How to Avoid Medication Side Effects ("Start Low, Go Slow")

The frequency and intensity of side effects are directly proportional to the amount of medication taken (dosage, especially relative to an individual's body weight) and the rapidity with which it is absorbed. The more milligrams you take at one time and the faster you absorb them, the greater the potential for side effects.

So, to minimize side effects in general:

Take the lowest effective dose, and always start out with the lowest recommended dose and build up from there as tolerated and as recommended by your doctor, until you get the symptom relief you are seeking. It may be a good idea at the very start to halve the recommended dosage and take a few "test doses" that may not get the job done, but that will gradually introduce your body to the new substance. Once you are used to a medication, you develop a tolerance to many of the most unpleasant side effects, such as nausea, diarrhea and headaches. Generally speaking, the more unpleasant the side effect, the faster it improves, if it's going to improve at all.

Even at the target dose, divide the dosage into two or more separate administrations if your doctor says you can. Taking 100mg of anything in a single dose is always going to cause more stomach upset (or whatever the side effect may be) than taking 50mg twice a day, or 25mg four times a day. Dividing the dose is less convenient and can cause you to forget doses, which is countertherapeutic, but if you can remember and be disciplined and consistent, many side effects can virtually be eliminated by splitting doses.

Along the same lines, if you are taking more than one medication and it's not too inconvenient, try to avoid taking multiple medications at the same time. Side effects from one compound can be additive and even synergistic with those from another. Even waiting as little as ten or twenty minutes between one medication and the next can save you unpleasant physical sensations that otherwise come with the territory.

If it doesn't interfere with absorption in a negative way, take medication with food or milk (be sure that minerals in the food don't block absorption of the medicine!), and not just "with food," but after a substantial meal; i.e., on a full stomach. For example, taking ibuprofen on an empty stomach can cause painful acid indigestion, which can lead to peptic ulcer disease in some people, but taking Advil on a full stomach protects the stomach lining. For other medications that don't necessarily irritate the GI tract directly, food and/or milk coat the lining of the small intestine, simply slowing absorption, which slows the onset of side effects like nausea and headaches. Of course, the onset of efficacy is also slowed; something to consider if you are taking pain medication.

If you discontinue a medication for awhile and then resume taking it, treat it as though you were taking it for the first time and "start low, go slow." The longer you have been off of a medication, the more your body has lost whatever tolerance it had built up against the side effects.

Children and the elderly are often more sensitive to medications than others, and often require much lower doses than otherwise healthy adults. This has to do with factors as varied as body weight and liver function; your doctor will know the best dose for you, but keep this principle in mind with over-the-counter products.

Many side effects are subtle enough that they can be slept through! If not otherwise contraindicated, take your pill at bedtime and snooze through what you might otherwise have been awake to notice (we're talking generally mild, immediate effects here). Some side effects are aggravated by a lot of physical activity; you may not feel tired and dizzy on a medication unless you are standing up and sitting down and otherwise physically active after taking it. Narcotic pain medications are known to cause nausea, but the nausea is almost entirely dependent on moving around; if you lie still, the queasiness disappears. Taking medication at night or near bedtime can obviate the problem. If a medication makes you tired, why not take it when you're supposed to be relaxing anyway?

How to Maintain Good Sleep Hygiene

By S. Silva M.D.

Insomnia is a common complaint in any doctor's office and by far one of the most common complaints in psychiatry. While there are various medical conditions to be ruled out (such as obstructive sleep apnea), the vast majority of cases are either mood- or stress-related, or else have no obvious cause. Many cases are chronic. Likewise, while there are many medications available to treat this condition, medications are not without their side effects and, for chronic sufferers, even the most effective sleeping pills lose their efficacy over time.

Regardless of whether or not you choose to submit to pharmacological or other medical treatments for insomnia, a good starting point is what health care providers call good "sleep hygiene." These are important tips that should be followed by everyone, whether you suffer from clinical insomnia or just the occasional fitful night of sleep (or the lack thereof). Sleep hygiene refers to one's habits concerning sleep.

