05.Bipolar Disorder / Manic Depression

05.1.What is Bipolar Disorder (Manic Depression)?

Bipolar disorder (manic-depressive illness) is a serious but treatablemedical illness that occurs in all age groups but is most often diagnosed inthe late teens to the early adult years. It is a disorder of the brain markedby changes in mood, energy and behavior that are much more extreme than thenormal ups and downs that most people experience. Symptoms may be present sinceinfancy or early childhood, or may suddenly emerge in adolescence or adulthood.Until recently, a diagnosis of the disorder was rarely made in childhood. Childpsychiatrists can now recognize and treat bipolar disorder in very young children.

 Early intervention and treatment offer the best chance for children withpediatric bipolar disorder to achieve mood stability, gain the best possiblelevel of wellness and develop normally. Proper treatment can minimize theadverse effects of this illness on the lives of these children and theirfamilies.

05.2.Helping a Child with Bipolar Disorder

Parents concerned about their child's behavior, especially frequent,severe mood swings, depression, periods of "hyperactivity"accompanied by decreased need for sleep and hypersexuality, should have thechild evaluated by a board-certified child and adolescent psychiatrist familiarwith the symptoms and treatment of pediatric bipolar disorders. There is noblood test, genetic test or brain scan that can establish a diagnosis ofbipolar disorder.

05.3.Incidence of Bipolar Disorder in Children and Adolescents

According to the National Institute of Mental Health, community studiesestimate the lifetime prevalence of bipolar disorder for adolescents rangesfrom 0 to 3% of the population. Prevalence of bipolar disorder during childhoodis not well established. It is thought that a significant number of childrendiagnosed in the United States with attention-deficit disorder withhyperactivity (ADHD) have early-onset bipolar disorder instead of, or alongwith, ADHD.

05.4.Signs andSymptoms in Children

Bipolar disorder involves marked changes in mood and energy. In mostadults with the illness, ongoing states of extreme elation or agitationaccompanied by high energy are called mania. Ongoing states of extreme sadnessor irritability and low energy are called depression.

However, the illness can look different in children than it does inadults. Children often have an ongoing, continuous mood disturbance that is amix of mania and depression. This rapid and severe cycling between moodsproduces chronic irritability and few clear periods of wellness betweenepisodes. Children with bipolar disorder typically have 4-5 severe mood swingsa day and are more irritable than euphoric.

Symptoms mayinclude:

 An expansive or irritable mood

Depression

Rapidly changing moods lasting minutes to hours

Explosive, lengthy and often destructive rages

Sleeping little or sleeping too much

Excessive involvement in multiple projects and activities

Impaired judgment, impulsivity, racing thoughts and pressured speech

Inappropriate or precocious sexual behavior

Grandiose belief in own abilities that defy the laws of logic (ability tofly, for example)

05.5.Signs and Symptoms in Adolescents

In adolescents, bipolar disorder may resemble any of the followingclassical adult presentations of the illness.

05.6.Bipolar I

In this form of the disorder, the adolescent experiences alternatingepisodes of intense and sometimes psychotic mania and depression.

 Symptoms of mania include:

Elevated, expansive or irritable mood

Decreased need for sleep

Racing speech and pressure to keep talking

Grandiose delusions

Excessive involvement in pleasurable but risky activities

Increased physical and mental activity

Poor judgment

In severe cases, hallucinations

Symptoms of depression include:

Pervasive sadness and crying spells

Sleeping too much or inability to sleep

Agitation and irritability

Withdrawal from activities formerly enjoyed

Drop in grades and inability to concentrate

Thoughts of death and suicide

Low energy

Significant change in appetite

Periods of relative or complete wellness occur between the episodes.

05.7.Bipolar II

In this form of the disorder, the adolescent experiences episodes ofhypomania between recurrent periods of depression. Hypomania is a markedlyelevated or irritable mood accompanied by increased physical and mental energythat last three to four days. Bipolar II disorder is five to 10 times morecommon than Bipolar I disorder.

