiological, and structural brain damage, that may be not be repairable. The same kind of series of events may occur with bipolar episodes exactly paralleling the seizure disorder and its progression and outcome, thus the importance for adequate treatment.
29. Medications Classes That Stabilize Mood: a) Typical Neuroleptics like Thorazine the oldest medication or the group and the one that ushered in modern psychopharmacology, which works when others have failed especially in children who tolerate the possible negative effects remarkably well. Haldol and Prolixin high potency medications that have the advantage of being better for some forms of aggression, thinking problems, and psychotic symptoms like hallucinations, and paranoia, often with less weight gain, but with a higher incidence of muscle movement side effects. b) Atypical Neuroleptic c)Mood Stabilizing Anticonvulsants d) Lithium Carbonate