Avoid caffeine and other stimulating substances before bedtime. Not only will caffeine keep you alert, but it is a diuretic. Diuretics promote the excretion of water by the kidneys, making middle-of-the-night trips to the bathroom more necessary. This is already a problem for many older adults.

Avoid excessive use of alcohol. Alcohol of course is itself sedating (it's one of the principal ingredients in NyQuil), but taken during the day or early evening, alcohol can actually lead to a rebound state of wakefulness at bedtime or in the middle of the night, greatly exacerbating insomnia. It's also a potent diuretic.

Avoid going to bed on a full stomach immediately after eating a heavy meal. If you suffer from acid indigestion, remember that lying down tends to aggravate reflux; bedtime is one of the best times to take an antacid.

Avoid a heavy workout before bed. Adrenaline and other stress hormones that are released during vigorous exercise will keep you wide awake. Schedule your workouts for the early afternoon, or better yet, start your day off right and exercise first thing in the morning; it will set a great mood and energy level for the whole day!

Ensure the right sleeping environment: for most people, a dark, quiet, cool room. If you sleep better with a little "white noise," try an oscillating fan (which works nicely to keep you cool as well), or invest in a sound machine. The TV's sleep function works as well, but turn the volume down low and pick something you have no interest in. For children, a night light can make all the difference (for some adults, too!). An aquarium provides a little light and a nice, soothing water effect as well. If you work the night shift and sleep during the day, draw the blinds or consider a night mask.

Adjust the temperature of the room to your comfort; most people have trouble sleeping when it's too warm. On the other end of the spectrum, body temperature drops when you sleep, so light sheets are always a good idea and sometimes a blanket. In the winter, sleeping by a fire can be wonderfully cozy (but please, attend to fire safety measures, always!).

A soft but firm mattress and a comfortable pillow or two go without saying. (I sleep with two pillows, one of which is a long body pillow with which I travel whenever I can.)

Many people report that having an orgasm leads the body quickly into sleep, other physical parameters permitting.

A lot of people also recommend reserving the bedroom for sleep (and sex), so that the bedroom environment becomes associated with sleep in the mind. I'm not sure this behavioral principle (conditioning) is as relevant as it's cracked up to be. Watching a little television or reading in bed is okay for most people and can even be part of the process of winding down from the day.

Conversely (as far as operant conditioning is concerned), I do think it's useful to develop a little ritual before bed each night. Make it your own: wash your face, brush your teeth, pet your cat…whatever suits you. This starts the winding down process and begins to alert and mind and body that sleepytime is approaching. One of the most impossible things to do is to come directly home from work or some other stressful situation with the weight of the day's worries still on your mind and thoughts about everything you still have to do tomorrow and jump in bed and close your eyes and try to immediately fall asleep with no in-between downtime. It's not practical and it's not healthy.

Another behavioral/environmental principle suggests that if you don't fall asleep within the first half hour or so, don't lie in bed fretting and watching the clock. Instead--if it's practical--get up for a little while, maybe have that proverbial glass of warm milk* or fix a light snack, perhaps do a little tidying up or a quick chore you had left undone before going to bed, or read a little or watch a little television until you begin to feel like you can try again.

Again, this "if you can't beat 'em, join 'em" approach is not always practical; you may live with someone who is sleeping just fine whom you don't want to wake, or it may be very late at night and you have to be up early the next morning, but one of the worst things you can do is toss and turn. It ratchets up your stress level and decreases the likelihood that you will get any rest. And if you have to get up early anyway, sometimes it's simply best, if there's only an hour or two to go, to just go ahead and get up for the day. It avoids wallowing in misery until the bitter end when the alarm goes off and you haven't slept a wink anyway and hopefully you will be that much more prepared for sleep the following night.

