What is Bipolar Disorder?
Bipolar disorder, also known as manic depression, is a medical disorder that impairs the brain's ability to sustain a calm, steady mood. People with bipolar disorder experience a variety of intense emotional states, including elation and grandiosity, explosiveness and irritability, and periods of extreme sadness and low energy that they cannot easily control. Moods may shift abruptly many times per day, or they may persist for weeks, months, or even years and may seem inappropriate responses to actual circumstances and stresses.
Bipolar disorder is distinguished from depressive disorders by the presence of manic episodes (mania) in addition to depressive episodes (depression). Symptoms of mania and depression can also occur simultaneously, and these periods are called mixed episodes. In some individuals, particularly children and adolescents, the disorder produces chronic irritability or explosiveness with no discernible pattern and few periods of wellness. During mild manic episodes (known as hypomania), many individuals experience periods of tremendous productivity and creativity.
Bipolar disorder is a complex illness that tends to worsen over time if left untreated or if improperly treated. Without effective treatment, young people with bipolar disorder are at risk for substance abuse, school failure, accidents, incarceration, and suicide. Although there is no cure, the symptoms can be managed with proper treatment, understanding, and lifestyle and environmental modifications.
For reasons that are not understood, bipolar disorder is occurring with growing frequency at younger ages in children and adolescents. About one percent of the total population is affected by bipolar disorder. The tendency to develop bipolar disorder involves complex genetic and environmental factors. top
What Does Bipolar Disorder Look Like in Children and Adolescents?
Bipolar disorder may look different in young people than it does in adults. Children with bipolar disorder often have mood swings that shift rapidly over hours or even minutes, while adults' mood swings typically shift over days to weeks. Whereas adults with bipolar disorder generally have discrete periods of depression and discrete periods of mania, children with bipolar disorder are more likely to have moods that are not distinct. Children who develop the disorder very young are particularly likely to experience irritability and frequent mood shifts rather than discrete periods of mania and depression.
The first episode of bipolar disorder that a child or adolescent experiences may be in the form of depression, mania, or a combination of both. It may be difficult to identify a child's "first episode" of bipolar disorder if mania and depression occur at the same time, or if these moods occur chronically rather than during discrete periods of time.
During a depressive episode, children or adolescents may look frequently sad or tearful; they may be constantly irritable; or they may be tired, listless, or uninterested in favorite activities. Children or adolescents having an episode of mania often have more prominent irritability, aggression, and inconsolability than adults having an episode of mania. In a manic or mixed state they may be excessively giddy, happy, or silly; they may be intensely irritable, aggressive or inconsolable; and there may be changes in their sleep patterns. They may be restless, persistently active, and more talkative than usual; they may display behavior that is risky or hypersexual beyond what is age-appropriate; and they may have grandiose thoughts, such as the belief that they are more powerful than others; they may also hear voices. Explosive outbursts may involve physical aggression or extended, rageful tantrums.
Children with bipolar disorder have moods that often seem to occur unexpectedly and appear unresponsive to normally effective parenting efforts. Parents often become discouraged and exhausted by their child's difficult and erratic behaviors. They may try almost anything to avoid or stop the severe tantrums that can last for hours, and often end up feeling helpless to alleviate their child's suffering. They may feel guilty when neither "tough love" nor consoling the child works. Worst of all, children with bipolar disorder are frightened and confused by their own moods and often feel remorseful for the hurt they cause others when "under the influence" of a powerful mood.
A child or adolescent who first experiences symptoms of depression may in fact turn out to have bipolar disorder. Studies of children with depression show that 20 percent or more will go on to develop bipolar disorder, depending on the characteristics of the study population and the length of time they were followed. Since it is uncertain whether a child with a first episode of depression will later develop symptoms of mania, children with depression must be carefully monitored for the emergence of mania symptoms.
Because doctors only recently began to identify bipolar disorder in children, researchers have little data with which to predict the long-term course of the illness. It is not known whether early-onset bipolar disorder with rapidly shifting moods evolves over time if untreated into the more classic, episodic form of the disorder as the child reaches adulthood, or whether this outcome can be prevented by early intervention and treatment. Puberty is a time of high risk for the disorder to develop in individuals with genetic vulnerability.
