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Bipolar affective disorder

Bipolar Affective Disorder

Abnormal Psychology

Bi-polar Affective Disorder I, II and Pre-adolescent Onset, Current Review in Diagnosis and Treatment

Bi-polar affective disorder, formerly known as manic-depression is a disorder that is characterized by the occurrence of one or more manic episodes and often one or more major depressive episodes. The DSM-IV has divided bipolar disorder into two types. In bipolar I disorder the person has at least one manic (or mixed) episode and usually but not necessarily, at least one major depressive episode as well. "There are six separate criteria sets for Bipolar I disorder: single manic episode, most recent episode hypomanic, most recent episode manic, most recent episode mixed, most recent episode depressed, and most recent episode unspecified. In bipolar II disorder the person has had at least one major depressive episode and at least one hypomanic episode, but has never met the diagnostic criteria for manic or mixed episode" (DSM IV). Children and adolescents are also diagnosed with bipolar disorder. Although the DSM-IV criterion for bipolar disorder is used, due to the difficulty and difference in their symptoms, bipolar disorder in children will be discussed separately. "There are many people who chronically pass through depressed and expansive periods but whose condition is not severe enough to merit the diagnosis of bipolar disorder, such patterns, if they last for two years or more, are classified as cyclothymic disorder" (Alloy 1999). Although cyclothymic disorder is an important diagnostic category, it is not in the scope of this paper to discuss cyclothymic disorder.

Associated Features

Completed suicides occur in 10 – 15% of individuals with bipolar I disorder. Child abuse, spouse abuse, or other violent behavior may occur during severe manic episodes or during those with psychotic features. Other associated problems include school truancy, school failure, occupational failure, divorce, or episodic antisocial behavior. Other associated mental disorders include anorexia nervosa, bulimia nervosa, ADHD, panic disorder, social phobia, and most commonly substance-related disorders. Alcohol dependence is prevalent in people with Bipolar disorder, and is a major contributor to the morbidity and mortality of the disorder.

Etiology

The data to date are most consistent with the hypothesis that mood disorders are associated "with heterogeneous dysregulations of the biogenic amines. Of the biogenic amines, norepinephrine and serotonin are the two neurotransmitters most implicated in the pathophysiology of mood disorders" (Kaplan). Brain imaging shows a significant set of bipolar I disorder patients, predominantly men, have enlarged cerebral ventricles. Genetic data strongly indicate that a significant genetic factor is involved in the development of a mood disorder, but the pattern of genetic inheritance occurs by means of complex mechanisms. Family studies as well as adoption and twin studies support the role of genetic transmission (of a predisposition) for developing bipolar disorder. We will now turn our attention to an in-depth discussion of Bipolar I disorder, Bipolar II disorder and Bipolar disorder in children and adolescents.

Bipolar I Affective Disorder

Bipolar I disorder is less common than is major depressive disorder, with a lifetime prevalence of about 1- percent, similar to the figure for schizophrenia. Because it is increasingly appreciated that the course of bipolar I disorder is not as favorable as the course for major depressive disorder, the cost of bipolar I disorder to patients, their families and society is significant. Bipolar I disorder has an equal prevalence for men and women. The onset of bipolar I disorder ranges from childhood (as early as 5 or 6) to 50 years or even older in rare cases. The mean age of presentation is 30. 50% of all patients present between the ages of 20 and 50 (Kaplan 1998). Bipolar I disorder is more common in people who did not graduate from college than in college graduates, a fact that probably reflects the relatively early age of onset for the disorder (Kaplan 1998). To make the diagnosis of bipolar I disorder the DSM-IV requires the presence of a distinct period of abnormal mood lasting at least 1 week. Included are separate bipolar I disorder diagnoses for a single manic episode, and a specific type of recurrent episode, based on the symptoms of the most recent episode. Unlike Bipolar II disorder the DSM criteria for mania must be met to establish the diagnosis of bipolar I disorder. The criteria for a manic episode are:

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 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 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 the 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. medication electroconvulsive therapy, light therapy) should not count toward a diagnosis of bipolar I disorder

(DSM-IV)

Patients can be diagnosed with Bipolar I disorder, single manic episode if they are experiencing their first manic episode. "This requirement rests on the fact that patients who are having their first episode of bipolar I disorder depression cannot be distinguished from patients with major depressive disorder" (Kaplan 1998). If not diagnosed during the first manic episode the patient is diagnosed with bipolar I disorder, recurrent. The "DSM-IV specifies diagnostic criteria for recurrent bipolar I disorder based on the symptoms of the most recent episode as follows. Bipolar I disorder, most recent episode hypomanic, bipolar I disorder, most recent episode manic, bipolar I disorder, most recent episode mixed, bipolar I disorder, most recent episode depressed, or bipolar I disorder, most recent episode unspecified" (Kaplan, 1998). Further specifiers of: psychotic features, melancholic features, atypical features, catatonic features, postpartum onset or chronic should be used in describing the most recent episode.

Clinical Features

The two symptom patterns in mood disorders are those of depression and mania. Clinical signs of mania include an elevated expansive or irritable mood. The elevated mood is euphoric and is easily recognized as unusual to someone who knows the patient well. The patient may drink alcohol excessively, engage in pathological gambling, disrobe in public places, and wear clothing and jewelry in bright colors and outlandish combinations. Patients act impulsively and yet with conviction and purpose. They are often preoccupied by religious, political, sexual or persecutory ideas that can evolve into complex delusional systems. Rather than the euphoric mood usually seen, occasionally, patients’ mood is one of high excitement but is irritable and agitated. The depressive episodes include depressed mood and loss of interest or pleasure in things the patient used to find enjoyable. Patients feel blue, hopeless, down, or worthless. The clinical features of the depression in bipolar I disorder are the same as for major depressive disorder. "In many studies, researchers have attempted to find reliable differences between bipolar I disorder depression and major depressive disorder, but the differences are elusive. In a clinical situation, only the patient’s history, family history and future course can help differentiate the two conditions" (Kaplan 1998).

Treatment

The treatment of bipolar is multifaceted, but in almost all instances pharmacotherapy is used in addition to psychotherapy. Cade, was the first to report the anti-manic effect of lithium and the late 1960s established its role in the prophylaxis of bipolar disorder. In the next decade it became widely used on both sides of the Atlantic, as the first line of treatment for the condition. "Recent prescribing patterns indicate that the use of lithium in the United States is declining relative to its use in European and other countries such as Australia. The evidence, however, suggests that lithium should be the first choice in the prophylactic treatment of most patients with bipolar disorder" (Cade). Some American clinicians no longer prescribe lithium because it is too toxic and alternatives are available. Despite the recent trends in prescribing in the United States, lithium has the largest data set available for any mood stabilizer. Placebo controlled studies show efficacy in both the manic and depressive phases of illness and in the long-term prophylaxis. To date there are 12 placebo-controlled trials examining the prophylactic value of lithium. When these studies are combined the relapse rate on placebo and lithium is 80% and 35% respectively (Goodwin).