This is not about giving up; it's about finding some peace of mind through acceptance.

This is another way of saying: DON'T WATCH THE CLOCK. If it's the middle of the night and getting out of bed is not a reasonable option, it's better to lie there quietly with your eyes closed and your mind relaxed than it is to fight being awake. You won't sleep if you are fighting anything anyway, and so acceptance of not being asleep will at least make it less arduous. This technique of being okay with being awake removes at least one barrier to deeper relaxation: frustration and anxiety. Oftentimes boredom will set in, and if you can avoid becoming irritated by THAT, and remain still and quiet, the body's natural response will actually be…to slip into a light sleep! So don't fret, and just be awake if that's what you have to be, but don't be surprised if letting go doesn't just give you what you've been struggling to achieve all along.

This actually works. It depends on stopping yourself from thinking, "I'm still awake…When am I going to fall asleep?...What time is it?...I have to work in the morning…I'm still awake…What time is it now?" At first you may have to remind yourself to stop reminding yourself that you're not asleep yet, which is obviously a bit counterproductive in itself, but eventually you'll get the hang of it.

Counting sheep (metaphorically speaking, of course). This is a bad idea. By this I mean thinking about anything, no matter how mundane. Reviewing the day and planning for tomorrow should be part of the winding down process, not part of the falling into sleep process. It's just another form of watching the clock, really.

The brain goes to sleep when it has nothing better to do. In other words, the mind can only fall asleep when it goes blank; so long as you are thinking about something--anything--you won't fall asleep, you'll go on thinking. Concentrating on anything (sheep included) is counterproductive.

You might think that you fell asleep last night thinking about this or that, but in actuality, you fell off to sleep in that moment when your mind wandered away from whatever it was you were thinking about, and for a few seconds your mind forgot to contemplate anything, allowing it to slip into the first stage of light sleep. Even thinking about how tired you are will keep you awake, as most of us have experienced, to our utter consternation. It's not until you allow yourself to simply feel tired, with no thoughts or commentary of any kind attached, that you will slip away.

Practicing mind-clearing meditation during the day helps a lot of people repeat the practice at night; when you are lying down and your mind goes completely blank, you WILL fall asleep. That's why yogis and yoginis don't meditate lying down: it quickly leads to unconsciousness!

The trick is clearing your mind of all thoughts. When it is awake and rested, clearing itself of thoughts is the last thing the mind wants to do; it is not the mind's function. Its function is to distract us with perceptions and ideations. Mindfulness is antagonistic to slumber.

If you have a bed partner, you will want to negotiate with that person regarding your individual sleeping habits and problems that may arise (such as snoring, hogging the sheets and tossing and turning).

Be mindful of your circadian rhythm; naps are usually healthy parts of a person's day if they are well-timed, but excessive sleeping during the day has obvious deleterious effects on one's ability to find sleep at night.

Other considerations such as jet lag can come into play. With regard to jet lag, some people report modest success taking melatonin at bedtime, a homeopathic, over-the-counter hormone remedy that helps adjust the sleep-wake cycle. On the stronger pharmacological side, the medication Provigil is an excellent means of resetting one's circadian rhythm by extending wakefulness until it's time to sleep, without interfering with sleep when the time for that comes (but that's another topic that is outside of the scope of simple, non-medicinal sleep hygiene).

*Does a glass of warm milk really induce sleep? This folk remedy has been explained by some who point out that milk contains tryptophan, an essential amino acid that is metabolized into serotonin and melatonin, all of which affect sleep, but in actuality the amount of tryptophan in a glass of milk is physiologically negligible. It's not an unpleasant way to achieve a placebo effect, though, and lowfat milk is a great source of calcium and vitamins A and D!

How to Make Your Sleeping Pill Keep Working

By S. Silva M.D.