If bipolar disorder is left untreated, all major realms of the child’s life (including peer relationships, school functioning, and family functioning) are likely to suffer. Early treatment with proper medication and other interventions generally improves the long-term course of the illness. A trained clinician (such as a child psychiatrist, child psychologist, or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis of bipolar disorder. top
► At Home
A child or adolescent with bipolar disorder can behave quite differently at home than at school or in the doctor's office. Because the child appears different in different settings, diagnosing bipolar disorder sometimes invites disagreement between parents, schools, and clinicians. Children's behavior, which reflects their brain's mood regulation, may be well controlled at school or at a doctor's office, but the same child may have severe temper outbursts at home.
In general, young people with bipolar disorder are most symptomatic at home, since moods are harder to control when the child feels tired (morning or evening), stressed by the intensity of family relationships, or pressured by the demands of daily responsibilities (such as homework and having to get ready for school on time). They are also more likely to show troubling emotions such as anger, anxiety, and frustration when they are in the security and privacy of home and immediate family.
At home, children with bipolar disorder may have some or all of the symptoms listed below.
- Rapidly shifting moods, from extreme happiness or silliness to tearfulness for no apparent reason
- Depressed or downcast mood, including disinterest in things they used to enjoy, or showing little expression
- Talk of suicide, self-harm behaviors, or hurting oneself or others may accompany depressed moods
- Manic (overexcited) or giddy mood
- Feelings of superiority, beliefs they can succeed in superhuman efforts, or risky behaviors may accompany the elevated moods
- Heightened sensitivity to perceived criticism. These children also are far more easily frustrated than a typical child.
- Impaired ability to plan, organize, concentrate, and use abstract reasoning
- Intense irritability accompanying the lows or the highs
- Rages, tantrums, crying spells, or explosive outbursts that can last hours and occur with small provocations (such as being told "no"). These episodes may be triggered more easily,
occur multiple times each day or week,
last longer, involve greater intensity, and require more recovery time than tantrums in other children.
- Episodes of unusual aggression, directed to the most available person. Family members, particularly parents and siblings, are often the primary targets.
- Restlessness or excessive physical activity, which is often chaotic
- Noticeable changes in sleep patterns including too much or too little sleep or difficulty falling asleep
- Side effects from medications, including cognitive effects that interfere with academic performance as well as physically uncomfortable side effects such as fatigue, excessive thirst, or stomach upset
- Unusual sexualized behaviors or comments
- Unusual beliefs ("People are talking in my closet") or fears ("Everyone at school hates me, so I'm not going") top
► At School
The differences in behaviors seen at home and at school can be dramatic. Because children react differently to the stresses of schoolwork, classroom noise, and transitions between classes and activities, some children show more severe symptoms at school, while others show more severe symptoms at home. Over time, these symptoms may worsen if the child is untreated, if the illness worsens, or if new problems develop. Families often seek treatment once problem behavior affects a child's school performance.
At school, children with bipolar disorder may be affected by some or all of the following symptoms.
- Fluctuations in cognitive abilities, alertness, processing speed, and concentration, which may occur from day to day and may reflect a child's overall mood stability
- Impaired ability to plan, organize, concentrate, and use abstract reasoning. This can affect behavior and academic performance.
- Heightened sensitivity to perceived criticism. These children also are far more easily frustrated than a typical child.
- Hostility or defiance at small provocations, as their moods dominate how they "hear" directions from a teacher
- Crying for no apparent reason, appearing upset out of proportion to actual events, or seeming inconsolable when distressed. School staff may notice how "irrational" these children seem to be, and that trying to reason with them often doesn't work. Most of these children suffer from extremely high levels of anxiety that interfere with their ability to logically assess a situation.
- Side effects from medications. Medications may have cognitive effects or physically uncomfortable side effects that interfere with school performance. Sharing information with the school about a child's medications may allow parents to obtain helpful feedback regarding overall effectiveness and any side effects that should be addressed.
- Other conditions, such as Attention Deficit/Hyperactivity Disorder (ADHD), which also may be present, compounding any learning challenges. Having one mental health condition does not "inoculate" the child from having other conditions as well.
