Bipolar Disorder in Adults

This article reviews bipolar disorder in adult patients. About 3 million US residents, or 1% of the total US population, suffer from this disease, including similar figures in the world. This disease affects both men and women alike. Most often it develops at the age of 15 to 24 years.

What is bipolar disorder?

Bipolar disorder is a disease that causes a sharp change in mood, for example, the excessively elevated state of mania suddenly turns into a serious state of depression. This disease has another disease - manic-depressive syndrome.

Bipolar disorder affects your mood so much that you can not fully perform your duties at work, adequately behave in the family or with surrounding people. Some people with this disease become prone to suicide.

This disease can cause a sick person to feel helpless and hopeless. However, the sick person is not alone. If he visits a support group and talks to people like him, he will understand that there is a hope for a better life. And the treatment will help him regain control over his mood.

Also relatives of the patient feel helpless. If your family has a person suffering from bipolar disorder, you should visit psychotherapy sessions yourself. Psychotherapy sessions will also help a child whose parents are sick with this disease.

Causes of the bipolar disorder in adults

To date, scientists can not say exactly what is the cause of bipolar disorder. It is only known that this disease is hereditary. It can also develop against the background of the environment or family problems. One of the most common causes is the imbalance of the chemical elements of the brain.

Although the causes of the development of bipolar disorder have not yet been studied, there is evidence that this disease is inherited. Problems in the family or the negative influence of the environment can also lead to the development of this disease. In addition, attacks of mania or depression can be caused by an imbalance of chemical elements in the brain, such as neurotransmitters.

Antidepressants can cause an attack of mania in a patient on bipolar disorder. This can happen even before the patient is diagnosed with bipolar disorder, at a time when he will be treated for depression.

Sleep disorders, alcohol abuse or stimulants, such as caffeine, can also cause a manic attack in a person with this disease.

The provoking factors

Bipolar disorder is inherited. If your family has had cases of bipolar disorder, then your chances of getting sick with this disease are increasing.

If you have bipolar disorder, changes in the sleep schedule or daily routine can lead to an attack of mania. Also, the cause of an attack of mania can be and antidepressants. But this can show up after the development of mania, when trying to cure an attack of depression.

Stressful situations in life can cause both mania and depression.

Your chances of developing a bout of mania or depression are increasing. If you do not follow the doctor's instructions and do not take medication regularly. Very often during an attack of mania, when the patient is celebrating himself well, he stops taking medication. Even if you feel relieved, do not stop taking medication, this will help you control your condition.

Abuse of alcohol, drugs or experienced violence increases your chances of a second attack of the disease.

[1], [2], [3]

Symptoms of the bipolar disorder in adults

Symptoms of the disease depend on what phase of mood you are in. For example, if you have a craze, then you will feel extremely energetic, happy and sexually excited. You will feel that you do not want to sleep at all. You will feel excessively self-confident. Some people spend too much money during periods of mania or behave in a life-threatening way.

After the phase of mania, you can return to a normal state, or, conversely, fall into the opposite feelings of sadness, oppression and helplessness. Being in a depressed mood it will be difficult for you to make a decision and to think soberly. There may be memory problems. You can lose interest in once-loved pursuits. There may also be thoughts of committing suicide.

Mood swings in bipolar disorder can occur in both mild and severe forms. The attack can begin slowly over several days or weeks or develop suddenly within a few hours. The attack can last from several hours to several months.

Bipolar disorder causes sudden mood swings, when the patient at one point feels overwhelmed with strength, and after a while becomes oppressed and powerless.

During an attack of mania patient:

• Feels extremely happy or very irritable.
• Has too high self-esteem.
• Does not need a dream, as usual (feels rested after three hours of sleep).
• It becomes excessively talkative.
• More active than usual.
• Can not focus on one thing, because it has too many ideas at the same time (wandering thoughts).
• Easily distracted by sounds or pictures.
• Behaves impulsively or irresponsibly, for example, spends large sums of money, inadvertently drives a car, takes part in questionable transactions and becomes illegible in sexual relations, which leads to unprotected sex.

