Table of Contents
1. Bipolar Disorder: Prevalence and history
a. Mood disorders
i.warning signs & signals
i.Grandiosity & fixations
3. Co-morbidity & Misdiagnosis
a. Attention Deficit/Hyperactivity Disorder
b. Oppositional Defiant Disorder
c. Conduct Disorder
d. Obsessive Compulsive Disorder
a. Substance abuse
b. Post Traumatic Stress Disorder
b. Mood stabilizers
c. Atypical antipsychotics
6. Sleep disturbance
7. Natural Supplements
8. Diet & exercise
9. Bipolar proofing
10. Therapy & alternatives
11. Family Life 20
a. Appendix A: Diagnosis
b. Appendix B: Medical conditions
Bipolar Disorder: prevalence and history
Bipolar Disorder, formerly known as manic depressive illness, is an affective disorder that is characterized by periods of mania alternating with periods of depression; these are usually interspersed with relatively long intervals of normal mood. It is interesting to note that this disorder has been shown to be one of the commonest disorders but has only recently been given its own classification, having previously been confused with many other disorders.
In the 1998 American census it was discovered that 20% of the adult population, some 44.3 million, had a mental-health issue. In addition to this, 20% of the children had also been diagnosed with a behavioural or emotional issue; this equates to between 7.7 and 12.8 million children (Stillman, 2005). Bipolar Disorder is believed to affect around 2.3 million adults in America and a conservative estimate of a million children. In Sue, Sue & Sue (1997) the prevalence of bipolar disorder is placed at around 1% of the adult population while 8-17% have experienced some form of major depressive episode.
Bipolar disorder seems to be rare in children but there have been documented cases of children as young as four years old displaying the symptoms (Poznanski, Israel, & Grossman, 1984). It is interesting to note here that Taylor & Abrams (1981) suggest that about a third of all bipolar cases begin during adolescence, adding value to the focus of bipolar disorder in childhood. Papolos & Papolos (2006) add that an estimated third of all children who have been diagnosed with attention-deficit disorder with hyperactivity (ADHD) have been misdiagnosed and are actually suffering from a mood disorder. The American Academy of Child and Adolescent Psychiatry suggest that a third of the 3.4 million children who appear to be suffering from depression will progress to the bipolar form of a mood disorder.
While most investigators agree that mood disorders are fundamentally similar in children and in adults (Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993), Papolos & Papolos suggest that children have a more “chronic course of illness” than their adult counterparts and cycle between mania and depression with relatively few periods or normal mood (2006, p. 6). Barlow & Durand give an apt description of bipolar disorder as “the tendency of manic episodes to alternate with major depressive episodes in an unending roller-coaster ride from the peaks of elation to the depths of despair”, and while this has a humorous tone, it is indicative of the cyclical nature of this disorder (2005, p. 212). While adults seem to be riding a roller-coaster at a snail’s pace, children seem to be riding it in fast forward.
As far back as the second century A.D., Aretaeus of Cappadocia, a Greek physician, was one of the first to identify the symptoms associated with bipolar disorder (Stillman, 2005). He noticed that his patients were dull or stern; dejected or unreasonably sluggish, without a noticeable cause. At the time there was no apparent way to substantiate his claims and his work went relatively unnoticed until cited by the scientist Richard Burton in 1650, when Burton referred to Aretaeus’s work in his book The Anatomy of Melancholia.
It was not until 1854 that the term ‘bipolar’ made its appearance, when Jean Pierre Falret, a French doctor, noticed periods of depression alternating with periods of elation in his patients. Falret documented his work in 1875 for the first time and used the term “manic-depressive psychosis” to explain his findings. In addition to coining the term, he also noticed that families seemed to manifest similar symptoms. However, it was only in 1952 that an article appearing in The Journal of Nervous and Mental Disorder showed a prevalence of manic-depression in families. Subsequent to the work of Falret, Kraepelin’s Psychiatry: a textbook published in 1913 also referred to bipolar disorder as manic depressive psychosis (Barlow & Durand, 2005).
Bipolar disorder in children is believed to be more prevalent than previously stated, partially due to the fact that is has relatively recently been accepted as a legitimate diagnosis in children (Stillman, 2005). While the DSM-IV (Diagnostic Manual of Mental Disorders) gives clear guidelines for the diagnosis of bipolar disorder, it is unfortunate that there is little distinction between criteria relative to the age of the patient in therapy. Simply put, it is an impractical guideline for children experiencing symptoms of bipolar disorder. A more appropriate definition for the diagnosis of juvenile-onset bipolar disorder is outlined in Papolos & Papolos (2006), and has been reproduced in Appendix A. While it is a significantly lengthy guide, it is both thorough and age appropriate.
Bipolar disorder is part of the category of mood disorders. These mood disorders are divided into two major categories, those of depressive disorders (often referred to as unipolar disorder) and bipolar disorder (Sue, Sue & Sue, 1997). The category depressive disorders can be sub-divided into depressive disorders, mood disorder due to a general medical condition and substance-induced mood disorder.
The bipolar disorder category is comprised of the following sub-categories:
- Bipolar I disorder
- Bipolar II disorder
- Cyclothymic disorder
- Bipolar disorder NOS (not otherwise specified)
Bipolar disorder is found to have two mood components, depressive episodes and manic episodes, and the different forms of bipolar disorder are caused by different combinations of depression and mania.