- Learning disorders, which are often overlooked in this population. A child's difficulties or frustrations in school should not be presumed to be due entirely to the bipolar disorder. If the child still has academic difficulty after moods are treated, an educational evaluation for learning disabilities should be considered. A child's repeated reluctance to attend school may be an indicator of an undiagnosed learning disability. top
► At the Doctor's Office
The mood and behavior problems prompting an office visit may look different or may not be seen during the actual appointment. Clinicians may need to talk with parents, schools, and other important caregivers to evaluate a child's functioning in these areas.
Clinicians may have to deal with some of the following challenges in diagnosing and treating a child or adolescent with bipolar disorder.
- Symptoms vary over time and their appearance changes as the child grows. A clinician may need to see a child over a period time to determine the appropriate diagnosis.
- Symptoms caused by other medical conditions and by certain medications can be confused with bipolar disorder. These conditions include hyperthyroidism, seizure disorders, multiple sclerosis, strokes, tumors, and infections. Prescribed medications (steroids, antidepressants, stimulants, and some treatments for acne) and non-prescribed drugs (cocaine, amphetamine) can cause severe mood changes. Relevant laboratory tests and physical examinations may be helpful when bipolar disorder is considered.
- Bipolar disorder often first appears as depression in adolescents. Sudden onset depression, accompanied by sluggishness and excessive sleeping has been the most common "depression profile" seen in young people who later develop manic symptoms.
A family history of bipolar disorder also increases the possibility that a depressed child may go on to develop bipolar disorder. In children with bipolar disorder, antidepressants may improve depressive symptoms but can sometimes unmask or worsen manic symptoms. Careful monitoring is recommended for any child receiving antidepressants.
- Bipolar disorder is often misdiagnosed as ADHD because some symptoms overlap, and many children with early onset of bipolar disorder also have ADHD. Stimulants (such as Ritalin, Concerta, Adderall) can aggravate mood instability, so it is important to stabilize the child's mood before beginning treatment for ADHD.
- Children may be unaware, or unwilling to admit,
that their behavior may indicate symptoms of a disorder
- Especially during periods of relative wellness, older children and adolescents may refuse to take their medication. They may prefer to think of themselves as totally well.
- Medication side effects, such as significant weight gain
or acne, may create further difficulties for the child
- Families may need to be coached about what they can
reasonably expect from their child. Children who suffer from bipolar
disorder will benefit if their family understands that therapy
and medicines may reduce, but do not cure, symptoms.
- Families and children should be prepared to expect periodic relapses as part of the normal course of the illness. It can be very discouraging to see the return of prior symptoms that were presumed to be "conquered," but less so if it is understood that these temporary relapses are to be expected. Symptoms tend to return during times of high stress: the start of a new school year, holidays, physical illness, moving to a new community, and so on. These relapses may indicate the need to make an adjustment to medications or they may have a seasonal pattern. top
How is Bipolar Disorder Treated?
Bipolar disorder is treatable through ongoing interventions provided by a child's medical practitioners, therapists, school staff, and family. These treatments include psychological interventions (counseling), biological interventions (medicines), and accommodations at home and school that are designed to reduce sources of stress for the child. Open, collaborative communication between a child's family, school, and clinicians optimizes the care and quality of life for the child with bipolar disorder. top
► Psychological Interventions (Counseling)
Counseling can help children with bipolar disorder, and everyone around them, to understand that their symptoms reflect a biological illness with complex genetic and environmental origins--not personality or an oppositional attitude. Counseling also can reduce the impact of symptoms on daily life. A variety of psychological interventions can be helpful, and parents should discuss their child's particular needs with their clinician to determine which psychological treatments could be most beneficial for their child.
- Individual psychotherapy may be useful for young people with bipolar disorder, particularly when there are ongoing stressors in their lives that make symptoms worse. Children with the disorder often carry a sense of failure, as if the illness was their fault. In many cases, they are aware that when they are unable to control their behavior, they may hurt people closest to them, which can increase their sense of self-blame. Individual psychotherapy can help young people become aware of and address these feelings.
- Cognitive Behavior Therapy (CBT) helps a child or adolescent to become aware of, and to describe, negative thoughts, feelings or reactions. A trained clinician guides the child to think of new, more positive alternatives. The young person is then given a chance to practice new thoughts, feelings, or reactions outside the clinical visit, and to discuss his or her experiences with the clinician afterwards. These methods are based upon practices that have helped many children and adolescents.
