Understanding People Who Have Bipolar Disorders
description
Transcript of Understanding People Who Have Bipolar Disorders
![Page 1: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/1.jpg)
Understanding People Who Have Bipolar Disorders
Mary Bittle, PhD, RN, LMFTA
![Page 2: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/2.jpg)
Objectives• Recognize characteristics of bipolar disorders.• Differentiate DSM-IV-TR and DSM-V characteristics,
effective 1/1/14.• Differentiate between mania and hypomania• Recognize contributing factors of genetics and brain
chemistry. • Recognize common treatments • Recognize challenges of managing • Recognize famous people who have/had• Acknowledge people with successful management
can lead successful lives
![Page 3: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/3.jpg)
What are Bipolar Disorders?
• Disturbances of mood that significantly interfere with the daily functioning of an individual. DSM IV-TR mood DO. DSM V places in separate category
• Two types: Bipolar I and Bipolar II• 19th century called manic-depressive, no
longer a correct term.American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.:
American Psychiatric Publishing.
![Page 4: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/4.jpg)
Bipolar Disorders U.S.
• Prevalence: 2.6%• Classified Severe: 82.9% (2.6%) = 2.2%National Institute for Mental Health. National Institutes for Health. (2005). Bipolar disorder among adults.
Retrieved 11/13/13 from http://www.nimh.nih.gov/statistics/1bipolar_adult.shtml
• Some 10 million peopleNational Alliance on Mental Illnesses. Bipolar Disorder FACT SHEET. Retrieved 11/13/13 from
http://www.nami.org/factsheets/bipolardisorder_factsheet.pdf
![Page 5: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/5.jpg)
Bipolar IA. Must have at least one manic episode lasting at
least 1 weekB. During manic episode must have 3 or more out
of 7 behavioral manifestations of mania(next slide)
C. Major impairment in life functioningD. Cannot be explained by medications or drugs for
another medical conditionMay also be followed or preceded by hypomania
and/or major depression. Hypomania/MD not necessary for BPI DO.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
![Page 6: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/6.jpg)
Behaviors of Mania1. Grandiosity, increased self esteem2. Insomnia3. Pressured or continuous talking4. Expresses that thoughts are racing or expressed thoughts
jump rapidly from one topic to another, called flight of ideas
5. Distractibility6. Increase in goal-directed or non-goal-directed activity,
called psychomotor activity7. Activities are of increased risk: pain, excessive spending,
hypersexuality…
May include psychotic behaviorAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric
Publishing.
![Page 7: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/7.jpg)
Behaviors of Hypomania
Same as for mania except:A.Lasts at least 4 daysB.Uncharacteristic for usual behaviors of the
personC.Others notice the increased/expansive
behaviorsD.Not severe enough for major impairment in
life functioningAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
![Page 8: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/8.jpg)
Bipolar I• Typical age of onset ~18 years old• Prevalence:– US 0.6%– 11 other countries 0.0% - 0.6%
• Male to female occurrence 1.1:1• More common in countries with higher
incomes• Higher rates in separated, widowed• Suicide risk 15 X that of general population• 36.3% Lifetime riskAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ).
Washington D.C.: American Psychiatric Publishing.
![Page 9: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/9.jpg)
Bipolar II
Same as Bipolar I EXCEPT:A.Elevated mood of at least 4 days.B.Not characteristic of personC.Observable by othersD.Does not significantly interfere with functioning
nor require hospitalizationMust include at least one major depressive episode, present or past
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
![Page 10: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/10.jpg)
Other Characteristics of Bipolar II
• Common impulsive behaviors troublesome. • Suicide ideation and risk increased– 1/3 have suicide attempt in lifetime, 32.4 %– Use more lethal means , so success greater
• Substance abuse• Value of increased creativity leads to denial and
aversion to treatmentAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
![Page 11: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/11.jpg)
Bipolar II• Prevalence – 0.8% US– 0.3% Internationally
• Typical age for development mid 20s• Usually begins with a depressive episode• Once there is ever a hypomanic episode, DX = BP II
and not MDD• More lifetime episodes than BP I • May be rapid cycling, females more likely, poorer
prognosis• Once there is a manic episode, DX changes to BP IAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
![Page 12: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/12.jpg)
Mania _____________________________________
Hypomania _____________________________________
Normal Mood - Eupnea
_____________________________________
DysthymicCyclothymic
_____________________________________
Depressed _____________________________________
Bipolar MoodsTime -----------------------------------------------
![Page 13: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/13.jpg)
Comparison
Bipolar I1 week elevated mood3/7 characteristics (4 if
mood irritable)Marked impairment ADLsPsychosis when present
defines BP I
May have major depression
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
Bipolar II4 days elevated mood3/7 Characteristics (4 if mood
irritable)ADLs NOT markedly affected.