During a depression the patient can:

• Most of the time be depressed or worried about something.
• Feel pessimistic or hopeless.
• To suffer slowness in movements or speech because of the decline of strength.
• Have difficulty concentrating, remembering, or making decisions.
• Survive changes in appetite or sleep disturbance, which leads to excessive overeating or increased sleepiness or vice versa.
• Experiencing indifference to once-loved pursuits, including sex.
• Have suicidal thoughts.
• Do not rejoice at the things that caused positive emotions in the past.

[4], [5], [6], [7]

Stages

[8]

Bipolar disorder of the first degree

This species is considered a classic form of bipolar disorder and causes seizures of both mania and depression. A bout of depression can last a short time or months. After this, the patient can either return to normal state, or go directly to the phase of mania.

[9], [10], [11], [12], [13], [14], [15]

Bipolar disorder of the second degree

With this form of the disease, the patient experiences an attack of depression, as well as with bipolar disorder of the first degree, but attacks of mania proceed in a lighter form, the so-called attacks of hypomania. With the second degree of bipolar disorder, patients are more likely to suffer bouts of depression than hypomania.

[16], [17], [18], [19]

Bipolar disorder of cyclic form

With this form of the disease, the patient experiences at least 4 bouts of mania, depression or a combination of them within one year. Most often, seizures often follow one another, moving from one phase of mood to another. Sometimes a patient can not be in a normal state for a short time between attacks. There are bouts of mania and depression as well as with other types of this disease, however, the frequency with which they change each other and speaks about the cyclical nature of bipolar disorder.

Sometimes patients with this disease may have mixed symptoms, that is, the symptoms of mania and depression manifest simultaneously. These symptoms include a feeling of sadness, euphoria and irritability. They can also include excitement, lack of sleep, a change in appetite and, possibly, thoughts of suicide. This course of the disease complicates the process of its treatment and complicates the patient's life.

In addition to mood swings, some patients with bipolar disorder may have symptoms of anxiety syndrome, panic attacks, or symptoms of psychosis.

Symptoms of bipolar disorder in children may completely differ from the symptoms of this disease in adults and are often perceived as other mental illnesses of children, for example, attention deficit hyperactivity disorder or depression. Bipolar disorder in children affects their academic performance in school, their ability to communicate with friends and relatives.

There are such diseases, the symptoms of which at first glance are similar to the symptoms of bipolar disorder, for example, depression, schizophrenia and attention deficit hyperactivity disorder.

People diagnosed with bipolar disorder are more likely to abuse alcohol and drugs, while men more often abuse these substances than women. The use of alcohol or drugs can affect the effectiveness of treatment and medication. Against the background of bipolar disorder, diseases such as:

• Obsessive-compulsive disorder
• Panic disorder or panic attacks

These diseases must be treated together.

[20], [21]

Complications and consequences

In bipolar disorder, the patient balances between bouts of mania or depression. Between attacks, the patient can either completely return to normal, or have minor symptoms. Attacks of mood changes can start abruptly and suddenly or slowly.

During an attack of mania, the patient feels extremely happy and full of energy or very irritable for a week or longer. The patient also becomes excessively efficient and creative. He feels powerful and seductive and believes that he can achieve any goal. However, with the further development of this attack the patient begins to behave unchecked and irrational. He begins to spend large sums of money, gets involved in questionable transactions and sleeps very little. At this time, he is experiencing difficulties at work and in communication with his beloved people.

After an attack of mania goes on a recession, the patient can return to a normal state or immediately switch to the opposite mood, he feels useless, hopeless and sad. During a bout of depression, the patient has difficulty concentrating, he becomes forgetful and can not make a decision on his own. His appetite changes and sleep is disturbed. He loses interest in once-loved pursuits. Some people during this period may commit suicide or deliberately inflict wounds. Others believe that they can not move, think and take care of themselves.

Men are more prone to manic attacks while women are more likely to experience bouts of depression.

The cause of the development of an attack of mania or depression can be experienced stress. But with the development of the disease, these attacks can appear for no reason. Without proper treatment, bipolar disorder will intensify, and it will result in frequent attacks of mania and depression.

People with this disease become prone to diseases such as cardiovascular disease, obesity, high blood pressure and diabetes. If you undergo treatment, your doctor will monitor your health.