Prescription sleep aides are among the most commonly administered of medications, and they can be a Godsend for many patients. Although once only approved by the FDA for brief trials, recently the FDA approved Ambien for long-term use. In actuality, any prescription sleeping pill can be used safely and reliably on a chronic (i.e., nightly) basis, with favorable results. The problem over time, however, is that a person develops tolerance to the sedative effect of these medications and requires ever-increasing dosages to reap the same benefit as when s/he first began taking them, which in many cases leads to drug dependence, withdrawal effects, and even in some cases addiction and/or overdose. This article addresses how to avoid the problem of escalating the dosage of a sleep aide, while maintaining considerable benefit from the prescribed medication.

When you have chronic insomnia that requires nightly dosing with a medication that cannot be increased indefinitely without risking serious side effects (to say nothing of the fact that, sooner rather than later, the higher dose itself will fail to work as expected), here's what you may be doing wrong, along with some secrets to preserving the efficacy of any sleeping preparation:

• Begin with the lowest effective dose of the medication and do not increase it unless or until absolutely necessary. This will conserve those higher doses for when you really need them. The sooner and faster you up the dosage, the more rapidly you will develop tolerance to the sedative effect of the drug, and the sooner you will become frustrated by the fact that the medication is apparently no longer working for you.

Once you have increased the dosage once or twice, feel free to back down on those subsequent nights when you already feel especially tired, or think that you might not have particular difficulty getting to sleep; better yet, skip the medication entirely whenever you can. This will preserve efficacy over time, because tolerance is always reversible.

• Take the full dose of the medication on an empty stomach, with plenty of water. This will speed the rate of absorption, which will maximize the medication's potency. With a sleeping pill, you want to absorb it rapidly and completely, so that you get to sleep in the same manner: quickly and fully. If you take the medication on a full stomach, this will result in its being absorbed more gradually over time, as it dissolves into the food present in your stomach; the food itself presents a physical barrier to absorption. This in turn results in a gradual relaxation that, if too gradual, may not tip you over into desired sleep. For example, 10mg of Ambien will have a much more impressive effect if you absorb it over a period of, say, 15-20 minutes than that same dosage will have if it takes an hour and a half to enter the bloodstream, and thus, reach the brain. This is true regardless of your body weight, liver function, or level of tolerance.

Along the same lines, take the full dose all at once. If you know you will need more than 5mg of Ambien to get to sleep, don't take 5mg an hour before bedtime and then wait to take another 5mg when you actually get in bed; you may find with this strategy that you are tempted to take yet another 5mg at 3 a.m., and still not get to sleep. This wastes the potency of the dosage you are needing. Take all 10mg or 15mg at once, preferably on an empty stomach, 10-20 minutes before lights out.

This is not to say that taking another 5 or 10mg later, if absolutely necessary (and okayed by your doctor), won't work: often extra doses do help, but it's a bad habit to get into, splitting the dosage of a sleeping pill. Take what you need when you need it and be done with it. Taking extra doses of a sleeping medication while under the influence of that medication is particularly unadvisable because this can lead to unintentionally taking more of the medication than is needed or safe, and exceeding your doctor's recommendation. This is because you will begin experiencing cognitive dysfunction after the first dose; even if you don't feel sleepy, you WILL be impaired, and that includes memory and judgment. You don’t want to be titrating your dose of sleeping medication once you become confused and forgetful. People have accidentally overdosed because they take extra doses of medication after they've taken doses they've forgotten they've taken!

• Take "drug holidays" when feasible. As previously stated, if you are already tired and feel like sleeping without it, or if it's the weekend and it's not absolutely necessary to be asleep before midnight, skip the medication entirely that night. This will delay and even reverse the tolerance you have built up for the drug up to that point, likewise preserving the efficacy of the medication over the long-term.

The more regularly you take a sleeping pill, the more surely you will develop some immunity to its sleep-inducing effect, but the more nights in a row that you go without the medication each time you take a "holiday" from the drug, the more you reverse any tolerance you have acquired up to that point. Frequent drug holidays can prevent the development of tolerance in the first place, which is ideal.

