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Child, Adolescent and Adult Psychiatry
Chicago

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Bipolar Disorder

Bipolar disorder (once known as manic-depression disorder) is a treatable medical illness that is marked by extreme changes in mood, energy and behavior.

Symptoms may occur in early childhood, or may not emerge until adolescence or adulthood.  In fact, until the mid-1990s, children rarely were diagnosed with the disorder.  Now, however, it is known that an individual can have bipolar disorder and ADHD at the same time, making appropriate evaluation of symptoms critical in determining a treatment plan.

The most effective treatment today for bipolar disorder is a combination of medication and therapy, which allows patients to effectively build on their strengths and make the best use of their talents.

FOR MORE INFORMATION
You can learn more about bipolar disorder
and associated support groups on
the National Institute of Mental Health (NIMH) website
www.nimh.nih.gov

The list of famous and accomplished people throughout history who had symptoms of bipolar disorder might be surprising.  It includes Abraham Lincoln,  Winston Churchill, Theodore Roosevelt, Goethe, Balzac, Handel, Schumann, Berlioz, Tolstoy, Virginia Woolf, Hemingway, Robert Lowell, and Anne Sexton. Biographies of Beethoven, Newton and Dickens, in particular, reveal severe and debilitating recurrent mood swings that began in childhood.

Although the illness tends to be genetic, bipolar disorder can skip generations and take different forms in different individuals.  Also, environmental factors play a role in whether bipolar disorder will occur in a particular child, adolescent or adult.

One of the most important things a patient can do during evaluation for this disorder is to provide a candid and complete family medical history.  People sometimes hold back information because they are afraid of how they or their family will be perceived during the evaluation. It is very important to remember that none of us chooses our genetics, or even have total control over the many different kinds of stresses that can affect our lives.

In the following section, you will find answers to some of the most common questions about the disorder.

Early-Onset Bipolar Disorder and Children

How common is bipolar disorder in children?

The more we learn about this disorder, the more prevalent it appears to be among children with depression or with ADHD.

  • According to the American Academy of Child and Adolescent Psychiatry, up to one-third of the children and adolescents with depression in the United States may be experiencing the early onset of bipolar disorder.

  • It is suspected that a significant number of children diagnosed in the United States with attention-deficit disorder with hyperactivity (ADHD) have early-onset bipolar disorder instead of, or in conjunction with, ADHD.

What are the symptoms of bipolar disorder in children?

Bipolar disorder involves marked changes in mood and energy, but the specific symptoms that children experience are different than those experienced by the adult with bipolar disorder. Most adults with the illness will demonstrate persistent states of extreme elation or agitation accompanied by high energy (mania) and persistent states of extreme sadness or irritability accompanied by low energy (depression).

On the other hand, children with the disorder usually have an ongoing, continuous mood disturbance that is a mix of mania and depression. This rapid and severe cycling between moods produces chronic irritability and few clear periods of wellness between episodes.

Symptoms may include:

  • an expansive or irritable mood

  • depression

  • rapidly changing moods lasting a few hours to a few days

  • explosive, lengthy and often destructive rages

  • separation anxiety

  • defiance of authority

  • hyperactivity, agitation and distractibility

  • sleeping little or, alternatively, sleeping too much

  • bed-wetting and night terrors

  • strong and frequent cravings, often for carbohydrates and sweets

  • excessive involvement in multiple projects and activities

  • impaired judgment, impulsivity, racing thoughts, and pressure to keep talking

  • daredevil behaviors

  • inappropriate or precocious sexual behavior

  • delusions and hallucinations

  • grandiose belief in own abilities that defy the laws of logic (ability to fly, for example)

Symptoms of bipolar disorder can emerge as early as infancy. Mothers of often report that children later diagnosed with the disorder were extremely difficult to settle and slept erratically. They seemed extraordinarily clingy, and from a very young age often had uncontrollable, seizure-like tantrums or rages out of proportion to any event. The word "no" often triggered these rages.

Healthy children often have moments when they have difficulty staying still, controlling their impulses, or dealing with frustration. Some behaviors by a child, however, should raise a red flag.  These include:

  • destructive rages that continue past the age of four

  • rapid-cycling periods of mood or energy shifts several time a day (observed in more than 70% of children with bipolar disorder)

  • talk of wanting to die or kill themselves

  • trying to jump out of a moving car or high window or roof

Adolescents and Bipolar Disorder 

What are the symptoms of bipolar disorder in adolescents?

In adolescents, bipolar disorder may resemble any of the following classical adult presentations of the illness.

Bipolar I. In this form of the disorder, the adolescent experiences alternating episodes of intense and sometimes psychotic mania and depression.