Hospitalization not necessary.
Behaviors noted by othersMust include Major
Depression
![Page 14: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/14.jpg)
DSM V Coding
• 296. for Bipolar I• Codes following decimal:– Mild, Moderate, Severe– Most current episode Mania, Hypomania,
Depressed– Psychotic feature present – Partial or Full Remission
• 296.89 for Bipolar II– Further modifiers are written in words
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
![Page 15: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/15.jpg)
Major Depression
A. For at least a period of 2 weeks, 5 of 9 symptoms (next slide) have occurred.
Depressed mood or anhedonia (loss of pleasure) Represents change from usual.
The symptoms are not due to another medical condition.
B. Major impairment in life functioning/distressC. Not due to another medical condition or effects
of a substanceAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
![Page 16: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/16.jpg)
Behaviors of Depression
1. Depressed mood (sadness, emptiness, hopelessness, crying) most all day, most every day.
2. No or nearly no interest in pleasure or activities, most all day, most every day. (Anhedonia)
3. Significant loss of appetite with unplanned weight loss (=/>5%)
4. Too much or too little sleep, insomnia or hypersomnia
5. Significant activity slowing or irritability American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
![Page 17: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/17.jpg)
Behaviors of Depression6. Continuous low energy and/or fatigue 7. Feeling of excessive guilt (may be delusional)
or worthlessness.8. Less ability to concentrate or make decisions
most all day, most every day. 9. Thoughts of death: suicidal ideation with or
without a planThe above may be subjective or observed by
others. The above may not be normal reactions to significant loss
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
![Page 18: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/18.jpg)
Depression
Major depressive SX are the most common first presentation for which people with BP II disorder seek medical attention, particularly hospitalization.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
![Page 19: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/19.jpg)
Suicide Ideation
• Thoughts of – Death– Wanting relief– The world will be better off w/o me– Significant others will be better off w/o me
• Contemplation – Plan– Means and lethality– Energy with which to carry out
![Page 20: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/20.jpg)
Clues to Suicide and Interventions• Verbalizing the future w/o oneself• Giving things away• ThreatsALWAYS take any clue to suicide seriously.• ADDRESS person openly• Do want to harm yourself?• Do you have a plan?• What is you plan?• Notify significant others and /or authorities• Offer HOPE. • Things NOT to say: guilt, shame, false reassurance, can
“snap out of it.”
![Page 21: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/21.jpg)
Suicide Prevention?
• Research does not support effectiveness of “Suicide Contracts.” American Psychiatric Association. (2003). Practice guidelines for the assessment and treatment of patients with suicidal behaviors. American Journal of Psychiatry, 160(11Suppl.), 1-60.
• Use written “Plan for Life” (positive approach)– When I feel______________ (describe)– I will ___________________ (activities)– I will call ________________ (support persons)– I will call ________________ (Suicide Contact ph. #s, 911)
![Page 22: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/22.jpg)
PsychosisBPI may have psychotic features
Psychoses of BPD are usually of the type of Delusions – strongly held/fixed beliefs that defy evidence or reality
Examples: grandiosity, persecutory, referential, erotomanic, somatic, nihilistic….
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
![Page 23: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/23.jpg)
Bipolar Typical Characteristics• People who have mania or hypomania frequently
do not recognize/deny that their behaviors are abnormal.
• They may enjoy their elevated moods. • They may value ability to accomplish goals.• If behaviors are serious enough, persons may
have to be hospitalized. Usually they are resistant to hospitalization resulting in involuntary admission.
