Bipolar Disorder in Children

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Bipolar Disorder

  

Bipolar I disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in a person's mood, energy, and ability to function. Different from the normal ups and downs that everyone goes through, the symptoms of bipolar disorder are severe. They can result in damaged relationships, poor job or school performance, and even suicide. But there is good news: bipolar disorder can be treated, and people with this illness can lead full and productive lives.

About 1.2 percent of the population age 18 and older in any given year, have bipolar I disorder. (Another 1.5% of the population have the less severe forms of bipolar disorder, called bipolar II disorder and cyclothymia.) Bipolar disorders typically develop in late adolescence or early adulthood. However, some people have their first symptoms during childhood, and some develop them late in life. These disorders are often not recognized as illness, and people may suffer for years before being properly diagnosed and treated. Like diabetes or heart disease, bipolar disorders are long-term illnesses that must be carefully managed throughout a person's life.

"Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live. It is an illness that is biological in its origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering and, not infrequently, suicide.

Kay Redfield Jamison, Ph.D., An Unquiet Mind, 1995

What Are the Symptoms of Bipolar I Disorder?

  

Bipolar I disorder causes dramatic mood swings—from overly "high" and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. The periods of highs and lows are called episodes of mania and depression.

Signs and symptoms of mania (or a manic episode) include:

  • Increased      energy, activity, and restlessness 
  • Excessively      "high," overly good, euphoric mood 
  • Extreme      irritability 
  • Racing      thoughts and talking very fast, jumping from one idea to another 
  • Distractibility,      can't concentrate well 
  • Little      sleep needed 
  • Unrealistic      beliefs in one's abilities and powers 
  • Poor      judgment 
  • Spending      sprees 
  • A      lasting period of behavior that is different from usual 
  • Increased      sexual drive 
  • Abuse      of drugs, particularly cocaine, alcohol, and sleeping medications 
  • Provocative,      intrusive, or aggressive behavior 
  • Denial      that anything is wrong 

A manic episode is diagnosed if elevated mood occurs with 3 or more of the other symptoms most of the day, nearly every day, for 1 week or longer. If the mood is irritable, 4 additional symptoms must be present.

Signs and symptoms of depression (or a depressive episode) include:

  • Lasting      sad, anxious, or empty mood 
  • Feelings      of hopelessness or pessimism 
  • Feelings      of guilt, worthlessness, or helplessness 
  • Loss      of interest or pleasure in activities once enjoyed, including sex 
  • Decreased      energy, a feeling of fatigue or of being "slowed down" 
  • Difficulty      concentrating, remembering, making decisions 
  • Restlessness      or irritability 
  • Sleeping      too much, or can't sleep 
  • Change      in appetite and/or unintended weight loss or gain 
  • Chronic      pain or other persistent bodily symptoms that are not caused by physical      illness or injury 
  • Thoughts      of death or suicide, or suicide attempts 

  

A depressive episode is diagnosed if 5 or more of these symptoms last most of the day, nearly every day, for a period of 2 weeks or longer.

A mild to moderate level of mania is called hypomania. Hypomania may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. Thus even when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything is wrong. Without proper treatment, however, hypomania can become severe mania in some people or can switch into depression. If a person has episodes of hypomania and episodes of depression with no episodes of mania, they have bipolar II Disorder. A person who experiences exaggerated mood swings without episodes of mania or severe depression has cyclothymia.

Sometimes, severe episodes of mania or depression include symptoms of psychosis (or psychotic symptoms). Common psychotic symptoms are hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person's usual cultural concepts). Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time. For example, delusions of grandiosity, such as believing one is the President or has special powers or wealth, may occur during mania; delusions of guilt or worthlessness, such as believing that one is ruined and penniless or has committed some terrible crime, may appear during depression. People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia, another severe mental illness.


  

In some people symptoms of mania and depression may occur together in what is called a mixed bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling extremely energized.

Bipolar disorder may appear as a problem other than mental illness—for instance, alcohol or drug abuse, poor school or work performance, or strained interpersonal relationships. Such problems in fact may be signs of an underlying mood disorder. 

Descriptions offered by people with bipolar disorder give valuable insights into the various mood states associated with the illness: 

Depression: I doubt completely my ability to do anything well. It seems as though my mind has slowed down and burned out to the point of being virtually useless…. [I am] haunt[ed]… with the total, the desperate hopelessness of it all…. Others say, "It's only temporary, it will pass, you will get over it," but of course they haven't any idea of how I feel, although they are certain they do. If I can't feel, move, think or care, then what on earth is the point?