Although lithium has good data to support the use in bipolar I disorder, Recent trends have been toward using anti-epileptics for mood stabilization. The anti-epileptics are less toxic and have fewer side effects, and many of them don’t require ongoing blood-level monitoring. The study by Bowden et al has undoubtedly had an impact on the use of lithium in the United States. It compared the efficacy of valproic acid (semisodium valproate, divalproex), lithium, and placebo as prophylactic treatment in 372 patients over 52 weeks after a manic episode. "Valproate was found to be better than lithium in terms of a longer duration of successful prophylaxis and less deterioration in depressive symptoms." However, a recent Cochrane review of this and related valproate studies conclude that; "the shift of prescribing practice to valproate is not justified by the evidence, which provides equivocal support for the efficacy of valproate". In contrast, expert consensus guidelines from the United States support the view that either valproate or lithium is the cornerstone choice for both the acute treatment and prevention of mania. Both are viewed as equivalent and it is suggested that if monotherapy fails a combination of these agents should be used. Valproate may be of particular benefit in the subgroup of patients who present with a mixed state or as rapid cyclers. Side effects of lithium are a major factor in non-compliance and contribute to its decreased usage in the United States. "Most patients who are prescribed lithium experience some adverse effects, though mainly of a minor nature"(Cookson). One known side effect of Lithium is it’s negative impact on thyroid function, even within the therapeutic range the impact on thyroid function can be profound. "Overt hypothyroidism occurs in 5-10% of patients and 5% develop a goiter. Such effects are related to the dose and duration of therapy" (Cookson). Whether or not lithium results in memory disturbances is unclear, with a few studies reporting an effect but most failing to find any. "Surveys show that many patients rightly or wrongly associate lithium with deterioration in their memory"(Sachs). Significant gain in weight on lithium is often a source of concern for women. Approximately one in four patients prescribed lithium put on weight of 5 kg or more. However, alternatives to lithium have significant side effects for many patients. The main side effects from Valproate are sedation as well as mild weight gain. Dilantin and Neurontin have also been used widely in the United States for mood stabilization with good results, however, using these for mood stabilization is an "off label" uses, and is not as well studied. The choice really is of which mood stabilizer to choose depending on how well the patient tolerates it. Although there is ongoing research regarding which mood stabilizer may be best, there is little doubt that a mood stabilizer is necessary.

Another important aspect of treatment is to identify any co-morbid conditions that may exist. "Alcohol dependence frequently coexists with mood disorders. Patients with bipolar I disorder are likely to meet the diagnostic criteria for an alcohol use disorder. Substance related disorders other than alcohol dependence are also commonly associated with mood disorders." (Kaplan, 1998). Patients in a manic phase rarely use sedatives however; patients in a depressive phase often use stimulants such as cocaine or amphetamines. It is critical to determine if a patient has a co-morbid substance use disorder as that needs to be addressed before treatment of bipolar I disorder can be successful.

Bipolar I disorder is generally a chronic disorder, thus it is very important for the patient to have an established ongoing relationship with a therapist. The relationship is important for ongoing psychotherapy as well as medication monitoring. There are a number of psychotherapies, which are helpful including cognitive behavioral therapy; insight oriented therapy and family therapy. Generally, patients in a depressive phase of bipolar respond to similar therapies as patients with major depressive disorder. Beck’s cognitive behavioral method uses a technique of recording and monitoring cognition’s, correcting distorted themes with logic and experimental testing and providing alternative ways of framing experiences. The patient usually does thought content "homework" in order to start restructuring depressed schemas. The main difference between CBT and psychoanalytically oriented approach are the active and directive roles of the therapist and direct goals for the patient. Insight oriented therapy is also important for patients with bipolar disorder in order to facilitate an understanding of the patients behavior and feelings during the different phases of the disorder. Social skills’ training is especially important during a manic phase so those patients don’t engage in any dangerous or socially unacceptable behavior. It is critical for bipolar patients to learn how to "self monitor". Family therapy can also be a valuable component to therapy. "Family therapy is indicated if the disorder jeopardizes a patient’s marriage or family functioning or if the mood disorder is promoted or maintained by the family situation. Family therapy examines the role of the mood-disordered member in the overall psychological well-being of the whole family; it also examines the role of the entire family in the maintenance of the patient’s symptoms" (Kaplan 1998).

Bipolar II Disorder

"Bipolar II affective disorder, defined as major depression with hypomania, has been reported to be different from other affective disorders in genetic, biological, clinical, and pharmacological aspects" (Dunner 1993).

Bipolar II affective disorder criteria as described in the DSM-IV:

A. Presence (or history) of one or more major depressive episodes.

B. Presence (or history) of at least one hypomanic episode.

C. There has never been a manic episode.

D. The mood symptoms in criteria A and B are not better accounted for by schizoaffective disorder, and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.

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

Specify current or most recent episode:

Hypomanic: if currently (or most recently) in a hypomanic episode

Depressed: if currently (or most recently) in a major depressive episode

Specify (for current or most recent major depressive episode only if it is the most recent type of mood episode):

Severity/psychotic/remission specifiers:

Chronic

With catatonic features

With melancholic features

With atypical features

With postpartum onset

Specify:

Longitudinal course specifiers (with or without interepisode recovery)

With seasonal pattern (applies only to the pattern of major depressive episodes

with rapid cycling.

The DSM-IV lists the criteria for a hypomanic episode separately:

A. A distinct period of persistently elevated, expansive, or 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

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).

(DSM-IV)

The key distinction between a true manic episode and hypomanic episode is one of functioning. The manic episode impairs functioning in occupation, social activities and relationships, while hypomanic episodes do not impair functioning. The depressive episodes in Bipolar I and II share the same features, and both meet the DSM-IV criteria for major depressive disorder. "The differential diagnosis of patients being evaluated for a mood disorder should include the other mood disorders, psychotic disorders, and borderline disorder. The differentiation between major depressive disorder and bipolar I disorder on one hand and bipolar II disorder on the other hand rests on the clinical evaluation of the mania-like episodes" (Kaplan 1989).

One of the most difficult distinctions to make is between borderline personality disorder (BPD) and bipolar II disorder. Patients with borderline personality disorder often have a severely disrupted life, similar to that of patients with bipolar II disorder, because of the multiple episodes of significant mood disorder symptoms. This "overlap" of symptoms has been the source of recent studies examining the phenomenon of how to distinguish the two disorders, or if they are a "continuum" of the same disorder. The other possibility being examined is that there is a high frequency of bipolar II and PD, (especially BPD) occurring co-morbidly.

Several investigators have asserted that bipolar II disorder and BPD are the same disorder. "The relationship of borderline personality disorder (BPD) and bipolar mood disorder remains controversial. The impulsivity, emotional liability, stormy relationships, and depressed episodes associated with BPD have led many investigators (Akiskal 1995) to believe that borderline syndromes are variants of mood disorder. The efficacy and use of mood stabilizers in borderline patients support these assumptions. In addition, borderline patients also share the sleep and other neurophysiologic disturbance characteristic of primary mood disorder".