One way to take more drug holidays is to make sure you have good "sleep hygiene." Just follow the rules for maintaining good sleep that are well-known (see my article on How To Maintain Good Sleep Hygiene).

• Avoid consuming alcohol, because you will develop cross-tolerance to many prescription sleep aides if you regularly drink (especially the benzodiazepine class of medications, whose names end in "-pam," such as Valium, ****, Klonopin, Ativan and others, as well as Ambien, Sonata, Lunesta and most other, newer and commonly prescribed agents). While drinking alcohol and then taking sleeping pills can lead to a synergistic effect (which can actually be quite dangerous and is responsible for the majority of deaths due to accidental overdose), drinking alcohol in the early evening several hours before bedtime can lead to a direct state of rebound wakefulness as the effects of the alcohol diminish. This can lead to insomnia all on its own. In the context of treatment with a sleep aide, there is no longer an additive effect when a person takes the sleeping pill, but because of cross-tolerance due to alcohol consumption, the brain resists the sleepy effect of the medication. Cross-tolerance of sleeping pills with alcohol is more of a long-term effect, but drinking alcohol in the early evening can diminish the effects of a sleeping pill that night by this mechanism.

People who drink regularly and/or heavily often notice that they have a "built-in" resistance to sleeping medications from the start; that is, at the starting doses that are prescribed by doctors. This existing tolerance can be reversed, however, by laying off the alcohol in much the same way that any level of drug tolerance can be reversed by weaning off of the habit-forming substance and avoiding it as much as possible in the future.

People who take certain anti-anxiety medications during the day (for panic attacks, for example) will encounter the same phenomenon of not being as sensitive to the sedative effects of a given dosage of sleeping medication, if that medication is also a benzodiazepine or a medication like Ambien that is cross-tolerant with benzos.

• If you have chronic insomnia that requires nightly dosing with a medication that cannot be increased in dosage indefinitely (that would be all of them!), here's what you should realize:

When you first take a medication for sleep, the medication works powerfully to shut down your brain, assuming that your body hasn't already built up some immunity to it due to cross-tolerance with alcohol or other sedating substances. In that case, after you first take the medication and begin absorbing it, the drowsiness that comes upon you basically forces you to sleep. If you are already tucked in, that makes it easy to drift into unconsciousness. If you are still up and about, you will stop whatever it is you are doing and find your bed, because it's that, or fall on the floor.

However, once you have developed a tolerance to the medication, it will no longer "force" you unconscious; it will no longer compel you to find your bed whatever you may be doing. It will still help considerably in gently encouraging you--allowing you, as it were--to fall asleep…if you are comfortably in bed, in the right position, with the lights out, trying to relax and clear your mind. The medication that once put you to sleep now merely assists you in drifting off, and while this effect can also wane over time with tolerance, it rarely disappears completely. That is to say, you will definitely develop tolerance to being "knocked out" by a given dosage of a sleep medication, but that dosage or perhaps a slightly higher one will always significantly relax your mind and your muscles and it will always promote sleepiness to some degree. But in order to take advantage of that sleep assistance, you have to be sure that your mind and body are not working against you.

What happens is that, depending on how quickly and fully you absorb the medication, there will be a window of time during which your blood concentration of the medication will be peaking. It is during this window of opportunity that you should be in bed, ready to drift off. If you miss it--if you're emptying the trash or brushing your teeth or talking on the phone or yelling at the kids--when you do finally get in bed and turn the lights out, your blood levels may already be dropping and you may have missed your chance to take full advantage of the medication's soporific effect.

• This is a very common mistake people make: they take their pill before they are ready to commit to sleepytime, and while they are "waiting for it to kick in," they're paying bills, surfing the internet, reading, or seeing what's on TV.