- Parent guidance sessions can help parents to manage their child's illness, identify effective parenting skills, learn how to function as a family despite the illness, and to address complex feelings that can arise when raising a child with a psychiatric disorder. Family therapy may be beneficial when issues are affecting the family as a whole.
- Group psychotherapy can be valuable to a child by providing a safe place to talk with other children who face adversity or allowing a child to practice social skills or symptom-combating skills in a carefully structured setting
- School-based counseling can be effective in helping a child with bipolar disorder navigate the social, behavioral, and academic demands of the school setting top
► Biological Interventions (Medicines)
Medication usually plays a critical role in managing the symptoms
of bipolar disorder. Several classes of medications are available
that reduce the severity and frequency of changing moods. Because
of the complexity of symptoms, doctors commonly prescribe more than
one type of medication for young people with bipolar disorder.
The U.S. Food and Drug Administration (FDA) has not approved specific
medications for the treatment of children and adolescents with bipolar
disorder. However, medications approved by the FDA for other uses
and age groups are prescribed for young people with bipolar disorder.
The FDA allows doctors to use their best judgment to prescribe medication
for conditions for which the medication has not specifically been approved.
The following medications are commonly prescribed for children
and adolescents with bipolar disorder:
- Mood stabilizers. Depakote, lithium, Tegretol, Trileptal,
and other mood stabilizers are prescribed to treat the symptoms
of bipolar disorder. With the exception of lithium, these medicines
are anticonvulsants that researchers have found to be helpful
with mood stabilization. Mood stabilizers are commonly prescribed
for people with bipolar disorder who are taking antidepressants,
in order to minimize the risk that manic symptoms will be worsened
by the antidepressant.
- Antipsychotic medications. These medications (also known
as neuroleptics) may be prescribed to reduce aggressive behavior
and mood swings. Examples of these drugs are Abilify, Geodon,
Risperidal, Seroquel, Zyprexa.
- Antidepressants are sometimes prescribed to treat symptoms
of depression that are caused by bipolar disorder. The most commonly
prescribed antidepressants, including Celexa, Lexapro, Luvox,
Paxil, Prozac (fluoxetine), and Zoloft, belong to a group of medications
called Selective Serotonin Reuptake Inhibitors, or SSRI's. Other
commonly prescribed antidepressants include Effexor, Remeron and
In most cases these medicines begin to be effective in reducing
symptoms after the child or adolescent has taken them for at least
2-4 weeks. Fully 12 weeks may be required in order to determine
whether the medication is going to be effective for a particular
individual. Medications should only be started, stopped, or adjusted
under the direct supervision of a trained clinician.
There is no "best" medicine to treat bipolar disorder, and it
is important to remember that medicines usually reduce rather than
eliminate symptoms. Different medicines or dosages may be needed
at different times in a child's life or to address the emergence
of particular symptoms. Successful treatment requires taking medicine
daily as prescribed, allowing time for the medicine to work, and
monitoring for both effectiveness and side effects. The family,
clinician and school should maintain frequent communication to ensure
that medications are working as intended and to monitor and manage
The following cautions should be observed when any child or adolescent
is treated with antidepressants.
- Benefits and risks should be evaluated. Questions have
arisen about whether antidepressants can cause some children or
adolescents to have suicidal thoughts. The evidence to date shows
that antidepressants, when carefully monitored, have safely helped
many children and adolescents. The latest reports on this issue
from the U.S. Food and Drug Administration can be found on its
web site at www.fda.gov.
Consideration of any medicine deserves a discussion with the prescribing
clinician about its risks and benefits.
- Careful monitoring is recommended for any child receiving
medication. Though most side effects occur soon after starting
a medicine, adverse reactions can occur months after medicines
are introduced. Agitation, restlessness, increased irritability,
or comments about self-harm should be addressed immediately with
the clinician if any of these symptoms emerge after the child
starts an antidepressant. Frequent follow-up (weekly for the first
month) is now advocated by the FDA for children starting an antidepressant.
- Bipolar depression may need to be treated differently than
"ordinary" depression. In some individuals with bipolar disorder,
antidepressants may initially improve depressive symptoms but
can sometimes worsen manic symptoms. While antidepressants
do not "cause" bipolar disorder, they can unmask or worsen manic
Helpful information about specific medications can be found at
(click on "Drug Information") and in the book Straight Talk About
Psychiatric Medications for Kids (Revised Edition) by Timothy
E. Wilens, MD. top
► Interventions at Home
At home, as well as at school, providing a sympathetic and low-stress environment and making some adaptations may be helpful to aid a child or adolescent with bipolar disorder.