Some investigators, (Harrison) however, believe that although BPD and mood disorders often coexist, BPD is not a mood disorder. A study by Altri-Vaidya looked at the issue in a study titled; "Bipolar mood disorder versus Borderline Personality Disorder, two distinct disorders or one continuum." They stated "Our preliminary findings clarify the boundaries of bipolar mood disorder and BPD. We found that less than 50% of the patients receiving the clinical diagnosis of BPD actually satisfy the DSM criteria for BPD. Usually the diagnosis of "borderline" in a clinical setting is often synonymous with poor treatment response and poor compliance. Our findings emphasize the value of careful diagnostic assessment in patients' labeled as BPD, especially because other investigators (Streeter 1995) have demonstrated that more than 50% of patients satisfying DSM criteria for borderline have a history of head injury". In addition to pointing out the importance of careful diagnosis, the study also demonstrated that "borderline patients could be distinguished from bipolar mood disorder based on temperament and character deviation" (Cade). Investigators have argued that BPD is a variant of bipolar mood disorder. However, "we do not find these two groups to be identical in temperament. Therefore, although preliminary, our data support the current classification of BPD as a personality disorder" (Altre-Vaidya).

There is also some speculation that they are not the same disorder but frequently occur together. "Clinical differences may include a higher presence of co-morbidity, especially with personality disorders (PD)" (Coryell 1985). Some researchers have argued that the only difference between bipolar I and II is that of co-morbidity and bipolar II is not really a separate entity. "Some authors argue that this is a questionable category, because of the low reliability of the diagnosis of hypomania and the high rates of comorbidity, especially with PD" (Cooke). Akiskal has "questioned the validity of the diagnosis of PD in such patients, on the basis of the difficulty in distinguishing subsyndromal affective features from pathological character traits". In a study by Vieta, "Personality disorders in bipolar patients", the authors found a high co-morbidity of personality disorders and bipolar II disorder. Although various researchers have found different PD present, most of them do describe co-morbidity. As Vieta summarizes "Our rates of PD, although not entirely comparable by means of assessment tools and diagnostic criteria, do not confirm results from other studies Pica, (1990) found a higher prevalence of histrionic (50%), antisocial (15%), and borderline PD (23%) among bipolar I and II patients. Borderline disorder was precisely the most prevalent PD in our sample (12%), which is consistent with some previous reports (Peselow 1995) but not with others. For instance, (Kupfer) reported high rates of avoidant personality and dependent traits. "In our sample, no patient fulfilled DSM-IV criteria for avoidant or dependent PD, nor for schizotypal PD, even though Kupfer found schizotypal features in 18% and 7% bipolar II probands, respectively. Antisocial PD was also absent in our sample" (Vieta) So, although different forms of PD are described researchers across the board describe a high amount of co-morbidy in bipolar II disorder and personality disorders. It is still unclear if bipolar II is a distinct diagnosis, a continuum with borderline personality disorder, or perhaps a disorder that develops early in life and so co-morbid character disorders also develop.

Treatment

"The paharmacological treatment of bipolar II disorder must be approached cautiously, treatment for depressive episodes with antidepressants can freqently precipitate a manic episode. Whether typical bipolar I disorder medication strategies (lithium and anticonvulsants) are effective in the treatment of patients with bipolar II disorder is still under investigation. A trial of such agents is usually warranted" (Kaplan 1998) If a therapeutic trial is successful medications should be continued prophylactically in hopes of reducing relapse rates, however, the data are still not clear on the pharmacological treatment of choice. Patients with bipolar II disorder will benefit from the same psychotherapies described for bipolar I patients. Because the depression is the more debilitating symptom of bipolar II disorder specific cognitive therapies that are successful for major depressive disorder are helpful. Therapy should be fairly directive with a patient and therapist restructuring the patients’ faulty schemas and evaluating their origins. Social skills training is also beneficial to bipolar II patients, similarly, to borderline personality disorder patients. Videotaped "empty chair" work can be helpful in allowing the patient to understand their behavior and it’s impact on others.

Bipolar Disorder in Children and Adolescence

"Bipolar I disorder can affect both the very young and older people. The incidence of bipolar I disorder in children and adolescents are about 1 percent, and the onset can be as early as age 8. Bipolar I disorder with such an early onset is associated with a poor prognosis" (Kaplan). Bipolar disorder in children and adolescence is being examined closely at this time. It is a difficult diagnosis for most clinicians. The presentation of mania in the pre-adolescent age group is "atypical" or different from that of adults. There is also a large overlap in symptoms with other pre-adolescent disorders such as ADHD, Conduct Disorder and Oppositional Defiant disorder. Current thinking is that pediatric BP illness may not be rare, but difficult to diagnose because of its atypical presentation compared with that of adults with the disorder. In an early study, Carlson, suggested "that prepubertal mania may be characterized by severe irritability, the absence of discrete episodes of mood disturbance, and hyperactivity." Current studies also suggest that pediatric BP (bipolar I) most often co-occurs with other mental health disorders. "There has been continuing controversy over the validity of mania in prepubertal children, complicated by limited empirical studies investigating BP symptom clusters in children" (Carlson). "As BP was believed to be rare before adolescence, symptoms of mania have not been included in many epidemiological studies of childhood psychiatric disorders. Early reports of pediatric mania were beleaguered by small samples, no control groups, unstandardized assessment, or retrospective designs" (Weckerly). Nonetheless, there is increasing agreement that pediatric mania may be a valid diagnostic category. Much discussion concerning its validity centers on the meaning of the atypical presentation in pediatric mania compared to the adult form. Recent investigations provide empirical support and constitute important first steps in the efforts to identify the core symptoms and clinical features of mania across ages. In the Phenomenology and Course of Pediatric Bipolar Disorders project, Geller, reported "that children meeting criteria for mania endorsed cardinal symptoms of elated mood, grandiosity, hypersexuality (in the absence of abuse or overstimulation), psychotic symptoms, decreased need for sleep, flight of ideas, racing thoughts, social intrusiveness, and increased goal-directed activity".

However, one of the key differences in presentation of mania, in pediatrics, is the pervasive symptom of irritability. "In contrast with the euphoria and expansiveness most often associated with the classic model of adult mania, the "mood of mania" in children is predominately irritable" (Davis). The irritability observed in children with mania has been described as very severe, persistent, and often violent. "Frequently, irritability evolves into explosive temper tantrums involving physical aggression, such as kicking, biting, and hitting, depending on the age of the child, and verbal aggression that includes threats, cursing, and taunting. Often these rages or "affective storms" last for hours, during which family members or teachers are threatened and/or attacked. Often property is destroyed, as tantrums involve kicking holes in walls or doors, breaking windows, and fire setting, depending on the age of the child. These explosive outbursts have been described as responses to what would otherwise appear to be minimal stimuli or stressors, and often, in response to parental limit setting" (Wozniak).