Symptoms of mania include:

  • elevated, expansive or irritable mood

  • decreased need for sleep

  • racing speech and pressure to keep talking

  • grandiose delusions

  • excessive involvement in pleasurable but risky activities

  • increased physical and mental activity

  • poor judgment

  • in severe cases, hallucinations

Symptoms of depression include:

  • pervasive sadness and crying spells

  • sleeping too much or inability to sleep

  • agitation and irritability

  • withdrawal from activities formerly enjoyed

  • drop in grades and inability to concentrate

  • thoughts of death and suicide

  • low energy

  • significant change in appetite

Periods of relative or complete wellness occur between the episodes.

  • Bipolar II. In this form of the disorder, the adolescent experiences episodes of hypomania between recurrent periods of depression. Hypomania is a markedly elevated or irritable mood accompanied by increased physical and mental energy. Hypomania can be a time of great creativity.

  • Cyclothymia. Adolescents with this form of the disorder experience periods of less severe, but definite, mood swings.

  • Bipolar Disorder NOS (Not Otherwise Specified). Doctors make this diagnosis when it is not clear which type of bipolar disorder is emerging.

For some adolescents, a loss or other traumatic event may trigger a first episode of depression or mania.  Later episodes may occur independently of any obvious stresses, or may worsen with stress.  Puberty is a time of risk. In girls, the onset of menses may trigger the illness, and symptoms often vary in severity with the monthly cycle.

Once the illness starts, episodes tend to recur and worsen without treatment. Studies show that after symptoms first appear, typically there is a 10-year lag until treatment begins.  We encourage parents to take their adolescent for an evaluation when four or more of the above symptoms persist for more than two weeks.  Early intervention and treatment can make all the difference in the world during this critical time of development.

Are substance abuse and addiction related to bipolar disorder?

A majority of teens with untreated bipolar disorder abuse alcohol and drugs.  Any child or adolescent who abuses substances should be evaluated for a mood disorder.

Adolescents who seemed normal until puberty and experience a sudden onset of symptoms are thought to be especially vulnerable to developing addiction to drugs or alcohol.  These substances may be readily available among their peers, and teens may use them to attempt to control their mood swings and insomnia.  If addiction develops, it is essential to treat both the bipolar disorder and the substance abuse at the same time.

Adults and Bipolar Disorder

Bipolar disorder involves marked changes in mood and energy.  Most adults with the illness will experience persistent states of extreme elation or agitation accompanied by high energy�mania�and persistent states of extreme sadness or irritability accompanied by low energy�depression.

It is also urged that adults with bipolar disorder review the adolescent symptoms:

  • Bipolar II. In this form of the disorder, the individual experiences episodes of hypomania between recurrent periods of depression. Hypomania is a markedly elevated or irritable mood accompanied by increased physical and mental energy. Hypomania can be a time of great creativity.

  • Cyclothymia. Individuals with this form of the disorder experience periods of less severe, but definite, mood swings.

  • Bipolar Disorder NOS (Not Otherwise Specified). Doctors make this diagnosis when it is not clear which type of bipolar disorder is emerging.

Among some patients, a loss or other traumatic event may trigger a first episode of depression or mania.  Later episodes may occur independently of any obvious stresses, or may worsen with stress.  Studies show that after symptoms first appear, typically there is a 10-year lag until treatment begins.

Genetics and Environmental Factors in Bipolar Disorder

The illness tends to be highly genetic, but there are clearly environmental factors that influence whether the illness will occur in a particular child, adolescent or adult.  Bipolar disorder can skip generations and take different forms in different individuals.

In every generation since World War II, there has been a higher incidence and an earlier age of onset of bipolar disorder and depression.  On average, children with bipolar disorder experience their first episode of illness 10 years earlier than their parents' generation did. The family histories of many children who develop early-onset bipolar disorder include individuals who suffered from substance abuse and/or mood disorders (often undiagnosed).  Also, their family trees include highly accomplished, creative, and extremely successful individuals in business, politics and the arts.

The studies that have been done vary in the estimate of risk to a given individual:

  • Disorders in the bipolar spectrum may affect 4-6%.

  • When one parent has bipolar disorder, the risk to each child is l5-30%.

  • When both parents have bipolar disorder, the risk to each child increases to 50-75%.

  • The risk in siblings and fraternal twins is 15-25%.

  • The risk in identical twins is approximately 70%.

Disorders that can mask or sometimes occur
along with bipolar disorder include:

In children:

  • attention-deficit disorder with hyperactivity (ADHD)

  • conduct disorder (CD)

  • oppositional-defiant disorder (ODD)

  • depression

  • panic disorder

  • generalized anxiety disorder (GAD)

  • obsessive-compulsive disorder (OCD)

  • Tourette's syndrome (TS)

  • intermittent explosive disorder

  • reactive attachment disorder (RAD)

  • In adolescents and adults:

  • borderline personality disorder

  • chronic depression

  • post-traumatic stress disorder (PTSD)

  • schizophrenia

 


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