05.7.1.Cyclothymia

Adolescents with this form of the disorder experience periods of lesssevere, but definite, mood swings between mild euphoria and depression thatlast a year or more.

05.7.2.Bipolar Disorder NOS (Not Otherwise Specified)

Significant mood symptoms suggestive of bipolar I, II or cyclothymia butnot sufficient duration or severity to meet criteria for these disorders.

For some adolescents, a loss or other traumatic event may trigger a firstepisode of depression or mania. Later episodes may occur without any obviousstresses, or may worsen with stress. Puberty is a time of risk. In girls, theonset of menses may trigger the illness, and symptoms often vary in severitywith the monthly cycle.

05.8.Substance Abuse and Addiction

Many teens with untreated bipolar disorder abuse alcohol and drugs. Anychild or adolescent who abuses substances should be evaluated for a mooddisorder.

 Adolescents who seemed normal until puberty and experience a sudden onsetof symptoms are thought to be especially vulnerable to developing addiction todrugs or alcohol. Substances may be readily available among their peers andteens may use them to attempt to control their mood swings and insomnia. Ifaddiction develops, it is essential to treat both the bipolar disorder and thesubstance abuse at the same time.

05.9.Genetics and Family History

The illness tends to be highly genetic, but there are clearlyenvironmental factors that influence whether the illness will occur in aparticular child. Bipolar disorder can skip generations and take differentforms in different individuals.

 The small group of studies that have been done vary in the estimate ofrisk to a given individual:

 For the general population, a conservative estimate of an individual'srisk of having full-blown bipolar disorder is one percent. Disorders in thebipolar spectrum may affect four to six percent.

When one parent has bipolar disorder, the risk to each child is 15-30percent.

When both parents have bipolar disorder, the risk increases to 50-75percent.

Many children who develop early-onset bipolar disorder have a familyhistory of individuals who suffered from substance abuse and/or mood disorders(often undiagnosed).

05.10.Diagnosis in Children and Adolescents

The importance of proper diagnosis and treatment cannot be overstated. Theresults of untreated or improperly treated bipolar disorder can include:

 An unnecessary increase in symptomatic behaviors leading to removal fromschool

Hospitalization in a psychiatric hospital

A worsening of the disorder due to incorrect medications

Drug abuse, accidents and suicide

It is important to remember that a diagnosis is not a scientific fact - itis based on the behavior of the child over time, what is known of the child'sfamily history, the child's response to medications, and the child’sdevelopmental stage. These factors (and the diagnosis) can change as moreinformation becomes available.

 Competent professionals can disagree on which diagnosis fits an individualbest. Diagnosis is important, however, because it guides treatment decisionsand allows the family to put a name to the condition that affects their child.

 It is important that if you are concerned about your child’s behaviors, donot hesitate to obtain a full psychiatric evaluation. Mental healthprofessionals are available to provide information about diagnosis andtreatment options and to support you as you care for your child.

 While it is difficult to diagnose bipolar disorder in children, somebehaviors by a child should raise a red flag:

 Frequent, severe and prolonged mood swings that continue past the age of 4years

Frequent talk of wanting to die or kill themselves

Trying to jump out of a moving car

Rages lasting for hours

Sexual behavior in the absence of abuse

 05.11.BipolarDisorder Compared to Other Conditions

Correct diagnosis of bipolar disorder remains challenging. Bipolardisorder is often accompanied by symptoms of other psychiatric disorders. Insome children, proper treatment for the bipolar disorder clears up thetroublesome symptoms thought to indicate another diagnosis. In other children,bipolar disorder may explain only part of a more complicated case that includesneurological, developmental and other components.

     Diagnoses that mask or sometimes occur along (comorbid) with bipolar disorder include:

Depression

Conduct disorder (CD)

Oppositional-defiant disorder (ODD)

Attention-deficit disorder with hyperactivity (ADHD)

Panic disorder

Generalized anxiety disorder (GAD)

Obsessive-compulsive disorder (OCD)

Tourette's syndrome (TS)