[22], [23]

Diagnostics of the bipolar disorder in adults

Bipolar disorder is a disease that is very difficult to diagnose. Unfortunately, there are no specific laboratory tests by which this disease could be determined. Instead, your doctor will ask you a lot of questions about your symptoms, their intensity and duration. To diagnose bipolar disorder of the first degree, the patient must be in the mania phase for at least a week (or less, if he had to be hospitalized). During this time, the patient should display three or more symptoms of mania, for example, reduced need for sleep, increased talkativeness, irresponsible behavior, or a feeling that thoughts are confused. For the diagnosis of bipolar disorder of the second degree, the attack of mania can be shorter and proceed in a lighter form.

Also, during the diagnosis, the doctor should prescribe blood and urine tests to exclude other diseases that cause similar symptoms.

[24], [25], [26], [27]

Analyzes

There are no special laboratory tests by which bipolar disorder could be diagnosed. Instead, the doctor will ask detailed questions about the symptoms of the disease, including their duration and frequency. The doctor will discuss with you the history of illness in your family and make a conclusion about the mental state.

Conclusion about the mental state will allow the doctor to evaluate your emotional functionality, the ability to think, remember and reason. This conclusion consists of an interview with a psychiatrist, a physical examination and a written or oral test. During the interview, the psychiatrist will evaluate your appearance, mood, behavior, your thoughts, your ability to reason, your memory, the ability to express yourself and the ability to maintain relationships.

Blood and urine tests will also be performed to exclude other diseases that cause symptoms, for example, thyroid dysfunction. Analyzes will also be conducted for the presence of narcotic substances in the blood.

[28], [29], [30], [31], [32]

Early diagnosis

The earlier the bipolar disorder is diagnosed and the treatment is prescribed, the earlier you can regain control over your mood. Early diagnosis also helps to avoid the consequences of the disease, such as alcohol or drug abuse, or suicide.

About 10-15% of patients with bipolar disorder die due to suicide. About 60% of patients have alcohol or drug dependence, which affects the effectiveness of treatment.

[33], [34], [35], [36], [37]

Treatment of the bipolar disorder in adults

The earlier you diagnose bipolar disorder and start treatment, the higher your chances of regaining control of your mood. One of the most important moments in the treatment of bipolar mania is the recognition of its first signs, which will give you the opportunity to begin treatment with medications as soon as possible, which should ease the condition of mania.

In the treatment of bipolar disorder, a large number of medications are used. It is possible that you will have to try several different drugs while you choose the medicine that suits you.

• Most patients with this disease have to take medications called mood stabilizers every day.
• Medications, called neuroleptics, help to quickly cope with a bout of mania.
• In some cases, antidepressants are used to treat an episode of depression, but this must be done with great care, as they can cause a manic attack.

Regular visits to the doctor will help you find the medicine that suits you more quickly.

Also important role in the treatment is played by psychotherapy, the sessions of which should be visited not only by the sick, but also by its relatives. Psychotherapy will help the patient cope with some problems that can arise at work or at home because of his illness.

Maintaining a mood diary will help you learn to recognize the smallest changes and notice symptoms faster. Write down in your diary your feelings and the reasons that caused them. If you understand what is causing you to change your mood, in time you will learn to avoid it.

Very often, during mania, when the patient feels very good, he stops taking the medicine. But this should not be done. You should take the medicine all the time, even if you feel healthy.

Despite the fact that bipolar disorder is not a curable disease, it can be treated with a combination of medications and psychotherapy sessions. Before your doctor selects the appropriate medicine for you, you will have to try several different drugs.

Initial treatment

Usually the first treatment is prescribed in the acute phase of bipolar disorder, when the patient is experiencing his first attack of mania. In the acute phase of the disease, the patient may be in a psychopathic state, be prone to suicide, or can not reason so sensibly that it can harm himself. In such cases, the doctor may prescribe hospitalization in order to protect the patient from ill-considered actions.

In the acute phase of the disease, the following medicines can be used:

• Stabilizers of mood, for example, lithium carbonate. Experts believe that lithium affects certain chemical elements of the brain (neurotransmitters) that cause a change in mood. However, the mechanism of action of this drug is not known.
• Anticonvulsant mood stabilizers, for example, sodium valproate, divalproex and carbamazepines. Valproate and divalproex are used in the treatment of manic attacks. Anticonvulsant lamotrigine has been approved for long-term use and is used in the treatment of bipolar disorder of the first degree or bouts of depression. These drugs also showed their effectiveness in the treatment of bipolar disorder, which is difficult to treat. The combination of anticonvulsants and mood stabilizers is often used in the treatment of acute attacks of mania.
• Neuroleptics, for example, olanzapine, risperidone, quetiapine and arapiprazole. They help to relieve the symptoms of both a manic attack and an episode of depression. They can be used in combination with mood stabilizers and anticonvulsants.
• Benzodiazepines, for example, diazepam (Valium). They are used in place of neuroleptics or as an additional tool in the treatment of manic attack.