This is a huge mistake. Take your medication and then GO TO BED. Don't take it and do other nighttime stuff, waiting to pass out. I once had a patient who admitted to me that she took her sleeping pill, then drove to the convenience store for a carton of milk! Besides being dangerous, she was obviously not ready for sleep. It's no wonder the medication didn't help her find sleep: she wasn't looking for it. And thank goodness she didn't find it on the way--or rather, that it didn't find her! (Even had she walked to the store it would not have been a good idea.)

• The thing to understand here is that, very soon after regularly taking a sleeping medication, it induces sleep more gently than it did the first few times, because your brain develops natural immunity to the sedative effect. The medication has to work harder to put your adapted brain to sleep, which means you either have to take more milligrams or you have to make it easier on your body to succumb to the medication's attenuated effect. Since it is neither feasible nor safe to continue escalating the dose of a sedating medication (or any medication, for that matter), if you want your sleeping pill to keep working you have to do everything you can to let it work, which means don't fight it with an alert mind and an active body. Take the medicine, lie down, close your eyes, clear your mind and relax into it.

• The other thing to remember is that, if you take a drug holiday, and you wait long enough, the medication will work like new the next time you take it. You should still follow the rules outlined in this article, but you will find that the medication works better--and at a significantly lower dosage--than it had been before you took the break.

How to Know If You Have Been Misdiagnosed With Bipolar Disorder

While only a qualified mental health professional can diagnose bipolar disorder, it is by far the most over-diagnosed mental illness today (along with ADHD). This article will help you sort through some of the basics, to better prepare yourself for that talk with a psychiatrist or therapist, if you think you may be suffering from this disease.

The key is understanding mania. We all get depression, and we all understand that there are different levels of depression; most of us, thankfully, have never experienced true endogenous major depression. Mania, however, is widely misunderstood. The lay public and even many (if not most) mental health professionals mislabel various types of agitated moods as "manic episodes." There are different levels of mania as well, but even the simplest, lowest grade of mania--hypomania--is a step or two above and beyond any of the familiar forms of agitation all of us feel from time to time.

Do not confuse "mania" with other forms of emotional turmoil. Manic episodes can be characterized by elation, irritability or anxiety, for example, but they are not just euphoria, not simply aggravation. Mania is not even just extreme instances of these; mania is a sustained (usually weeks to months) state of psychomotor agitation, along with other neurovegetative signs (physical findings, like a decreased need for sleep, markedly increased libido and/or sped-up mental processes which manifest as super-fast thinking and pressured speech). In a nutshell, mania is like being on a stimulant drug, without the drug. There is sleeplessness and other forms of physical agitation, increased goal-directed activity, and increased risk-taking behavior. See below for disclaimers on each of these common, but commonly misunderstood, symptoms.

One major distinguishing characteristic is that manic episodes do not last minutes or hours, unless they are induced by stimulant drugs whose effects wear off. In that case, the diagnosis would be a substance-induced manic episode, which is not endogenous bipolar disorder. Bipolar disorder, or manic depression, occurs spontaneously, is often inherited, and usually starts fairly early in life (early adulthood or, less commonly, adolescence--rarely in childhood). It consists of alternating episodes of major depression (which usually comes first) and mania; untreated episodes of either of which last months, even years. Not minutes, or even hours! If you think you were "manic" last night (and you weren't high on drugs), but today you feel normal or even a little down, you were almost certainly not clinically manic last night. Whatever the agitation was, it was not due to bipolar disorder; untreated mania lasts 6-9 months, on average. Even "rapid-cycling" bipolar doesn't cycle from morning to night, no matter what even some health care providers might be saying.

Racing Thoughts. Patients report "racing thoughts" because enough mental healthcare providers have asked enough patients point-blank, "Do you have racing thoughts?" that the term has entered the popular vernacular. This is unfortunate, because what people usually mean when they spontaneously endorse "racing thoughts" is worries, even obsessive thinking. Not being able to shut the mind off at bedtime, for example. This is not what psychiatrists meant when they coined the term, referring to mania. For one thing, a manic individual doesn't need to sleep, doesn't want to sleep, doesn't lie in bed trying to turn the thoughts off; a manic individual runs with his or her thoughts and impulses (usually to his or her detriment). So those sleepless nights when you're tossing and turning and can't stop thinking about all your problems--common enough, but nothing to do with "racing thoughts."

