The Painted Ponies: Introduction to Bipolar Disorder

The Painted Ponies:
Bipolar Disorder in Children and Adolescents
Diagnosis and treatment, including sandplay, play therapy, family therapy, medication and psychoeducation

by
Kate Amatruda MFT, CST-T

This course meets the qualifications for 5 hours of continuing education

By the time Sophie was 10, she had been kicked out of seven schools and seen four therapists. Her family suffered as she struggled with temper tantrums, mood swings, night terrors, oppositional behavior, social problems, and psychotic episodes. One week after her 11th birthday Sophie attempted suicide.

Gary was the "teenager from hell", according to his family. His rages had escalated to the point at which the police were frequently called. Was Gary bipolar, an addict, or just out-of-control?

This course will follow the treatment of Sophie and Gary 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 and adolescents with this illness, as well as their families.

Different treatment options based upon the client, such as play therapy, supportive therapy, family therapy, psychoeducation, medication will be discussed.

Differential diagnosis, medication, heredity, countertransference , nature and nurture, body and soul and the importance of acknowledging the wholeness in each other will be explored in the cases presented and in the links.

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.

DSM-IV Criteria for Bipolar Disorder

Bipolar I Disorder
Bipolar II Disorder
Major Depressive Episode
Manic Episode
Mixed Episode
Hypomanic Episode

Bipolar I Disorder
Diagnostic Features (DSM-IV, p. 350)
The essential feature of Bipolar I Disorder is a clinical course that is characterized by the occurrence of one or more Manic Episodes or Mixed Episodes. Often individuals have also had one or more Major Depressive
Episodes. Episodes of Substance-Induced Mood Disorder (due to the direct effects of a medication, or other somatic treatments for depression, a drug of abuse, or toxin exposure) or of Mood Disorder Due to a General
Medical Condition do not count toward a diagnosis of Bipolar I Disorder. In addition, the episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. . . .

Bipolar II Disorder
Diagnostic Features (DSM-IV, p. 359)
The essential feature of Bipolar II Disorder is a clinical course that is characterized by the occurrence of one or more Major Depressive Episodes accompanied by at least one Hypomanic Episode. Hypomanic Episodes
should not be confused with the several days of euthymia that may follow remission of a Major Depressive Episode. Episodes of Substance- Induced Mood Disorder (due to the direct effects of a medication, or other somatic treatments for depression, a drug of abuse, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Bipolar I Disorder. In addition, the episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. . . .

Criteria for Major Depressive Episode (DSM-IV, p. 327)
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent
delusions or hallucinations.

1.depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels
sad or empty) or observation made by others (e.g. appears tearful). Note: In children and adolescents,
can be irritable mood.
2.markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
(as indicated by either subjective account or observation made by others)
3.significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in
a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to
make expected weight gains.
4.insomnia or hypersomnia nearly every day
5.psychomotor agitation or retardation nearly every day (observable by others, not merely subjective
feelings of restlessness or being slowed down)
6.fatigue or loss of energy nearly every day
7.feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day
(not merely self-reproach or guilt about being sick)
8.diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective
account or as observed by others)
9.recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or
a suicide attempt or a specific plan for committing suicide

B. The symptoms do not meet criteria for a Mixed Episode.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Criteria for Manic Episode (DSM-IV, p. 332)
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

1.inflated self-esteem or grandiosity
2.decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3.more talkative than usual or pressure to keep talking
4.flight of ideas or subjective experience that thoughts are racing
5.distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6.increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7.excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g.,
engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The symptoms do not meet criteria for a Mixed Episode.

D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatments) or a general medical condition (e.g., hyperthyroidism).
Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

Criteria for Mixed Episode (DSM-IV, p. 335)
A. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.

B. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Criteria for Hypomanic Episode (DSM-IV, p. 338)
A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.

B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

1.inflated self-esteem or grandiosity
2.decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3.more talkative than usual or pressure to keep talking
4.flight of ideas or subjective experience that thoughts are racing
5.distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6.increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7.excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g.,
engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.

D. The disturbance in mood and the change in functioning are observable by others.

E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.

F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder.

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:

Grandiosity

suicidal gesture,

irritability,

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 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 and adolescents with this illness, as well as their families.

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