Some of the most intense controversy surrounding pediatric BP concerns its relationship to ADHD. Many studies report very high rates of ADHD in children or adolescents with BP (up to 90%). "In a prospective study of 140 children with ADHD, 11% of the ADHD sample also met diagnostic criteria for BP at baseline, and an additional 12% of the sample went on to develop BP within 4 years" (West). Butler, found a similar rate (22%) of BP in hospitalized adolescents with ADHD. The interesting clinical point to note is that the symptoms of pre-adolescent bipolar disorder and ADHD have 80% of their features in common. The key difference is the irritability and aggression that differentiates the BP from ADHD only disorders. Geller, has suggested that attention-deficit hyperactivity disorder (ADHD) "is an age-dependent manifestation of BP illness, as normal prepubertal children are more hyperactive than their postpubertal counterparts, with hyperactivity understood as the child analogue to the intense energy surges in the manic episodes of adults." Although an interesting theory most researchers assert a misdiagnosis because of the similar symptoms in both disorders, or a high co-morbidity, rather than ADHD being a pre-adolescent form of bipolar.

Diagnosis

"As many children with bipolar I will first present to pediatricians in primary care or to developmental/behavioral pediatricians, there is no singular "red flag," as no one symptom is definitive in the diagnosis of pediatric mania. In fact, differential diagnoses in children with BP can be complicated by a host of factors, including co-morbid psychiatric conditions, the recognition of developmental antecedents of mood disorders, and a history of early trauma" (Wells). However, if parents report prolonged and severe temper tantrums, a constellation of hyperactivity, and irritable and rapidly alternating moods, with a family history of mood disorders and/or substance abuse, BP should be considered. "A diagnosis of pediatric BP in a young child with no family history of psychiatric illness should rarely be made because of the difficulties of diagnosis in young children" (Wells). The emerging literature indicates that mania in childhood may not be as rare as previously considered, but the difficulty may be in its identification, especially given the many symptoms displayed by preadolescents with manic symptoms. "Results to date suggest that mania in childhood is associated with a chronic course, severely irritable mood, and a mixed symptom presentation with co-occurring symptoms of depression and mania, often with psychotic features. Pediatric mania or early-onset bipolar mood disorder (BP) is also associated with comorbid disruptive disorders, anxiety, and attention-deficit hyperactivity disorder (ADHD). Finally, it is associated with greater familial loading for affective illnesses than adult-onset BP" (Carlson)

Treatment

The treatment of pediatric bipolar disorder should be directed toward several goals. First, the patient (and families) safety must be assured. Second, a complete diagnostic evaluation of the patient must be carried out. This is essential because of the difficulty of diagnosis as discussed above in this population. Third, a treatment plan must be developed that addresses the immediate symptoms as well as a future plan.

Unfortunately, pharmacotherapy of pediatric BP is complicated not only by the limited studies of mood stabilizers and antidepressants in children, but also by the risk of inducing a manic episode with the use of antidepressants in children with suspected or undiagnosed BP illness. "Careful monitoring should be undertaken when prescribing SSRIs, TCAs, or bupropion in any child with a family history of mood disorders or other risk factors of BP illness, such as depression involving a rapid onset, psychomotor retardation, and/or psychotic features" (Biederman). Given the high rates of coexisting conditions, children with pediatric mania may require combinations of medications to adequately manage symptoms. For example, many children with both BP and ADHD also need stimulant treatment, as ADHD symptoms are not responsive to mood stabilizers. Although stimulants may exacerbate manic symptoms in some children, the risk of precipitating mania with stimulants or antidepressants in children with BP is greatly reduced with the concurrent use of mood stabilizers. "Although children with mania frequently demonstrate an atypical picture compared with the classic mania of some adults, there is promise that a systematic and comprehensive assessment approach may greatly improve recognition of this disorder. More accurate diagnosis could, in turn, lead to earlier and more effective treatment" (Biederman) Although the efficacy of mood stabilizers has not been as well studied in children, many anti-seizure medications have. Knowing the safety of anti-seizure medications in the pediatric population allows the clinician to choose a medication that has been studied in children although it was for a different use. There is also some preliminary data that some of the new atypical antipsychotics, like Zyprexa, are well tolerated and effective in pediatric bipolar disorder.

Due to the chronicity of pediatric bipolar illness it is especially important that the child, and family have an ongoing relationship with a therapist well trained in treating Bipolar as well as the co-morbid disorders that often accompany it. The first decision that needs to be made is if the patient needs hospitalization. Clear indications for hospitalization are the need for diagnostic procedures (ie CT scan, rule out medical pathology) or the risk of harm to self or others including suicide. If the patient is not "out of control" and the family is comfortable with the patient at home a therapist can safely treat bipolar disorder as an outpatient.

Family therapy is extremely important when a child has an illness such as bipolar because the entire family will be involved and affected. Borrowing from the medical model we often tell parents of juvenile diabetics "Joey does not have diabetes, the family has diabetes", and so it goes with any childhood disorder. The family needs to be supported and trained, and can be used as an ally in helping to produce more positive outcomes. Because bipolar illness can be very disruptive for a family they need tools to make the home environment as harmonious as possible. One useful therapeutic approach would be Alderian family therapy. "Alderian family therapists want to engage parents in a learning experience and a collaborative assessment. Part of this assessment includes an investigation of the multiple ways parents function as family leaders, or loses the ability to do so. Under most conditions, a goal of therapy is to establish and support parents as effective leaders of the family" (Corey). This is especially important with a bipolar child, as they can easily become the focus and "director" of the family. Alderian principles were used to develop what is now called authoritative-responsive parenting. This type of parenting optimizes child security, feelings of self-reliance and provides excellent modeling for the child’s future relationships. The manner the therapy is operated is through systematic investigation and education. "The systemic investigation focuses on (a) the family constellation or system and, (b) motivations behind problematic interactions and, (c) the family process throughout a typical day. The results of this investigation are used to develop interventions and recommendations designed to correct mistaken goals and provide parents with an understanding of parenting skills" (Corey).

Individual therapy would also be utilized. For the younger child behavior therapy and play therapy are going to be the most appropriate. As a child moves into adolescence they will benefit from some insight oriented therapy, especially cognitive therapy like Alderian therapy with the emphasis on reeducation and reorientation. The main goal of Alderian therapy is directed toward educating clients on new ways of looking at themselves, others and life. "This is accomplished by increasing the client’s self-awareness and challenging and modifying his or her fundamental premises, life goals and basic concepts" (Corey). This would have an especially positive impact on an adolescent to form pro-social behavior.

Conclusion

It is increasingly recognized that a small, but substantial, number of children experience particularly severe psychiatric symptoms associated with extreme irritability, aggression, and substantial functional impairment that are consistent with the emerging descriptions of pediatric mania. Clarifying the diagnoses for these children would have considerable clinical implications, including more effective treatment.

The need for Clinicians and therapists to understand Bipolar I, II and Pediatric Bipolar disorder cannot be overstated. The diagnosis is very difficult and there is a substantial amount of "symptom overlap" with other conditions, as well as a substantial amount of co-morbidity associated with bipolar disorder. One needs to keep Bipolar disorder on the differential when evaluating adults with apparent affective and personality disorders and children with ADHD and disorders of conduct. If it is not considered an important therapeutic opportunity will be missed. "Overall, The treatment of bipolar disorder is rewarding for therapists. Specific treatments are now available for both manic and depressive episodes, and available data indicate that prophylactic treatment is also effective. Because the prognosis for each episode is good, optimism is always warranted and is welcomed by both the patient and the patient’s family" (Kaplan).