Hypomania: At first when I'm high, it's tremendous… ideas are fast… like shooting stars you follow until brighter ones appear…. All shyness disappears, the right words and gestures are suddenly there… uninteresting people, things become intensely interesting. Sensuality is pervasive; the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria… you can do anything… but, somewhere this changes.

Mania: The fast ideas become too fast and there are far too many… overwhelming confusion replaces clarity… you stop keeping up with it—memory goes. Infectious humor ceases to amuse. Your friends become frightened…. everything is now against the grain… you are irritable, angry, frightened, uncontrollable, and trapped.

Suicide

Some people with bipolar disorder become suicidal. Anyone who is thinking about committing suicide needs immediate attention, preferably from a mental health professional or a physician. Anyone who talks about suicide should be taken seriously. Risk for suicide appears to be higher earlier in the course of the illness. Therefore, recognizing bipolar disorder early and learning how best to manage it may decrease the risk of death by suicide.

Signs and symptoms that may accompany suicidal feelings include:

  • talking      about feeling suicidal or wanting to die 
  • feeling      hopeless, that nothing will ever change or get better 
  • feeling      helpless, that nothing one does makes any difference 
  • feeling      like a burden to family and friends 
  • abusing      alcohol or drugs 
  • putting      affairs in order (e.g., organizing finances or giving away possessions to      prepare for one's death) 
  • writing      a suicide note 
  • putting      oneself in harm's way, or in situations where there is a danger of being      killed.

   

If you are feeling suicidal or know someone who is:

  • call a doctor, emergency room, or 911 right away to get immediate help 
  • make sure you, or the suicidal person, are not left alone 
  • make sure that access is prevented to large amounts of medication, weapons, or other items that could be used for self-harm 

While some suicide attempts are carefully planned over time, others are impulsive acts that have not been well thought out; thus, the final point in the box above may be a valuable long-term strategy for people with bipolar disorder. Either way, it is important to understand that suicidal feelings and actions are symptoms of an illness that can be treated. With proper treatment, suicidal feelings can be overcome.


  

What Is the Course of Bipolar Disorder?

Episodes of mania and depression typically recur across the life span. Between episodes, most people with bipolar disorder are free of symptoms, but as many as one-third of people have some residual symptoms. A small percentage of people experience chronic unremitting symptoms despite treatment.

The classic form of the illness, which involves recurrent episodes of mania and depression, is called bipolar I disorder. Some people, however, never develop severe mania but instead experience milder episodes of hypomania that alternate with depression; this form of the illness is called bipolar II disorder. When 4 or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycling tends to develop later in the course of illness and is more common among women than among men.

People with bipolar disorder can lead healthy and productive lives when the illness is effectively treated. Without treatment, however, the natural course of bipolar disorder tends to worsen. Over time a person may suffer more frequent (more rapid-cycling) and more severe manic and depressive episodes than those experienced when the illness first appeared. But in most cases, proper treatment can help reduce the frequency and severity of episodes and can help people with bipolar disorder maintain good quality of life.

Can Children and Adolescents Have Bipolar Disorder?

Both children and adolescents can develop bipolar disorder. It is more likely to affect the children of parents who have the illness.

Unlike many adults with bipolar disorder, whose episodes tend to be more clearly defined, children and young adolescents with the illness often experience very fast mood swings between depression and mania many times within a day. Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated. Mixed symptoms also are common in youths with bipolar disorder. Older adolescents who develop the illness may have more classic, adult-type episodes and symptoms.

Bipolar disorder in children and adolescents can be hard to tell apart from other problems that may occur in these age groups. For example, while irritability and aggressiveness can indicate bipolar disorder, they also can be symptoms of attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, or other types of mental disorders more common among adults such as major depression or schizophrenia. Drug abuse also may lead to such symptoms.

For any illness, however, effective treatment depends on appropriate diagnosis. Children or adolescents with emotional and behavioral symptoms should be carefully evaluated by a mental health professional. Any child or adolescent who has suicidal feelings, talks about suicide, or attempts suicide should be taken seriously and should receive immediate help from a mental health specialist.

What Causes Bipolar Disorder?

Most scientists now agree that there is no single cause for bipolar disorder—rather, many factors act together to produce the illness. Bipolar disorder tends to run in families. If you have bipolar disorder and your spouse does not there is a 1 in 7 chance that your child will develop it.

How Is Bipolar Disorder Treated?