Supportive treatment

Supportive treatment of bipolar disorder consists of attending sessions of psychotherapy and medications that are taken to avoid repeated attacks of mania or depression. It may take months for the symptoms of the disease to ease and you will be able to return to normal life.

Usually, mood stabilizers are prescribed for prolonged reception. However, despite their reception, you can experience repeated attacks of mania or depression. In such cases, the doctor will prescribe additional medications. If you have had several manic episodes or one acute attack, you will have to take the medicine all your life. Psychotherapy will help you restore your relationship and return to work.

Atypical anticonvulsants are currently used for maintenance treatment, but their effectiveness has not been proven.

Antidepressants, including fluoxetine, which are used to treat bouts of depression, must be taken very carefully, as they can cause a bout of mania. Currently, experts advise taking antidepressants for a short period of time and only with acute episodes of depression and in combination with mood stabilizers.

Treatment in the event that the disease worsens

In some cases, electroconvulsive therapy is used. During this procedure, a controlled electric charge is passed through the electrodes that are attached to the skull of the patient. This charge should provoke a small spasm in the brain, which is able to balance the chemical elements of the brain.

If, in addition to bipolar disorder, you have symptoms of anxiety syndrome, for example, anxiety and loss of sleep, panic attacks or signs of psychosis, you will need to take additional medications.

Information for consideration

When discussing this or that drug with your doctor, think about whether your lifestyle will take medication every day at the same time. If you are unable to remember about taking the medication, you can ask the doctor to prescribe a drug that is taken once a day.

You also should not forget about the side effects of medications. Perhaps with some side effects you will not be able to cope. Before you start taking medication, be sure to discuss all the side effects with your doctor, this may affect the choice of the drug.

It is proved that the use of antidepressants as independent drugs in the treatment of bipolar depression can cause a manic attack. Therefore, the use of antidepressants should occur under the supervision of a physician.

Unfortunately, many people do not consult a doctor with symptoms of bipolar disorder. This is due to the fact that a person thinks as if he can cope with the symptoms on his own. However, it is not.

Timely diagnosis of the disease and its effective treatment will help you avoid unpleasant and life-threatening consequences.

Precautionary measures

Unfortunately, bipolar disorder can not be prevented, but with the help of medications, it is possible to control mood swings.

Every third patient is completely cured of the symptoms of bipolar disorder if mood stabilizers are taken all their lives, for example, carbamazepines or lithium.

To prevent an attack of mania or depression, you can:

• Adhere to a well-balanced diet.
• Do physical exercises every day.
• Avoid traveling to other time zones.
• Try to go to bed and wake up at the same time every day.
• Avoid alcohol and drugs.
• Reduce stressful situations at work and at home.
• Reduce the use of caffeine and nicotine.
• Start treatment as soon as you notice the symptoms of an attack of mania or depression.

Changes in your usual sleep schedule can cause a bout of mania or depression. If you are planning a trip to another time zone, consult your doctor before this. Ask him if you need to change the dose of the medicine and what to do if you get an attack in the distance.

Home Treatment

Treatment at home plays an important role in the overall treatment of bipolar disorder. To help yourself control the mood, you can:

• Take the medicine every day according to the prescription of the doctor.
• Do sport. You can do light exercises for 30 minutes every day. To such exercises it is possible to carry foot walks.
• Watch your sleep. Keep in the bedroom silence and twilight and try to go to bed in the bottom and at the same time.
• Adhere to a healthy, balanced diet. By a balanced diet, we mean a set of foods from different groups, for example, whole grains, dairy products, fruits and vegetables, protein. Eat foods from each food group (for example, eat different fruits, and not just some apples). This will help you get along with food all the necessary nutrients, because one type of product will not be able to provide them. Eat a little, but do not overeat. A healthy diet can be made up of foods from all food groups, but on condition that you adhere to the rule of restraint.
• Monitor stressful situations in life. Organize your time and responsibilities, create a strong social support group, create effective methods of fighting stress and lead a healthy lifestyle. Methods for reducing stress include physical activity and exercise, breathing exercises, muscle relaxation techniques and massage.
• Avoid alcohol and drugs.
• During an attack of mania, reduce the intake of caffeine and nicotine.
• Learn to recognize the first signs of bouts of mania or depression.
• Ask relatives or friends to help you in a difficult moment. For example, if you are depressed, you may need to help with homework or you need to be monitored during a manic attack.