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Carrie Sclar

Abnormal Psychology

Bi-polar Affective Disorder I, II and Pre-adolescent Onset, Current Review in Diagnosis and Treatment

Bi-polar affective disorder, formerly known as manic-depression is a disorder that is characterized by the occurrence of one or more manic episodes and often one or more major depressive episodes. The DSM-IV has divided bipolar disorder into two types. In bipolar I disorder the person has at least one manic (or mixed) episode and usually but not necessarily, at least one major depressive episode as well. "There are six separate criteria sets for Bipolar I disorder: single manic episode, most recent episode hypomanic, most recent episode manic, most recent episode mixed, most recent episode depressed, and most recent episode unspecified. In bipolar II disorder the person has had at least one major depressive episode and at least one hypomanic episode, but has never met the diagnostic criteria for manic or mixed episode" (DSM IV). Children and adolescents are also diagnosed with bipolar disorder. Although the DSM-IV criterion for bipolar disorder is used, due to the difficulty and difference in their symptoms, bipolar disorder in children will be discussed separately. "There are many people who chronically pass through depressed and expansive periods but whose condition is not severe enough to merit the diagnosis of bipolar disorder, such patterns, if they last for two years or more, are classified as cyclothymic disorder" (Alloy 1999). Although cyclothymic disorder is an important diagnostic category, it is not in the scope of this paper to discuss cyclothymic disorder.

Associated Features

Completed suicides occur in 10 – 15% of individuals with bipolar I disorder. Child abuse, spouse abuse, or other violent behavior may occur during severe manic episodes or during those with psychotic features. Other associated problems include school truancy, school failure, occupational failure, divorce, or episodic antisocial behavior. Other associated mental disorders include anorexia nervosa, bulimia nervosa, ADHD, panic disorder, social phobia, and most commonly substance-related disorders. Alcohol dependence is prevalent in people with Bipolar disorder, and is a major contributor to the morbidity and mortality of the disorder.

Etiology

The data to date are most consistent with the hypothesis that mood disorders are associated "with heterogeneous dysregulations of the biogenic amines. Of the biogenic amines, norepinephrine and serotonin are the two neurotransmitters most implicated in the pathophysiology of mood disorders" (Kaplan). Brain imaging shows a significant set of bipolar I disorder patients, predominantly men, have enlarged cerebral ventricles. Genetic data strongly indicate that a significant genetic factor is involved in the development of a mood disorder, but the pattern of genetic inheritance occurs by means of complex mechanisms. Family studies as well as adoption and twin studies support the role of genetic transmission (of a predisposition) for developing bipolar disorder. We will now turn our attention to an in-depth discussion of Bipolar I disorder, Bipolar II disorder and Bipolar disorder in children and adolescents.

Bipolar I Affective Disorder

Bipolar I disorder is less common than is major depressive disorder, with a lifetime prevalence of about 1- percent, similar to the figure for schizophrenia. Because it is increasingly appreciated that the course of bipolar I disorder is not as favorable as the course for major depressive disorder, the cost of bipolar I disorder to patients, their families and society is significant. Bipolar I disorder has an equal prevalence for men and women. The onset of bipolar I disorder ranges from childhood (as early as 5 or 6) to 50 years or even older in rare cases. The mean age of presentation is 30. 50% of all patients present between the ages of 20 and 50 (Kaplan 1998). Bipolar I disorder is more common in people who did not graduate from college than in college graduates, a fact that probably reflects the relatively early age of onset for the disorder (Kaplan 1998). To make the diagnosis of bipolar I disorder the DSM-IV requires the presence of a distinct period of abnormal mood lasting at least 1 week. Included are separate bipolar I disorder diagnoses for a single manic episode, and a specific type of recurrent episode, based on the symptoms of the most recent episode. Unlike Bipolar II disorder the DSM criteria for mania must be met to establish the diagnosis of bipolar I disorder. The criteria for a manic episode are:

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 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 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 the 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. medication electroconvulsive therapy, light therapy) should not count toward a diagnosis of bipolar I disorder

(DSM-IV)

Patients can be diagnosed with Bipolar I disorder, single manic episode if they are experiencing their first manic episode. "This requirement rests on the fact that patients who are having their first episode of bipolar I disorder depression cannot be distinguished from patients with major depressive disorder" (Kaplan 1998). If not diagnosed during the first manic episode the patient is diagnosed with bipolar I disorder, recurrent. The "DSM-IV specifies diagnostic criteria for recurrent bipolar I disorder based on the symptoms of the most recent episode as follows. Bipolar I disorder, most recent episode hypomanic, bipolar I disorder, most recent episode manic, bipolar I disorder, most recent episode mixed, bipolar I disorder, most recent episode depressed, or bipolar I disorder, most recent episode unspecified" (Kaplan, 1998). Further specifiers of: psychotic features, melancholic features, atypical features, catatonic features, postpartum onset or chronic should be used in describing the most recent episode.

Clinical Features

The two symptom patterns in mood disorders are those of depression and mania. Clinical signs of mania include an elevated expansive or irritable mood. The elevated mood is euphoric and is easily recognized as unusual to someone who knows the patient well. The patient may drink alcohol excessively, engage in pathological gambling, disrobe in public places, and wear clothing and jewelry in bright colors and outlandish combinations. Patients act impulsively and yet with conviction and purpose. They are often preoccupied by religious, political, sexual or persecutory ideas that can evolve into complex delusional systems. Rather than the euphoric mood usually seen, occasionally, patients’ mood is one of high excitement but is irritable and agitated. The depressive episodes include depressed mood and loss of interest or pleasure in things the patient used to find enjoyable. Patients feel blue, hopeless, down, or worthless. The clinical features of the depression in bipolar I disorder are the same as for major depressive disorder. "In many studies, researchers have attempted to find reliable differences between bipolar I disorder depression and major depressive disorder, but the differences are elusive. In a clinical situation, only the patient’s history, family history and future course can help differentiate the two conditions" (Kaplan 1998).

Treatment

The treatment of bipolar is multifaceted, but in almost all instances pharmacotherapy is used in addition to psychotherapy. Cade, was the first to report the anti-manic effect of lithium and the late 1960s established its role in the prophylaxis of bipolar disorder. In the next decade it became widely used on both sides of the Atlantic, as the first line of treatment for the condition. "Recent prescribing patterns indicate that the use of lithium in the United States is declining relative to its use in European and other countries such as Australia. The evidence, however, suggests that lithium should be the first choice in the prophylactic treatment of most patients with bipolar disorder" (Cade). Some American clinicians no longer prescribe lithium because it is too toxic and alternatives are available. Despite the recent trends in prescribing in the United States, lithium has the largest data set available for any mood stabilizer. Placebo controlled studies show efficacy in both the manic and depressive phases of illness and in the long-term prophylaxis. To date there are 12 placebo-controlled trials examining the prophylactic value of lithium. When these studies are combined the relapse rate on placebo and lithium is 80% and 35% respectively (Goodwin).

