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Contact Steven R. Fricke |
An Informational Guide for Patients and Families |
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Severe changes in mood that seem excessively good, euphoric, or overly silly and elated |
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Sudden irritability, rage or paranoia |
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Needing little sleep yet having great amounts of increased energy |
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Increased talking—talks too much, too fast; changes topics too quickly; cannot be interrupted |
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Having an inflated feeling of power, greatness, or importance, extremely high self-esteem |
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Disregard of risk—excessive involvement in risky behaviors or activities without concern about possible bad consequences |
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Hyperactivity or physical agitation |
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Distractibility—attention moves constantly from one thing to the next |
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A milder form of mania with similar but less severe symptoms and less impairment |
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May have an elevated mood, feel better than usual, and be more productive, but does not severely impair functioning and generally does not require hospitalization |
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Feeling sad, blue, or down in the dumps, unexplained crying spells, or losing interest in things you normally enjoy |
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insomnia, excessive sleeping, or shallow sleep with frequent awakenings |
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Significant loss of appetite or eating too much |
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Problems concentrating or making decisions |
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Feeling slowed down or feeling too agitated to sit still |
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Feeling worthless or guilty or having very low self-esteem |
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Loss of energy or feeling tired all of the time |
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Aches and pains, constipation, or other physical ailments that cannot be otherwise explained. |
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Recurrent thoughts of suicide or death. |
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Severe depressions may also include hallucinations or delusions |
Episodes that involve symptoms of both mania and depression occurring at the same time or alternating frequently during the day. Individuals are excitable or agitated as in mania but also feel irritable and depressed, instead of feeling on top of the world.
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Bipolar I Disorder -characterized by manic or mixed episodes and almost always has depressions |
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Bipolar II Disorder - characterized by only hypomanic and depressive episodes, not full manic or mixed episodes. This type is often hard to recognize because hypomania may seem "supernormal," especially if the person feels happy, has lots of energy, and avoids getting into serious trouble |
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Rapid Cycling Bipolar Disorder - diagnosed by having at least four episodes per year, in any combination of manic, hypomanic, mixed, or depressive episodes |
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Schizoaffective Disorder - in addition to mania or depression, there are persistent hallucinations or delusions during times when mood symptoms are under control |
Symptoms of mania and depression in children and adolescents may be seen through a variety of different behaviors. When manic, children and adolescents, in contrast to adults, are more likely to be irritable and prone to destructive outbursts than to be elated or euphoric. When depressed, there may be many physical complaints such as headaches, muscle aches, stomachaches or tiredness, frequent absences from school or poor performance in school, talk of or efforts to run away from home, irritability, complaining, unexplained crying, social isolation, poor communication, and extreme sensitivity to rejection or failure. Other results of manic and depressive states may include alcohol or substance abuse and difficulty with relationships.
When the illness begins before or soon after puberty, it is often characterized by symptoms that resemble certain disruptive behavior disorders, especially attention deficit hyperactivity disorder (ADHD) or conduct disorder (CD. In contrast, later adolescent- or adult-onset bipolar disorder tends to begin suddenly, often with a classic manic episode. If a child or adolescent appears to be depressed and exhibits ADHD-like symptoms that are very severe, with excessive temper outbursts and mood changes, they should be evaluated by a psychiatrist or psychologist with experience in bipolar disorder, particularly if there is a family history of the illness.
A family history of manic-depressive illness may make a physician suspicious, but a diagnosis of bipolar disorder cannot be established until a manic episode has occurred. The American Psychiatric Association has established the following criteria for recognizing this phase of bipolar disorder:
· A distinct period of abnormally and persistently elevated, expansive, or irritable mood.
· During the mood disturbance, at least three of the mania symptoms must also occur (four, if the primary mood disturbance is irritability)
It is important; however, not to confuse bipolar disorder with other conditions that may be causing symptoms of mania. Thyroid disorders may cause mood swings, as can adrenal disorders (e.g., Addison's disease and Cushing's syndrome), vitamin B12 deficiency, certain neurologic disorders (e.g., Huntington's disease, epilepsy, brain tumors, encephalitis, multiple sclerosis), and various medications, including some drugs used to treat anxiety, Parkinson's disease, and depression. Severe manic episodes with delusions and hallucinations may be easily confused with schizophrenia.
Current research is seeking to discover factors in the blood that might help diagnose bipolar disorder and determine the effectiveness of treatment. Such tests would be particularly helpful in differentiating Attention Deficit-Hyperactivity Disorder (ADHD) from bipolar disorder in young people. High levels of factors known as G proteins have been detected in bipolar patients, but studies have been contradictory, and there is no evidence yet that can be reliably used for diagnostic purposes.