- Understand the illness. Understanding the nature of
bipolar disorder, its unpredictability, and its consequences for
the child will help parents sympathize with a child's struggles.
Children whose behavioral symptoms make life stressful for the
whole family are most likely vulnerable people who wish they could
be "normal" like other kids. It is also important to keep in mind
that because children with bipolar disorder are frequently quite
impulsive, their actions "in the moment" may not reflect behavioral
lessons they have already learned.
- Listen to the child's feelings. Daily frustrations and
social isolation can foster low self-esteem and depression in
these children. The simple experience of being listened to empathically,
without receiving advice, may have a powerful and helpful effect.
Parents should not let their own worries prevent them from being
a strong source of support for their child.
- Distinguish between symptoms, which are frustrating, and
the child. "It's the illness talking." Taking a supportive
stance in which parents, child and clinicians unite together to
fight symptoms is an effective strategy to encourage a child who
is doing the best he or she possibly can. Sometimes it is useful
to help the child distinguish himself or herself from the illness
("It sounds like your mood is not very happy today, and that must
make it extra hard for you to be patient").
- Plan for transitions. Getting to school in the morning
or preparing for bed in the evening may be complicated by fears,
anxieties, and the child's fluctuating energy and attention level.
Anticipating and planning for these transition times may be helpful
for family members.
- Adjust expectations until symptoms improve. Helping
a child make more attainable goals when symptoms are more severe
is important, so that the child can have the positive experience
of success. This requires reducing stress on the child where possible:
taking a break from after-school activities if they become too
stressful, allowing a child who is not functioning well to cut
back on homework, and supporting the child's decision to stay
home from large social or family functions that may feel overwhelming,
- Keep the "small stuff" small. A parent may need to choose
which issues are worth having an argument over (such as hitting
a sibling) and which issues are not worth an argument (tonight
choosing not to brush teeth). These decisions are not easy, and
at times everything may appear to be important. Parenting a child
with bipolar disorder requires flexibility that will reduce conflicts
at home and instill healthy habits in the child. For guidance
on how to "keep the small stuff small," visit the Collaborative
Problem Solving Institute web site at www2.massgeneral.org/cpsinstitute/.
- Understand parental limits. Fulfilling a child's extreme
wishes related to symptoms (for example, strong and persistent
urges to buy things) may be neither possible nor advisable. Such
well-intended efforts to support a child may actually delay the
development of new coping strategies and reduce the benefits of
behavior therapy. Finding the balance between supportive flexibility
and appropriate limit setting is frequently challenging for parents
and may be aided by the guidance of a trained professional.
- Talk as a family about what to say to people outside of
the family. Determine what feels comfortable for the child
(for example, "I was sick and got some help, and now I'm better").
Even if the decision is made not to discuss this medical condition
with others, having an agreed-on plan will make it easier to handle
unexpected questions and minimize family conflicts about this.
- Behavioral plans may be useful to reinforce a child's
successful efforts. Children tend to benefit from behavioral
plans that reward good behaviors (rather than punish misbehaviors)
because they may otherwise feel as though they get feedback only
about their mistakes. Please see the table below.
Provide frequent acknowledgements of success. Experts encourage doing this six times per hour at home. This pattern may not be one parents grew up with, but it is an easy and effective means to help a child develop new habits. For example, tell the child, "Great job getting the table cleaned off with no sticky spots at all," rather than, "I've told you twice already to go pick up your clothes once you get the table cleaned off."
Reward the child for making efforts to reduce problem
behaviors. Avoiding a tantrum, demonstrating flexibility
in a potentially difficult situation, or increasing times
without a rageful episode can all improve daily life and warrant
reward or acknowledgment.
Develop meaningful incentives with the child. Praise, gold stars on a calendar, or sitting beside a parent in the car can all be effective rewards. Parents will need to determine with their child what the reward is, and will need to be consistent with the plan for it to be effective. Tangible reminders help children learn that they can be responsible for their actions and will be recognized for their good efforts. Parents can look to the school psychologist or guidance counselor or to their child's treatment professionals for help in developing behavioral plans for the home.