Although lithium has good data to support the use in bipolar I disorder, Recent trends have been toward using anti-epileptics for mood stabilization. The anti-epileptics are less toxic and have fewer side effects, and many of them don’t require ongoing blood-level monitoring. The study by Bowden et al has undoubtedly had an impact on the use of lithium in the United States. It compared the efficacy of valproic acid (semisodium valproate, divalproex), lithium, and placebo as prophylactic treatment in 372 patients over 52 weeks after a manic episode. "Valproate was found to be better than lithium in terms of a longer duration of successful prophylaxis and less deterioration in depressive symptoms." However, a recent Cochrane review of this and related valproate studies conclude that; "the shift of prescribing practice to valproate is not justified by the evidence, which provides equivocal support for the efficacy of valproate". In contrast, expert consensus guidelines from the United States support the view that either valproate or lithium is the cornerstone choice for both the acute treatment and prevention of mania. Both are viewed as equivalent and it is suggested that if monotherapy fails a combination of these agents should be used. Valproate may be of particular benefit in the subgroup of patients who present with a mixed state or as rapid cyclers. Side effects of lithium are a major factor in non-compliance and contribute to its decreased usage in the United States. "Most patients who are prescribed lithium experience some adverse effects, though mainly of a minor nature"(Cookson). One known side effect of Lithium is it’s negative impact on thyroid function, even within the therapeutic range the impact on thyroid function can be profound. "Overt hypothyroidism occurs in 5-10% of patients and 5% develop a goiter. Such effects are related to the dose and duration of therapy" (Cookson). Whether or not lithium results in memory disturbances is unclear, with a few studies reporting an effect but most failing to find any. "Surveys show that many patients rightly or wrongly associate lithium with deterioration in their memory"(Sachs). Significant gain in weight on lithium is often a source of concern for women. Approximately one in four patients prescribed lithium put on weight of 5 kg or more. However, alternatives to lithium have significant side effects for many patients. The main side effects from Valproate are sedation as well as mild weight gain. Dilantin and Neurontin have also been used widely in the United States for mood stabilization with good results, however, using these for mood stabilization is an "off label" uses, and is not as well studied. The choice really is of which mood stabilizer to choose depending on how well the patient tolerates it. Although there is ongoing research regarding which mood stabilizer may be best, there is little doubt that a mood stabilizer is necessary.

Another important aspect of treatment is to identify any co-morbid conditions that may exist. "Alcohol dependence frequently coexists with mood disorders. Patients with bipolar I disorder are likely to meet the diagnostic criteria for an alcohol use disorder. Substance related disorders other than alcohol dependence are also commonly associated with mood disorders." (Kaplan, 1998). Patients in a manic phase rarely use sedatives however; patients in a depressive phase often use stimulants such as cocaine or amphetamines. It is critical to determine if a patient has a co-morbid substance use disorder as that needs to be addressed before treatment of bipolar I disorder can be successful.

Bipolar I disorder is generally a chronic disorder, thus it is very important for the patient to have an established ongoing relationship with a therapist. The relationship is important for ongoing psychotherapy as well as medication monitoring. There are a number of psychotherapies, which are helpful including cognitive behavioral therapy; insight oriented therapy and family therapy. Generally, patients in a depressive phase of bipolar respond to similar therapies as patients with major depressive disorder. Beck’s cognitive behavioral method uses a technique of recording and monitoring cognition’s, correcting distorted themes with logic and experimental testing and providing alternative ways of framing experiences. The patient usually does thought content "homework" in order to start restructuring depressed schemas. The main difference between CBT and psychoanalytically oriented approach are the active and directive roles of the therapist and direct goals for the patient. Insight oriented therapy is also important for patients with bipolar disorder in order to facilitate an understanding of the patients behavior and feelings during the different phases of the disorder. Social skills’ training is especially important during a manic phase so those patients don’t engage in any dangerous or socially unacceptable behavior. It is critical for bipolar patients to learn how to "self monitor". Family therapy can also be a valuable component to therapy. "Family therapy is indicated if the disorder jeopardizes a patient’s marriage or family functioning or if the mood disorder is promoted or maintained by the family situation. Family therapy examines the role of the mood-disordered member in the overall psychological well-being of the whole family; it also examines the role of the entire family in the maintenance of the patient’s symptoms" (Kaplan 1998).

Bipolar II Disorder

"Bipolar II affective disorder, defined as major depression with hypomania, has been reported to be different from other affective disorders in genetic, biological, clinical, and pharmacological aspects" (Dunner 1993).

Bipolar II affective disorder criteria as described in the DSM-IV:

A. Presence (or history) of one or more major depressive episodes.

B. Presence (or history) of at least one hypomanic episode.

C. There has never been a manic episode.

D. The mood symptoms in criteria A and B are not better accounted for by schizoaffective disorder, and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.

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

Specify current or most recent episode:

Hypomanic: if currently (or most recently) in a hypomanic episode

Depressed: if currently (or most recently) in a major depressive episode

Specify (for current or most recent major depressive episode only if it is the most recent type of mood episode):

Severity/psychotic/remission specifiers:

Chronic

With catatonic features

With melancholic features

With atypical features

With postpartum onset

Specify:

Longitudinal course specifiers (with or without interepisode recovery)

With seasonal pattern (applies only to the pattern of major depressive episodes

with rapid cycling.

The DSM-IV lists the criteria for a hypomanic episode separately:

A. A distinct period of persistently elevated, expansive, or 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

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).

(DSM-IV)

The key distinction between a true manic episode and hypomanic episode is one of functioning. The manic episode impairs functioning in occupation, social activities and relationships, while hypomanic episodes do not impair functioning. The depressive episodes in Bipolar I and II share the same features, and both meet the DSM-IV criteria for major depressive disorder. "The differential diagnosis of patients being evaluated for a mood disorder should include the other mood disorders, psychotic disorders, and borderline disorder. The differentiation between major depressive disorder and bipolar I disorder on one hand and bipolar II disorder on the other hand rests on the clinical evaluation of the mania-like episodes" (Kaplan 1989).

One of the most difficult distinctions to make is between borderline personality disorder (BPD) and bipolar II disorder. Patients with borderline personality disorder often have a severely disrupted life, similar to that of patients with bipolar II disorder, because of the multiple episodes of significant mood disorder symptoms. This "overlap" of symptoms has been the source of recent studies examining the phenomenon of how to distinguish the two disorders, or if they are a "continuum" of the same disorder. The other possibility being examined is that there is a high frequency of bipolar II and PD, (especially BPD) occurring co-morbidly.

Several investigators have asserted that bipolar II disorder and BPD are the same disorder. "The relationship of borderline personality disorder (BPD) and bipolar mood disorder remains controversial. The impulsivity, emotional liability, stormy relationships, and depressed episodes associated with BPD have led many investigators (Akiskal 1995) to believe that borderline syndromes are variants of mood disorder. The efficacy and use of mood stabilizers in borderline patients support these assumptions. In addition, borderline patients also share the sleep and other neurophysiologic disturbance characteristic of primary mood disorder".