Family members often feel helpless when a loved one is experiencing a bout of mania or depression. But relatives and friends can help the patient in the following way:

• Maintain and encourage medication, even if the patient feels well.
• Be able to recognize the signs of suicide, which include:
  • Abuse of alcohol or drugs in large quantities.
  • Conversations, letters or drawings about death. Including writing death messages.
  • Talk about things that can be used to harm, such as pills, weapons, or knives.
  • Frequent spending time alone.
  • Handing out your own things.
  • Aggressive behavior or sudden calm.
• Recognize the first signs of an attack of mania or depression and encourage immediate treatment.
• Give your beloved person enough time to return to everyday life after an attack.
• Know the difference between just a good mood and the state of hypomania. Hypomania is an upbeat or irritable mood, which is very different from just a good mood and can last a week or longer.
• Encourage the patient to attend psychotherapy sessions and support groups, as well as visiting the support group himself, if necessary.

Medications

Medications can help control mood swings in the event that they are taken regularly and according to the prescription of the doctor. Despite the fact that a family doctor can prescribe a drug for the treatment of bipolar disorder, he will most likely send you to a psychotherapist who has experience in the treatment of such diseases.

Mood stabilizers, such as lithium, are the first drugs that are prescribed to treat an attack of mania, and subsequently as drugs that prevent bouts of mania and depression. To fully control your illness, you may need to take medication for many years or even a lifetime. To better control the symptoms of the disease, the doctor can prescribe additional medications - usually anticonvulsants.

Depending on your symptoms, the type of disease and your reaction to medications, the doctor will choose an individual dose of medications and their combination.

Choice of medicines

In the treatment of bipolar disorder, several types of medications are used. Before you pick up a suitable tool and its dose, you will have to try several drugs. The most common drugs include:

• Stabilizers of mood, for example, lithium carbonate. Experts believe that lithium affects certain chemical elements of the brain (neurotransmitters) that cause a change in mood. However, the mechanism of action of this drug is not known. To treat the acute phase of manic attack, doctors are advised to take mood stabilizers in combination with neuroleptics. Such drugs as sodium valproate, divalproex and carbamazepines are also considered mood stabilizers. Valproate and divalproex are used in the treatment of manic attacks. Anticonvulsant lamotrigine has been approved for long-term use and is used in the treatment of bipolar disorder of the first degree or bouts of depression. These drugs also showed their effectiveness in the treatment of bipolar disorder, which is difficult to treat.
• Neuroleptics, for example, olanzapine, risperidone, quetiapine and arapiprazole. Neuroleptics relieve the symptoms of mania. Olanzapine can be used in combination with mood stabilizers and anticonvulsants.
• Benzodiazepines, for example, diazepam (Valium). They are used in place of neuroleptics or as an additional tool in the treatment of manic attack.

Information for consideration

Antidepressants, including fluoxetine, which are used to treat bouts of depression, must be taken very carefully, as they can cause a bout of mania. Currently, experts advise taking antidepressants for a short period of time and only with acute episodes of depression and in combination with mood stabilizers.

If you are prescribed lithium, valproate or carbamazepine, you will have to do a regular blood test to monitor the level of these drugs in your blood. Exceeding the permissible level of lithium in the blood, can lead to serious side effects. During the taking of these drugs, the doctor will also monitor their effect on the function of the liver, kidney, thyroid and will measure the amount of blood in the body.

When you are at a doctor's appointment, do not forget to ask him:

• About the side effects of each of the medicines.
• How often should you take the medicine.
• How these drugs can interact with other medicines that you take.
• How important it is to take medication every day at the same time.

If you are taking medication for bipolar disorder during pregnancy, this may increase the risk of a child's birth defects. If you are pregnant or plan a pregnancy, tell your doctor about it. If your illness is acute, you will need to continue taking medication. The doctor will help you to compare the risk of treatment with the risk of harming the child.