• Behaviors, particularly delusional, may result in illegal transgressions.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
![Page 24: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/24.jpg)
Co Morbidity
• Drug and Substance use, abuse, and addictions are common– Alcohol– Marijuana
• Persons desperately want to relieve symptoms
![Page 25: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/25.jpg)
Etiology – Multiple - Complex• Familial – Relatives of those with Bipolar Disorders are more likely to
have. 10X the risk. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
-Both parents: 50-75% chance for children; one parent 27%-Identical Twins 78-80% concordance-Familial Twins 17-19% Concordance
Snow, D. (2009). Bipolar lecture. University of Texas at Arlington College of Nursing.
- White matter reduction Sprooten, E. et al. (2013). Reduced white matter integrity in sibling pairs discordant for bipolar disorder. Am J Psychiatry 2013;170:1317-1325
• Multiple genes involved– Polymorphisms at the G72/G30 gene locus, on L13q33
Hattori, E. et al. (2003). Polymorphisms at the G72/G30 gene locus, on L13q33, are associated with bipolar disorder in two independent pedigree series. American Journal of Human Genetics, 72(5), 1131-1140.
– Corticotropin receptor and subunit of G protein genes on C-18• Snow, D. (2009). Bipolar lecture. University of Texas at Arlington College of Nursing.
• Environmental
![Page 26: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/26.jpg)
Neurobiological Correlates
• Brain areas: prefrontal cortex (executive function),medial temporal lobe (memory functions), via PET & MRI evidence
• Neurotransmitters: norepinephrine, dopamine, serotonin- decreased availability associated with mood lowering
• Endocrine – thyroid:– Low thyroid– risk for depression , and rapid cycling
Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical Approach. St. Louis, MO. Saunders. 359-393.
![Page 27: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/27.jpg)
Treatment Options• Medications• Talk or Psychotherapy• Electroconvulsive Therapy (ECT)Every person is different with presentation of
BPD. Since multiple causal and environmental factors are involved, the management is challenging and often takes much trial and error and readjustment.
![Page 28: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/28.jpg)
Treatment Estimates
• ~48.8% receive• ~38.8% minimally adequateNational Institute for Mental Health. National Institutes for Health. (2005). Bipolar disorder among
adults. Retrieved 11/13/13 from http://www.nimh.nih.gov/statistics/1bipolar_adult.shtml
Parody of psychiatric and medical treatment access could increase these
![Page 29: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/29.jpg)
MedicationsMood Stabilizers
• Lithium is classic (Eskalith or Lithobid)– Long term necessary– Therapeutic and toxic levels are close– Lab tests closely monitor levels– Acts like salt, so balance /w table salt important– Decreased levels of salt can raise levels of lithium– Can cause dry mouth, sensitivity to cold,
muscle/joint pain, brittle nails/hair, acne, indigestion, restlessness
– Need monitoring of kidney and thyroid functionNational Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from
http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical Approach. St. Louis, MO. Saunders. 359-393.
![Page 30: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/30.jpg)
MedicationsMood Stabilizers
Anticonvulsants - FDA approved • Valproic acid or divalproex sodium (Depakote)• Lamotrigine (Lamictal) • Gabapentin (Neurontin)• Topiramate (Topamax)• Oxcarbazepine (Trileptal)National Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from
http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical Approach. St. Louis, MO. Saunders. 359-393.
![Page 31: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/31.jpg)
MedicationsMood Stabilizers
Side and/or Untoward Effects• Warnings of increased risk for suicide• GI: Diarrhea/constipation/heartburn• Nasal: Stuffy/runny nose• Neuro: Headache, drowsiness/dizziness• Potentially fatal skin rash from Lamotrigine
(Stevens-Johnson syndrome)• Young women & Valproic acid, risk for polycystic
ovaries/birth defectsNational Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from
http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical Approach. St. Louis, MO. Saunders. 359-393.
![Page 32: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/32.jpg)
Having Bipolar Disorders are serious life altering challenges to individuals who have them and to their families.