Some investigators, (Harrison) however, believe that although BPD and mood disorders often coexist, BPD is not a mood disorder. A study by Altri-Vaidya looked at the issue in a study titled; "Bipolar mood disorder versus Borderline Personality Disorder, two distinct disorders or one continuum." They stated "Our preliminary findings clarify the boundaries of bipolar mood disorder and BPD. We found that less than 50% of the patients receiving the clinical diagnosis of BPD actually satisfy the DSM criteria for BPD. Usually the diagnosis of "borderline" in a clinical setting is often synonymous with poor treatment response and poor compliance. Our findings emphasize the value of careful diagnostic assessment in patients' labeled as BPD, especially because other investigators (Streeter 1995) have demonstrated that more than 50% of patients satisfying DSM criteria for borderline have a history of head injury". In addition to pointing out the importance of careful diagnosis, the study also demonstrated that "borderline patients could be distinguished from bipolar mood disorder based on temperament and character deviation" (Cade). Investigators have argued that BPD is a variant of bipolar mood disorder. However, "we do not find these two groups to be identical in temperament. Therefore, although preliminary, our data support the current classification of BPD as a personality disorder" (Altre-Vaidya).

There is also some speculation that they are not the same disorder but frequently occur together. "Clinical differences may include a higher presence of co-morbidity, especially with personality disorders (PD)" (Coryell 1985). Some researchers have argued that the only difference between bipolar I and II is that of co-morbidity and bipolar II is not really a separate entity. "Some authors argue that this is a questionable category, because of the low reliability of the diagnosis of hypomania and the high rates of comorbidity, especially with PD" (Cooke). Akiskal has "questioned the validity of the diagnosis of PD in such patients, on the basis of the difficulty in distinguishing subsyndromal affective features from pathological character traits". In a study by Vieta, "Personality disorders in bipolar patients", the authors found a high co-morbidity of personality disorders and bipolar II disorder. Although various researchers have found different PD present, most of them do describe co-morbidity. As Vieta summarizes "Our rates of PD, although not entirely comparable by means of assessment tools and diagnostic criteria, do not confirm results from other studies Pica, (1990) found a higher prevalence of histrionic (50%), antisocial (15%), and borderline PD (23%) among bipolar I and II patients. Borderline disorder was precisely the most prevalent PD in our sample (12%), which is consistent with some previous reports (Peselow 1995) but not with others. For instance, (Kupfer) reported high rates of avoidant personality and dependent traits. "In our sample, no patient fulfilled DSM-IV criteria for avoidant or dependent PD, nor for schizotypal PD, even though Kupfer found schizotypal features in 18% and 7% bipolar II probands, respectively. Antisocial PD was also absent in our sample" (Vieta) So, although different forms of PD are described researchers across the board describe a high amount of co-morbidy in bipolar II disorder and personality disorders. It is still unclear if bipolar II is a distinct diagnosis, a continuum with borderline personality disorder, or perhaps a disorder that develops early in life and so co-morbid character disorders also develop.

Treatment

"The paharmacological treatment of bipolar II disorder must be approached cautiously, treatment for depressive episodes with antidepressants can freqently precipitate a manic episode. Whether typical bipolar I disorder medication strategies (lithium and anticonvulsants) are effective in the treatment of patients with bipolar II disorder is still under investigation. A trial of such agents is usually warranted" (Kaplan 1998) If a therapeutic trial is successful medications should be continued prophylactically in hopes of reducing relapse rates, however, the data are still not clear on the pharmacological treatment of choice. Patients with bipolar II disorder will benefit from the same psychotherapies described for bipolar I patients. Because the depression is the more debilitating symptom of bipolar II disorder specific cognitive therapies that are successful for major depressive disorder are helpful. Therapy should be fairly directive with a patient and therapist restructuring the patients’ faulty schemas and evaluating their origins. Social skills training is also beneficial to bipolar II patients, similarly, to borderline personality disorder patients. Videotaped "empty chair" work can be helpful in allowing the patient to understand their behavior and it’s impact on others.

Bipolar Disorder in Children and Adolescence

"Bipolar I disorder can affect both the very young and older people. The incidence of bipolar I disorder in children and adolescents are about 1 percent, and the onset can be as early as age 8. Bipolar I disorder with such an early onset is associated with a poor prognosis" (Kaplan). Bipolar disorder in children and adolescence is being examined closely at this time. It is a difficult diagnosis for most clinicians. The presentation of mania in the pre-adolescent age group is "atypical" or different from that of adults. There is also a large overlap in symptoms with other pre-adolescent disorders such as ADHD, Conduct Disorder and Oppositional Defiant disorder. Current thinking is that pediatric BP illness may not be rare, but difficult to diagnose because of its atypical presentation compared with that of adults with the disorder. In an early study, Carlson, suggested "that prepubertal mania may be characterized by severe irritability, the absence of discrete episodes of mood disturbance, and hyperactivity." Current studies also suggest that pediatric BP (bipolar I) most often co-occurs with other mental health disorders. "There has been continuing controversy over the validity of mania in prepubertal children, complicated by limited empirical studies investigating BP symptom clusters in children" (Carlson). "As BP was believed to be rare before adolescence, symptoms of mania have not been included in many epidemiological studies of childhood psychiatric disorders. Early reports of pediatric mania were beleaguered by small samples, no control groups, unstandardized assessment, or retrospective designs" (Weckerly). Nonetheless, there is increasing agreement that pediatric mania may be a valid diagnostic category. Much discussion concerning its validity centers on the meaning of the atypical presentation in pediatric mania compared to the adult form. Recent investigations provide empirical support and constitute important first steps in the efforts to identify the core symptoms and clinical features of mania across ages. In the Phenomenology and Course of Pediatric Bipolar Disorders project, Geller, reported "that children meeting criteria for mania endorsed cardinal symptoms of elated mood, grandiosity, hypersexuality (in the absence of abuse or overstimulation), psychotic symptoms, decreased need for sleep, flight of ideas, racing thoughts, social intrusiveness, and increased goal-directed activity".

However, one of the key differences in presentation of mania, in pediatrics, is the pervasive symptom of irritability. "In contrast with the euphoria and expansiveness most often associated with the classic model of adult mania, the "mood of mania" in children is predominately irritable" (Davis). The irritability observed in children with mania has been described as very severe, persistent, and often violent. "Frequently, irritability evolves into explosive temper tantrums involving physical aggression, such as kicking, biting, and hitting, depending on the age of the child, and verbal aggression that includes threats, cursing, and taunting. Often these rages or "affective storms" last for hours, during which family members or teachers are threatened and/or attacked. Often property is destroyed, as tantrums involve kicking holes in walls or doors, breaking windows, and fire setting, depending on the age of the child. These explosive outbursts have been described as responses to what would otherwise appear to be minimal stimuli or stressors, and often, in response to parental limit setting" (Wozniak).

