Bipolar Disorder in Children, Adolescents and Adults
Introduction to Bipolar Disorder
Sophie was 11 when she started treatment with her fifth psychotherapist. Sophie had tried to kill herself a few days earlier.
Gary, at 17, was raging out-of-control and had been "out-of-control" since birth, according to his exasperated parents.
Eva and her husband Peter had struggled for years to stay married throughout Eva's numerous psychiatric hospitalizations. In spite of years of therapy, Eva was non-compliant in taking the medications which kept her stable.
Sophie, Gary and Eva have all been diagnosed with Bipolar Disorder.
Bipolar Disorder, formerly known as Manic-Depressive Illness is a disease in which wide swings of mood appear; ranging from the deepest depression to flights of mania which can involve taking life-threatening risks. There is now an awareness that children and adolescents can have bipolar disorder. Yet, in that realization, please remember to hold onto the opposite; that not all troubled or raging children and teenagers have bipolar disorder.
Working with people with bipolar disorder offers a rare and compelling insight into biochemistry for the clinician. I feel challenged and invigorated by the exposure to this illness. Often following a night without sleep, it seems that you can feel the brain of someone who is bipolar shift into a manic state.
Sometimes, I even feel somewhat manic-depressive working with this population. When my patients are thriving, I feel good. The first flush of mania is often exhilarating. I can see why people resist the medications that prevent it. Initially, the colors are brighter. People in a manic state do feel more creative, as they are closer to an archetypal state. Left uncontrolled, it does become a terrifying ride: a roller coaster racing into psychotic thinking, grandiosity and irrationality. As a therapist, if you match and mirror your clients energetically, you might experience the true terror of a full blown manic episode. (I know I always feel it in the pit of my stomach.) The depressions are very dark and very deep. They feel like the 'night-sea-journey' without the possibility of daybreak. As someone closely witnessing this, I feel it too.
It is important to remember that this course addresses people with bipolar disorder. They are whole and complete and often wonderful people who have an illness. Please don't ascribe everything they face to their illness. We are all, perhaps, some combination of nature and nurture, body and soul. Let us not forget to acknowledge the wholeness in each other.
Please go to The National Institute of Mental Health (NIMH) for an on-line brochure at http://www.nimh.nih.gov/publicat/bipolar.cfm which describes Bipolar Disorder. (To get back to the course after looking at a link, press the "BACK" button on your browser.) This is a brief overview that is written for the public, rather than professional audience. This is potentially a good handout for your adult clients if they are newly diagnosed.
Differential diagnosis is crucial when dealing with the possibility of bipolar disorder especially when medication may be part of the treatment. Often there is a series of diagnoses, including Depression, Dysthymic Disorder, Cyclothymic Disorder, Schizoaffective Disorder, and often Psychosis for adults. Children often go through the diagnoses of ADHD (attention deficit hyperactivity disorder), OCD (Obsessive-Compulsive Disorder), ODD (Oppositional Defiant Disorder), Tourette's Syndrome, Adjustment Disorder With Disturbance of Conduct, Insomnia and Depression. While all of these diagnoses were no doubt appropriate when given, they often are insufficient to hold the range of the symptoms.
It is important to consult with a physician, to rule out Mood Disorder Due to a General Medical Condition. The DSM-IV specifically mentions the importance of evaluating the patient for the presence of general medical conditions such as cerebral neoplasms, thyroid disease, Cushing's disease, etc. that could mimic bipolar disorder. It is crucial to also assess for comorbid psychiatric conditions including alcohol and substance abuse.
The DSM-IV specifies criteria for 296.0x Bipolar I Disorder (Single Manic episode), with instructions to specify if mixed, and to indicate severity/psychotic/remission specifiers; with catatonic features; or with postpartum onset. There are codes for the current or most recent episode, whether it be depressive, manic, hypomanic, mixed or unspecified. Each of these diagnoses has its own code and specifiers. There are also codes to indicate the pattern and frequency of the episodes. The first three digits are 296, with the fourth and fifth digit changing depending on the specifiers. 296.89 is the code for Bipolar II Disorder (Recurrent Major Depressive Episodes With Hypomanic Episodes). Surprisingly, there is little mention of a pediatric bipolar diagnosis.
Criteria for Bipolar Disorder
Bipolar I Disorder
Bipolar II Disorder
Major Depressive Episode (DSM-IV, p. 327)
Manic Episode (DSM-IV, p. 332)
Mixed Episode (DSM-IV, p. 335)
Hypomanic Episode (DSM-IV, p. 338)
The idea that children can have bipolar disorder is fairly recent. A word of caution is perhaps unnecessary; but, as a profession I believe we must be very careful in our differential diagnoses. It may be that the bipolar diagnosis in childhood will become the new, 'in' thing to explain many children's behavior. (In the past few months, I have heard more about children who might be bipolar than in my previous 25 years in the field.) While bipolar children may have been under-diagnosed in the past, we should be vigilant about over-diagnosing this condition.
According to Emily L. Fergus, in a study quoted in Clinical Psychiatry News 27(8):8, 1999, there are five 'red flag' symptoms for bipolar disorder in children and adolescents. These symptoms, appearing together, have predicted bipolar disorder in 91% of the children surveyed:
decreased attention span,
and racing thoughts.
Sadly, there is usually a ten year lag between the symptoms occurrence and a diagnosis of bipolar disorder.
This course will follow the treatment of Sophie, Gary, Eva and their families and look at how the assessment of bipolar disorder was made. We will explore how bipolar disorder impacts the lives of children, adolescents and adults with this illness, as well as their families.
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