Can be managed successfully to have productive life.
Requires tremendous insight in individual and supportive understanding by those closest to them .
![Page 33: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/33.jpg)
Famous People Who may have had or have BPDs
• Vivien Leigh• Carrie Fisher• Jean-Claude Van
Damme• Linda Hamilton• Sinéad O'Connor
• Vincent van Gogh• Virginia Woolf• Jane Pauley• Mariette Hartley• Catherine Zeta-JonesBhatia, J. (2011). 10 Famous people with bipolar
disorder: The price of fame? Retrieved 11/14/13 from http://www.everydayhealth.com/bipolar-disorder-pictures/famous-people-with-bipolar-disorder.aspx#/slide-1
![Page 34: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/34.jpg)
Famous People Who may have had or have BPDs
Author. (2012). Retrieved 11/13/13 from http://famouspeoplewithbipolardisorder.blogspot.com/2012/12/bipolar-famous-people.html• Jack Nicholson• Jim Carey• Rowan Atkinson• Robert Pattinson• Ben Stiller• Hugh Laurie• Craig Manning• Rapper "DMX'“• Kurt Cobain• Alfred Hitchcock• Salvador Dali‘• Kim Novak• Richard Dreyfuss• Margot Kidder• Demi Lovato• Sir Winston Churchil
• Macy Gray• Jimi Hendrix• Madonna• Buzz Aldrin• Abraham Lincoln• Charley Pride• Kristy McNichol• Connie Francis• Ozzie Osbourne• Sir Isaac Newton• Ludwig Van Beethoven• John Forbes Nash Jr.• Rita Lee• Pete Wentz• Patti Duke• Pablo Picasso
![Page 35: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/35.jpg)
Resources
• Skywriting: A Life Out of the Blue, a book by Jane Pauley
• National Alliance on Mental Illness http://www.nami.org
• National Institute for Mental Health. National Institutes for Health www.nimh.nih.gov
• www.mayoclinic.com/health/bipolar-disorder
![Page 36: Understanding People Who Have Bipolar Disorders](https://reader035.fdocuments.net/reader035/viewer/2022062314/56814838550346895db55552/html5/thumbnails/36.jpg)
References• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ).
Washington D.C.: American Psychiatric Publishing.• American Psychiatric Association. (2003). Practice guidelines for the assessment and treatment of patients with
suicidal behaviors. American Journal of Psychiatry, 160(11Suppl.), 1-60.• Author. (2012). Famous people with bipolar disorder. Retrieved 11/13/13 from
http://famouspeoplewithbipolardisorder.blogspot.com/2012/12/bipolar-famous-people.html• Bhatia, J. (2011). 10 Famous people with bipolar disorder: The price of fame? Retrieved 11/14/13 from
http://www.everydayhealth.com/bipolar-disorder-pictures/famous-people-with-bipolar-disorder.aspx#/slide-1• Hattori, E. et al. (2003). Polymorphisms at the G72/G30 gene locus, on L13q33, are associated with bipolar disorder
in two independent pedigree series. American Journal of Human Genetics, 72(5), 1131-1140. • National Alliance on Mental Illnesses. Bipolar Disorder FACT SHEET. Retrieved 11/13/13 from
http://www.nami.org/factsheets/bipolardisorder_factsheet.pdf• National Institute for Mental Health. National Institutes for Health. (2005). Bipolar disorder among adults.
Retrieved 11/13/13 from http://www.nimh.nih.gov/statistics/1bipolar_adult.shtml• National Institute for Mental Health. National Institutes for Health. (2006). Retrieved 11/8/13 from
http://www.nimh.nih.gov/news/science-news/2006/early-findings-from-largest-nimh-funded-research-program-on-bipolar-disorder-begin-to-build-evidence-base-on-best-treatment-options.shtml
• National Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
• Snow, D. (2009). Bipolar lecture. University of Texas at Arlington College of Nursing. • Sprooten, E. et al. (2013). Reduced white matter integrity in sibling pairs discordant for bipolar disorder. Am J
Psychiatry 2013;170:1317-1325.• Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical
Approach. St. Louis, MO. Saunders. 359-393.