The major goals of treatment are to reduce the frequency, severity, and social and psychological consequences of bipolar episodes and to help the patient function as effectively as possible between episodes.
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Acute treatment phase - Treatment is aimed at ending the current manic, hypomanic, depressive, or mixed episode |
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Preventive treatment - Medication is continued on a long-term basis to prevent future episodes |
Medication: The two most important types of medication used to control the symptoms of bipolar disorder are mood stabilizers and antidepressants or antianxiety drugs. (Should not be used during pregnancy.)
Three mood stabilizers that are widely used in the United States:
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Lithium carbonate (Eskalith, Lithobid, Lithonate, and other brands) |
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Valproate (most commonly used as divalproex [Depakote]) |
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Carbamazepine (Tegretol). |
Education: It is crucial that individuals and families be informed about all aspects of the disorder and learn how to best manage and prevent its complications.
Psychotherapy: Used in combination with medications can helpful for many individuals and families in solving problems and dealing with stress. Psychotherapy can be individual, group, or family. Types of psychotherapy that appear to be particularly useful:
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Behavioral therapy - focusing on behaviors related to stress management, sleep management, and ways to increase pleasurable experiences that may help improve depressive symptoms |
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Cognitive therapy - focusing on identifying and changing the pessimistic thoughts and beliefs that can lead to depression |
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Interpersonal therapy - focusing on reducing the strain that a mood disorder may place on relationships |
Even when a child's behavior is unquestionably not normal, correct diagnosis remains challenging. Bipolar disorder is often accompanied by symptoms of other psychiatric disorders. In some children, proper treatment for the bipolar disorder clears up the troublesome symptoms thought to indicate another diagnosis. In other children, bipolar disorder may explain only part of a more complicated case that includes neurological, developmental, and other components.
Diagnoses that mask or sometimes occur along 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) |
| intermittent explosive disorder |
| reactive attachment disorder (RAD) |
In adolescents, bipolar disorder is often misdiagnosed as:
| borderline personality disorder |
| post-traumatic stress disorder (PTSD) |
| schizophrenia |
Tragically, after symptoms first appear in children, years often pass before treatment begins, if ever. Meanwhile, the disorder worsens and the child's functioning at home, school, and in the community is progressively more impaired.
The importance of proper diagnosis cannot be overstated. The results of untreated or improperly treated bipolar disorder can include:
| an unnecessary increase in symptomatic behaviors leading to removal from school, placement in a residential treatment center, hospitalization in a psychiatric hospital, or incarceration in the juvenile justice system |
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the development of personality disorders such as narcissistic, antisocial, and borderline personality |
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a worsening of the disorder due to incorrect medications |
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drug abuse, accidents, and suicide. |
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preschool special education testing and services |
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small class size (with children of similar intelligence) or self-contained classroom with other emotionally fragile (not "behavior disorder") children for part or all of the day |
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one-on-one or shared special education aide to assist child in class |
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back-and-forth notebook between home and school to assist communication |
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homework reduced or excused and deadlines extended when energy is low |
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late start to school day if fatigued in morning |
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recorded books as alternative to self-reading when concentration is low |
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designation of a "safe place" at school where child can retreat when overwhelmed |
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designation of a staff member to whom the child can go as needed |
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unlimited access to bathroom |
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unlimited access to drinking water |
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art therapy and music therapy |
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extended time on tests |
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use of calculator for math |
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extra set of books at home |
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use of keyboard or dictation for writing assignments |
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regular sessions with a social worker or school psychologist |
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social skills groups and peer support groups |
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annual in-service training for teachers by child's treatment professionals (sponsored by school) |
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enriched art, music, or other areas of particular strength |
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curriculum that engages creativity and reduces boredom (for highly creative children) |
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tutoring during extended absences |
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goals set each week with rewards for achievement |
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summer services such as day camps and special education summer school |
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placement in a day hospital treatment program for periods of acute illness that can be managed without inpatient hospitalization |
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placement in a therapeutic day school during extended relapses or to provide a period of extra support after hospitalization and before returning to regular school |
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placement in a residential treatment center during extended periods of illness if a therapeutic day school near the family's home is not available or is unable to meet the child's needs |
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Facts About Childhood-Onset Bipolar Disorder - National Alliance for the Mentally Ill (NAMI) |
| Bipolar Affective Disorder (Manic Depressive disorder) in Children and Adolescents - by James Chandler, MD, FRCPC |
| Child and Adolescent Bipolar Disorder: An Update from the National Institute of Mental Health (NIMH) |