It's a poor question to ask, clinically, "Do you ever have racing thoughts?" because the presence of racing thoughts will be evident to the examiner without having to ask: speech will be pressured, that is, rapid and difficult to interrupt, and may not make a lot of sense. The connections between individual thoughts are often loose, and it can really be impressive to hear.

Sure, sometimes individuals experiencing mania will have a subjective sense that their thoughts are racing. They might feel that they cannot speak fast enough to get the words out, that ideas are tumbling over themselves in their mind, but, alternately, a manic individual may be so sped up that s/he isn't aware that thinking and speech are abnormally rapid and over-inclusive.

If you are drowning in ideas and can't talk fast enough to get your point across and your mind is darting from one brilliant insight to the next, you may be having "racing thoughts," but at that point you have a formal thought disorder and the thoughts themselves are likely the least of your problems. Otherwise, thinking too hard and too much (almost always worried thinking) or obsessing or ruminating on a particular topic that's unwelcome to you and that you wish you could get out of your mind has nothing to do with mania.

Sleeplessness is another hallmark of mania, but again, it's not insomnia in the sense that you want to sleep but can't. When you experience mania, you don't feel the need for sleep, bedtime becomes an inconvenience and the fact that the rest of the hemisphere has called it a day is too bad for them! A manic person may know s/he is supposed to be sleeping and should be trying to, because everybody else is, but that person doesn't feel the need for sleep, or very much of it, at any rate, for days on end. Again, it's like being on speed, without having taken any drugs. Even as little as two or three hours a night is often more than enough sleep to satisfy the manic individual. Of course, as with the guy on drugs, a crash is inevitable. The difference is that, for the manic depressive, the crash might not come for many weeks or many months, by which point lots of havoc has been wrought in that person's life by ill-advised, impulsive behavior. It's not the wakefulness itself that's the problem, especially not to the person experiencing it, beyond the inconvenience of it; it's what the person does while not sleeping.

Impulsivity manifests as increased pleasure-seeking, and the risk-taking that goes along with that. As I've said, there are different levels of mania, so there are different levels of outrageous behavior that manic individuals accomplish, but the key is that the behaviors are way out of the norm: way, way, more heedless and hedonistic than is typical for the person at baseline, and for most of us that means pretty scandalous behavior. Things like extreme promiscuity, spending hundreds or thousands of dollars on things one doesn't need and can ill-afford, even criminal activity. Again like the gal on drugs, getting arrested is something that happens to acutely manic individuals all the time. Being high gets you in trouble, whatever the cause.

Spending sprees. We've all been on little spending sprees. The manic spree is beyond the pale. It's infused with overt grandiosity, a careless sense of "must-have" entitlement and it usually involves hundreds or even thousands of dollars spent on items of little or no practical value. In the middle of a manic episode, there is no hesitation or buyer's remorse, no guilty feeling that nags, "I shouldn't be spending so much," etc.

Instead, there's a sense of urgency that pervades everything during a manic episode: an acute need to spend, to acquire, to invest in material things. Often the spree is an expression of big plans to come, of a false sense of personal capability, even greatness. "I'm worth it."

Thoughts of, "Can I really afford this?" are entirely alien. Even if it's all being charged, the notion that the spender isn't clever and resourceful enough to raise the funds to pay for it all anyway is unthinkable. Manic individuals are often sure they are about to become very rich, and very famous, very soon, so why put off the purchases? Once on the spree, impulsivity takes over and truly bizarre items make the shopping cart, items that are often pretty or fancy or exotic, but items the utility of which is sometimes difficult to explain when things have calmed down. Have you ever asked yourself about a purchase, "What was I thinking?" If you have, it was probably limited to some article of clothing you later had second thoughts about. Multiply that feeling many times over and imagine asking yourself why you thought you needed an antique jewel-encrusted scimitar and you begin to imagine the types of purchases a truly manic spree can result in.