Bipolar I disorder is diagnosed in children who have at least one manic episode or mixed episode. These manic episodes can be of a single nature, most recent episode hypomanic, most recent episode manic, most recent episode mixed, most recent episode depressed or most recent episode unspecified (Sue, Sue & Sue, 1997).
Bipolar II disorder is diagnosed in children who have at least one major depressive episode with at least one hypomanic episode, but they never experience a manic episode. (If no hypomania is present, the disorder is diagnosed as unipolar).
Cyclothymic disorder is diagnosed when the child experiences many periods of hypomanic symptoms and many periods of depressive symptoms. It is important to note that the hypomania is less persistent than a manic episode and the depressive symptoms less severe than a major depressive episode. Cyclothymic disorder is a milder form of bipolar disorder but it is more chronic in its alternating between moods of elevation and depression (Barlow & Durand, 2005). It is noteworthy that the risk of a child with cyclothymic disorder developing bipolar disorder is 15 to 50 percent (American Psychiatric Association, 1994).
Bipolar disorder NOS is diagnosed in a child who may seem to have bipolar disorder but the symptoms do not meet the clinical criteria for a definitive diagnosis.
It may be of significance that Weissman and colleagues (1991) found that the prevalence rates for bipolar I and II to be 0.8 and 0.5 percent respectively (cited in Sue, Sue & Sue, 1997).
To clarify the plethora of jargon in the previous paragraphs, a brief explanation of some terms follows:
Manic episode is characterized by persistent elevated, expansive or irritable mood, lasting at least one week. The child may be irritable, have an increased need for sleep, and display pressurized speech, racing thoughts, grandiosity, and flight of ideas, distractibility and excessive involvement in potentially dangerous activities. According to Goodwin & Jamison (1990), the child who suffers from manic episodes alone also meets criteria for bipolar mood disorder because experience shows that they are expected to become depressed at a later stage (Barlow & Durand, 2005).
Major depressive episode is characterized by a minimum of five of the following symptoms during any two week period: depressed mood (or irritable mood), loss of pleasure or interest in life, fatigue, insomnia, worthlessness, suicidal ideation, and failure to make significant weight gains.
A mixed episode occurs when criteria for manic episode and a major depressive episode are met within the course of a day or at the outside within a week.
Hypomanic episode is characterized by an elevated, expansive or irritated mood which lasts for at least four days.
While the odd occasions of sleeplessness and mild obsession are relatively normal in all of us, when these conditions continue for at least a week and are more intense than would be deemed ‘normal’, they may be indicative of a manic episode. It is important to note that mania usually follows or precedes a period of depression. In some cases mania may commence in adolescence even though it typically begins with a first episode in the early twenties.
The person experiencing a manic episode may appear to be ‘on-top-of-the-world’ but the mood usually escalates until the person experiences burn-out which may be accompanied by violence or abusive behaviour. During a manic episode, the child may seem particularly jovial, joking and teasing others, accompanied by an abundance of smiles. They may experience grandiosity and feel like they can fly or defeat any opponent; this inflated self-esteem gives them the idea that they are invincible. One of the obvious signs for a parent is a marked decrease in the need for sleep; these children can get by with next to no sleep and still do not feel tired. The manic child may speak incessantly at a superhuman pace, with topics of discussion flitting constantly from one to another with very little or no connection between ideas or thoughts.
The child is liable to lose focus easily and get sidetracked, while appearing ‘hyperactive’ and visibly agitated they will take on a large number of different tasks or projects at the same time. There is also a fear that the child experiencing a manic episode, characterized by an increase in the need for pleasurable activities, may resort to dangerous sexual practices or potentially dangers activities.
It is quite normal for people to experience periods of sadness or a ‘depressed mood’, and these feelings are usually valid, having a trigger, and often lasting for a significant period of time. However when these feelings continue and begin to impact on the quality of life, if they lead the sufferer to feelings of suicide, if they lead to intense anxiety, physical illness, or if the sufferer needs to be hospitalized because of these feelings, it is possible that they are suffering with a major depressive episode.
When five or more of the symptoms listed here last for a two-week period or longer it can be indicative of the disorder. Symptoms include feelings of sadness, irritability and a depressed mood, decreased interest in previously enjoyable activities, a decrease or an increase in consumption of food that leads to noticeable changes in weight, insomnia, psychomotor agitation, fatigue, feelings of worthlessness or guilt, poor concentration, indecisiveness, and recurring thought of death or suicidal ideation possibly leading to suicide attempts.
It is commonly accepted that the environment and life-experiences of a child can trigger the development of a mental-health disorder; it also acknowledged that the genetic make-up of the child predisposes them to increased risk of the development of bipolar disorder.
Papolos & Papolos (2006) purport that the bulk of children who are diagnosed with bipolar disorder before puberty, tend to have a family history of mood disorders and/or alcoholism. “Bilineal transmission” occurs when both the maternal and paternal sides of the family suffer with these disorders; this occurrence increases the child’s susceptibility, noted in over 80 percent of sufferers (p. 153). In addition, 90 percent of people suffering with bipolar disorder have at least one close relative who also suffers with the disorder (Stillman, 2005). While genes are a precipitating factor in bipolar disorder, no specific bipolar genes appear evident; rather genes seem to have been altered or mutated in some manner in bipolar sufferers (Papolos & Papolos, 2006).