A chart system is often effective, in which a certain number of stars per day may be "cashed in" for the reward (an extra story with parent, a trip for ice cream, etc.). It is essential that these rewards not become the source of additional conflict. If the child doesn't have the required "points" for a reward, rather than saying, "No, you don't get your treat because you didn't pick up all your clothes today like we asked," parents report more success when they say, "You picked up all your clothing for six days so far-just one more day and you'll earn that ice cream we talked about for picking up for a whole week." Parents need to set appropriate limits, such as saying "no" to an extravagant toy as a reward. On the other hand, the reward needs to be something the child enjoys and will be motivated to earn. top
► Interventions at School
Educators can significantly reduce classroom stresses for children with bipolar disorder, thereby allowing them to succeed in school. Academic stresses, like other stresses, can destabilize a child. Regular meetings between parents and school faculty, such as teachers, guidance counselors, or nurses, will allow collaboration to develop helpful school structure and strategies for the child. The child may need particular changes (accommodations/modifications) to the workload. Bipolar disorder may need to be considered be a "disability," just like a broken arm or asthma.
Accommodations, modifications, and school strategies may include the following:
- Check-in on arrival to see if the child can succeed in certain classes that day. Where possible, provide alternatives to stressful activities on difficult days.
- Accommodate late arrival due to inability to awaken, which may be a medication side effect or a seasonal problem
- Allow more time to complete certain types of assignments
- Adjust the homework load to prevent the child from becoming overwhelmed
- Adjust expectations until symptoms improve. Helping a child make more attainable goals when symptoms are more severe is important, so that the child can have the positive experience of success.
- Anticipate issues such as school avoidance if there are unresolved social and/or academic problems
- Anticipate social difficulties and reduce opportunities for possible bullying by others. Children with bipolar disorder are often on a different "wavelength" than their peers and their behavior may be viewed as unusual. It is not uncommon for them to be socially isolated, and they may be targets for bullying. More often than other children, they may be ill-equipped to handle teasing in an appropriate way.
- Allow children to discreetly and frequently accommodate needs caused by medication side effects, such as excessive thirst and frequent bathroom breaks
- Set up a procedure that allows the child to quickly and safely exit from an overwhelming situation. Designate a place and staff member that is always available when the child needs to de-stress.
- Expect and accommodate learning and cognitive difficulties, which may vary in severity from day to day. Despite normal or high intelligence, many children and adolescents with bipolar disorder have processing and communication deficits that hinder learning and create frustration.
- Use alternative discipline approaches if children are unable to control their behavior. Traditional approaches to discipline are unlikely to produce the desired results, and an approach that is effective one day may not work the next day. Alternative strategies include providing additional time and then repeating a request, developing a list of options from which children may choose, and designating a special place for students to go during times of stress.
- Because transitions may be particularly difficult for these children, allow extra time for moving to another activity or location. When a child with bipolar disorder refuses to follow directions or to transition to the next task, schools and families should remember that anxiety may be the cause, rather than intentional inflexibility or oppositionality.
- Use behavioral plans at school that are consistent with those used at home. Please refer to "Interventions At Home," above, for details regarding behavioral plans.
- Encourage the child to help develop interventions. Enlisting the child in the task will lead to more successful strategies and will foster the child's ability to problem-solve.
- Please click on School-Based Interventions for a more complete list of school accommodations for children with bipolar disorder
Flexibility and a supportive environment are essential for a student with bipolar disorder to achieve success in school. Parents and school faculty may be able to identify particular problem times, such as transition times or unstructured periods, and develop remedies to reduce the child's difficulties in those situations. top
| Many online resources and books are available to help
parents, clinicians, and educators learn more about children and adolescents
with bipolar disorder. Click here for
a wide selection of resources. top
Information provided above on bipolar disorder draws from sources
American Psychiatric Association, Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition. Washington, DC: American
Psychiatric Association, 1994
Dulcan, MK and Martini, DR. Concise Guide to Child and Adolescent Psychiatry, 2nd Edition. Washington, DC: American Psychiatric Association, 1999
Lewis, Melvin, ed. Child and Adolescent Psychiatry: A Comprehensive Textbook, 3rd Edition. Philadelphia: Lippincott Williams and Wilkins, 2002 top