Most people with bipolar disorder—even those with the most severe forms—can achieve substantial stabilization of their mood swings and related symptoms with proper treatment. Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. A strategy that combines medication and psychosocial treatment is optimal for managing the disorder over time.

In most cases, bipolar disorder is much better controlled if treatment is continuous than if it is on and off. But even when there are no breaks in treatment, mood changes can occur and should be reported immediately to your doctor. The doctor may be able to prevent a full-blown episode by making adjustments to the treatment plan. Working closely with the doctor and communicating openly about treatment concerns and options can make a difference in treatment effectiveness.

In addition, keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events may help people with bipolar disorder and their families to better understand the illness. This chart also can help the doctor track and treat the illness most effectively.

Medications

Medications for bipolar disorder are prescribed by medical doctors with expertise in the diagnosis and treatment of mental disorders. .

Medications known as mood stabilizers usually are prescribed to help control bipolar disorder. Several different types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for extended periods of time (years). Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression that break through despite the mood stabilizer.

  • Lithium,      the first mood-stabilizing medication approved by the U.S. Food and Drug      Administration (FDA) for treatment of mania, is often very effective in      controlling mania and preventing the recurrence of both manic and      depressive episodes. 
  • Anticonvulsant      medications, such as valproate (Depakote®) or carbamazepine      (Tegretol®), also can have mood-stabilizing effects and may be      especially useful for difficult-to-treat bipolar episodes. Valproate was      FDA-approved in 1995 for treatment of mania. 
  • Newer      anticonvulsant medications, including lamotrigine (Lamictal®),      gabapentin (Neurontin®), and topiramate (Topamax®),      are also used as mood stabilizers. 
  • Anticonvulsant      medications may be combined with lithium, or with each other.
  • Children      and adolescents with bipolar disorder generally are treated with lithium,      but valproate and carbamazepine also are used. 
  • Women      with bipolar disorder who wish to conceive, or who become pregnant, face      special challenges due to the possible harmful effects of existing mood      stabilizing medications on the developing fetus and the nursing infant.      Therefore, the benefits and risks of all available treatment options      should be considered. 
  • Atypical      antipsychotic medications, including clozapine (Clozaril®),      olanzapine (Zyprexa®), risperidone (Risperdal®), and      ziprasidone (Geodon®), are other possible treatments for      bipolar disorder. Evidence suggests clozapine may be helpful as a mood      stabilizer for people who do not respond to lithium or anticonvulsants. Other research has      supported the efficacy of olanzapine for acute mania, an indication that      has recently received FDA approval. Olanzapine may also help relieve psychotic depression.
  • If      insomnia is a problem, a high-potency benzodiazepine medication such as      clonazepam (Klonopin®) or lorazepam (Ativan®) may be      helpful to promote better sleep. However, since these medications may be      habit-forming, they are best prescribed on a short-term basis. Zolpidem      (Ambien®) is sometimes used instead.
  • Although  mood stabilizers by themselves, especially lithium, sometime treat or      prevent depressive episodes, specific antidepressant medication may be      needed. If given alone, antidepressants can sometimes cause hypomania,      mania, or even rapid cycling. Therefore antidepressants are always given      together with a mood stabilizer. Antidepressants usually take several weeks to begin showing full      effects. Although the first drug tried will work for the majority of      patients, it is common to go through two or three trials of      antidepressants. While waiting for      the antidepressant to work, a sedating medication to help with sleep, anxiety,      or agitation may be used. Antidepressant      medications used in the treatment of depressive episodes include Bupropion      (Wellbutrin); selective serotonin reuptake inhibitors: fluoxetine      (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft);      mirtazapine (Remeron); nefazodone (Serzone); venlafaxine (Effexor); and      monoamine oxidase inhibitors: phenelzine (Nardil), tranylcypromine      (Parnate). Tricyclic      antidepressants: amitriptyline (Elavil), desipramine (Norpramin,      Pertofrane), imipramine (Tofranil), nortriptyline (Pamelor) are more      likely to cause side effects, set off manic episodes or rapid cycling and      are not recommended.
  • Changes to the treatment plan may be needed at various times during the course of bipolar disorder to manage the illness most effectively. A physician should guide any changes in type or dose of medication. 



Learn More

  

  • Be  sure to tell your physician about all other prescription drugs,      over-the-counter medications, or natural supplements you may be taking.      
  • This is important because certain medications and supplements taken      together may cause adverse reactions.


  • To reduce the chance of relapse or of developing a new episode, it is      important to stick to the treatment plan. Talk to your doctor if you have      any concerns about the medications.