Most people have never experienced a manic spending spree, because most people are not bipolar.

Expansiveness. Ever feel like going up to a complete stranger and bonding, becoming best friends instantly, or better yet, proposing you run off together to find adventure? Probably not. Manic individuals take "outgoing" to new, sometimes dangerous, heights. Social barriers become non-existent, and reasonable interpersonal boundaries often get trampled. This can be very unsettling to the person accosted by the manic individual (provided that person is not hyper-expansive herself).

When expansiveness meets hyper-religiosity, the person finds a street corner and starts preaching to the world; literally any passer-by could be the next repository of the manic individuals' endless, newfound sense of cosmic understanding.

Hyper-spirituality. If there is a gold-standard manic symptom, this is it. A manic person can become suddenly in touch with God (as s/he understands God). This is not merely a religious epiphany; it's paranoia in its grandiose form (not all paranoia is persecutory). When mania is strong enough, it is not at all uncommon for the person to feel a special connection with God, even to hold himself or herself forward as a prophet. History is replete with examples of individuals for whom this experience became an actual self-fulfilling prophecy (no pun intended): billions and billions of followers have been engendered by the greatness that pure spirituality endows.

These are some of the highlights of actual mania, albeit moderate-to-severe; several of the examples above qualify for mania with psychosis, that is, losing touch with reality, although most manic episodes do not result in psychosis. Of course there are milder, subtler forms, which is why so many practitioners confuse lesser forms of agitation for hypomania and diagnose "bipolar type II," which consists of major depression and minor episodes of mania. But true mania is still true mania, no matter how mild, and the fact remains that most of these "hypomanic" diagnoses are just plain wrong. Anxiety and irritability and sleeplessness and impulsivity, even when pronounced and protracted, are usually not signs of an actual manic episode. Actual mania is much rarer than garden-variety agitation.

The distinction between actual mania and other forms of agitation is a critical one, because the mood stabilizers used to treat mania can be quite toxic, much more so than the standard antidepressants that are on the market. The latter are safe and well-tolerated and even help those episodes of agitation that are mistakenly labeled as "manic episodes," whereas mood stabilizers per se (such as lithium and Depakote) are heavy-duty medications with heavy-duty side effects and should not be used carelessly.

Not only that, but if you are mistakenly diagnosed as bipolar a prescribing doctor may hold back on so-called mood elevators (like Prozac) because s/he thinks that they will make your "mania" worse, when your "mania" is actually extreme irritability and anxiety that's causing mood swings and what you need most is a medication like Prozac! Prozac and Zoloft and Celexa and other SSRIs will stabilize most (non-bipolar) moods, and are often underutilized in individuals because of a false bipolar label. Even in actual patients with bipolar disorder, these medications can be extremely beneficial, when properly paired with an antimanic agent.

Once a person has been diagnosed with bipolar disorder, the diagnosis tends to stick, regardless of its accuracy, as the individual goes from one mental healthcare provider to the next, because often the diagnosis is simply accepted by the new practitioner, who fails to take a comprehensive history and perform adequate serial mental status examinations himself or herself, to verify the diagnosis over time. I have treated literally scores of individuals who had been treated for years by numerous physicians for "bipolar disorder" who turned out not to be bipolar, so be skeptical, ask questions and make your treating physician prove to you why your symptoms are those of actual manic depression and how s/he ruled out other, more common syndromes like unipolar depression, adjustment disorders, substance abuse and personality disorders.

No one is equipped to diagnose himself or herself; see a qualified mental health professional, but it never hurts to research what you are being told. Good luck.

Read this: An Unquiet Mind