The Office for Control of Quality of Food and Drug Administration advises the following:

• Remember the increase in antidepressant risk of committing suicide. Management does not claim that patients should stop taking these drugs. Instead, it is necessary to monitor the person taking antidepressants for signs of suicidal behavior. Especially it concerns the beginning of taking medications and changing their dose.
• Remember to increase the anticonvulsant risk of committing suicide. Management does not claim that patients should stop taking these drugs. Instead, it is necessary to monitor the person taking anticonvulsants for signs of suicidal behavior. If you take anticonvulsant drugs and are worried about this side effect, consult your doctor.

[38], [39], [40]

Alternative therapies

Most patients with this disease need medication. But psychotherapy sessions also play an important role in the treatment process, as they help you cope with the problems at work and at home caused by your illness.

[41]

Other treatments

The types of psychotherapy that are used in the treatment of bipolar disorder include:

• Cognitive-behavioral therapy, which focuses on changing certain patterns of behavior and thinking, which helps you feel better. It is based on the theory that thoughts and behavior can affect the patient's symptoms and become a barrier to recovery.
• Interpersonal therapy, which focuses on the personal and social relationships of the patient and the problems associated with them. During the sessions the patient discusses his problems, the reasons for their occurrence and the ways of their resolution.
• Problem solving therapy, a simplified version of cognitive therapy, which in the past was used in the treatment of depression. She focuses on the problem and helps the patient find an immediate solution.
• Family therapy, therapy that helps relatives and family members cope with a stressful situation or an important life event. During the sessions, family members can express their fears about how the illness will affect the patient and the whole family as a whole.

In some cases, electroconvulsive therapy is used. During this procedure, a controlled electric charge is passed through the electrodes that are attached to the skull of the patient. This charge should provoke a small spasm in the brain, which is able to balance the chemical elements of the brain.

Supplementary Therapy

Omega-3 fatty acids found in fish oil can be used as an additional preparation to the main course of treatment of bipolar disorder. However, this food supplement requires additional research on the effectiveness of its use in the treatment of children and adolescents.

Information for consideration

Establish a long and trustful relationship with your psychotherapist. It will help you to see changes in behavior and personal characteristics that will indicate to you that you have a bout of mania or depression. Earlier treatment of an attack will help him to cope more quickly.

Bipolar disorder affects not only the patient, but affects all members of his family. They must understand what kind of illness and know how to help their native people.

Bipolar disorder: when to see a doctor?

If you have bipolar disorder, seek medical advice immediately or call an ambulance if:

• You think that you can not protect yourself from harming yourself or other people.
• Listen to voices that were never heard before or they upset you more than usual.
• You want to commit suicide or you know the person who is going to do it.

The signs of committing suicide include:

• Excessive use of alcohol or drugs.
• Conversations, drawings or letters of death, including writing death messages or talking about things that can be used to harm yourself, such as pills, weapons, or knives.
• Desire to remain alone.
• Handing out your own things.
• Aggressive behavior or a sudden state of calm.

[42], [43]

Waiting and watching

Observations of the patient's condition will be enough if he is at the beginning of the attack and takes the medication regularly. If the symptoms of an attack do not improve within 2 weeks, consult a doctor.

If a person you love suffers from an attack of mania and behaves irrationally, help him turn to a professional for help.

Who to contact?

Bipolar disorder is complex and difficult to diagnose a disease, because it has many different phases and symptoms. Sometimes he is wandering with depression, since it is during the period of depression that patients often seek help.

After the diagnosis is made, it is important that the patient develop a long and trustful relationship with the doctor. This will help the doctor choose the most effective medicine and the best dose.

Despite the fact that the diagnosis can put different doctors, you will be advised to contact a psychiatrist with experience in the treatment of such diseases and the right to prescribe medications.

Doctors who can diagnose bipolar disorder:

• Family doctors.
• Interns.
• Practicing psychiatric nurses.

Support for relatives

If a member of your family or someone you love is sick of bipolar disorder, it would not be bad and you seek help from a psychiatrist. This will help you find out how the illness of a loved one will affect your life.

Also, psychotherapy sessions will help the child survive the disease of the parents. Changing the mood of the parent can cause the child tears, anger, depression or disobedience.