Some of the most intense controversy surrounding pediatric BP concerns its relationship to ADHD. Many studies report very high rates of ADHD in children or adolescents with BP (up to 90%). "In a prospective study of 140 children with ADHD, 11% of the ADHD sample also met diagnostic criteria for BP at baseline, and an additional 12% of the sample went on to develop BP within 4 years" (West). Butler, found a similar rate (22%) of BP in hospitalized adolescents with ADHD. The interesting clinical point to note is that the symptoms of pre-adolescent bipolar disorder and ADHD have 80% of their features in common. The key difference is the irritability and aggression that differentiates the BP from ADHD only disorders. Geller, has suggested that attention-deficit hyperactivity disorder (ADHD) "is an age-dependent manifestation of BP illness, as normal prepubertal children are more hyperactive than their postpubertal counterparts, with hyperactivity understood as the child analogue to the intense energy surges in the manic episodes of adults." Although an interesting theory most researchers assert a misdiagnosis because of the similar symptoms in both disorders, or a high co-morbidity, rather than ADHD being a pre-adolescent form of bipolar.

Diagnosis

"As many children with bipolar I will first present to pediatricians in primary care or to developmental/behavioral pediatricians, there is no singular "red flag," as no one symptom is definitive in the diagnosis of pediatric mania. In fact, differential diagnoses in children with BP can be complicated by a host of factors, including co-morbid psychiatric conditions, the recognition of developmental antecedents of mood disorders, and a history of early trauma" (Wells). However, if parents report prolonged and severe temper tantrums, a constellation of hyperactivity, and irritable and rapidly alternating moods, with a family history of mood disorders and/or substance abuse, BP should be considered. "A diagnosis of pediatric BP in a young child with no family history of psychiatric illness should rarely be made because of the difficulties of diagnosis in young children" (Wells). The emerging literature indicates that mania in childhood may not be as rare as previously considered, but the difficulty may be in its identification, especially given the many symptoms displayed by preadolescents with manic symptoms. "Results to date suggest that mania in childhood is associated with a chronic course, severely irritable mood, and a mixed symptom presentation with co-occurring symptoms of depression and mania, often with psychotic features. Pediatric mania or early-onset bipolar mood disorder (BP) is also associated with comorbid disruptive disorders, anxiety, and attention-deficit hyperactivity disorder (ADHD). Finally, it is associated with greater familial loading for affective illnesses than adult-onset BP" (Carlson)

Treatment

The treatment of pediatric bipolar disorder should be directed toward several goals. First, the patient (and families) safety must be assured. Second, a complete diagnostic evaluation of the patient must be carried out. This is essential because of the difficulty of diagnosis as discussed above in this population. Third, a treatment plan must be developed that addresses the immediate symptoms as well as a future plan.

Unfortunately, pharmacotherapy of pediatric BP is complicated not only by the limited studies of mood stabilizers and antidepressants in children, but also by the risk of inducing a manic episode with the use of antidepressants in children with suspected or undiagnosed BP illness. "Careful monitoring should be undertaken when prescribing SSRIs, TCAs, or bupropion in any child with a family history of mood disorders or other risk factors of BP illness, such as depression involving a rapid onset, psychomotor retardation, and/or psychotic features" (Biederman). Given the high rates of coexisting conditions, children with pediatric mania may require combinations of medications to adequately manage symptoms. For example, many children with both BP and ADHD also need stimulant treatment, as ADHD symptoms are not responsive to mood stabilizers. Although stimulants may exacerbate manic symptoms in some children, the risk of precipitating mania with stimulants or antidepressants in children with BP is greatly reduced with the concurrent use of mood stabilizers. "Although children with mania frequently demonstrate an atypical picture compared with the classic mania of some adults, there is promise that a systematic and comprehensive assessment approach may greatly improve recognition of this disorder. More accurate diagnosis could, in turn, lead to earlier and more effective treatment" (Biederman) Although the efficacy of mood stabilizers has not been as well studied in children, many anti-seizure medications have. Knowing the safety of anti-seizure medications in the pediatric population allows the clinician to choose a medication that has been studied in children although it was for a different use. There is also some preliminary data that some of the new atypical antipsychotics, like Zyprexa, are well tolerated and effective in pediatric bipolar disorder.

Due to the chronicity of pediatric bipolar illness it is especially important that the child, and family have an ongoing relationship with a therapist well trained in treating Bipolar as well as the co-morbid disorders that often accompany it. The first decision that needs to be made is if the patient needs hospitalization. Clear indications for hospitalization are the need for diagnostic procedures (ie CT scan, rule out medical pathology) or the risk of harm to self or others including suicide. If the patient is not "out of control" and the family is comfortable with the patient at home a therapist can safely treat bipolar disorder as an outpatient.

Family therapy is extremely important when a child has an illness such as bipolar because the entire family will be involved and affected. Borrowing from the medical model we often tell parents of juvenile diabetics "Joey does not have diabetes, the family has diabetes", and so it goes with any childhood disorder. The family needs to be supported and trained, and can be used as an ally in helping to produce more positive outcomes. Because bipolar illness can be very disruptive for a family they need tools to make the home environment as harmonious as possible. One useful therapeutic approach would be Alderian family therapy. "Alderian family therapists want to engage parents in a learning experience and a collaborative assessment. Part of this assessment includes an investigation of the multiple ways parents function as family leaders, or loses the ability to do so. Under most conditions, a goal of therapy is to establish and support parents as effective leaders of the family" (Corey). This is especially important with a bipolar child, as they can easily become the focus and "director" of the family. Alderian principles were used to develop what is now called authoritative-responsive parenting. This type of parenting optimizes child security, feelings of self-reliance and provides excellent modeling for the child’s future relationships. The manner the therapy is operated is through systematic investigation and education. "The systemic investigation focuses on (a) the family constellation or system and, (b) motivations behind problematic interactions and, (c) the family process throughout a typical day. The results of this investigation are used to develop interventions and recommendations designed to correct mistaken goals and provide parents with an understanding of parenting skills" (Corey).

Individual therapy would also be utilized. For the younger child behavior therapy and play therapy are going to be the most appropriate. As a child moves into adolescence they will benefit from some insight oriented therapy, especially cognitive therapy like Alderian therapy with the emphasis on reeducation and reorientation. The main goal of Alderian therapy is directed toward educating clients on new ways of looking at themselves, others and life. "This is accomplished by increasing the client’s self-awareness and challenging and modifying his or her fundamental premises, life goals and basic concepts" (Corey). This would have an especially positive impact on an adolescent to form pro-social behavior.

Conclusion

It is increasingly recognized that a small, but substantial, number of children experience particularly severe psychiatric symptoms associated with extreme irritability, aggression, and substantial functional impairment that are consistent with the emerging descriptions of pediatric mania. Clarifying the diagnoses for these children would have considerable clinical implications, including more effective treatment.

The need for Clinicians and therapists to understand Bipolar I, II and Pediatric Bipolar disorder cannot be overstated. The diagnosis is very difficult and there is a substantial amount of "symptom overlap" with other conditions, as well as a substantial amount of co-morbidity associated with bipolar disorder. One needs to keep Bipolar disorder on the differential when evaluating adults with apparent affective and personality disorders and children with ADHD and disorders of conduct. If it is not considered an important therapeutic opportunity will be missed. "Overall, The treatment of bipolar disorder is rewarding for therapists. Specific treatments are now available for both manic and depressive episodes, and available data indicate that prophylactic treatment is also effective. Because the prognosis for each episode is good, optimism is always warranted and is welcomed by both the patient and the patient’s family" (Kaplan).

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