Bipolar disorder

People with bipolar disorder, also known as manic-depressive disorder, are afflicted with bouts of major depression and periods of mania—euphoria, poor judgment, and extreme risk-taking activity—in an often debilitating cycle. Onset usually occurs in mid-to-late adolescence, though there are rare cases in children. Perhaps 1 to 3% of the population has the disorder, which affects males and females equally. Bipolar disorder is treatable, but managing the episodes of depression and mania is a lifelong undertaking. The longer it goes untreated, the shorter the periods of normal functioning in between episodes.

Adolescents with bipolar disorder will show signs of both depression (prolonged sadness, lack of affect and interest in things they previously enjoyed, sleeping too much) and mania (periods of excitability or irritability, dramatically heightened self-confidence, even recklessness). For some, the onset of bipolar disorder is marked by a depressive episode; in others, it is a manic episode. Onset can also be a less severe, chronic form of depression called dysthymia or a milder form of mania called hypomania. The duration of and intervals between depressive and manic episodes are highly variable, particularly in younger people.

Your child might be having a manic episode if his personality seems to change drastically, he develops an inflated sense of his abilities, he displays grandiose thinking, he starts sleeping much less than he normally does, he becomes extremely energetic, foolhardy, and voluble. Psychotic episodes—breaks from reality—can occur during both manic episodes and severe depressive episodes. During a manic episode, these can include impossible assessments—I can fly—or delusional thinking. For some, a psychotic episode is the first sign of the disorder.

Being on the lookout for symptoms of mania is particularly important if your child already has depressive symptoms. Bipolar disorder with an unnoticed manic component can be misdiagnosed as major depressive disorder, as people are much more likely to seek professional help when gripped by a depressive episode. When a manic episode hits, a sufferer is often elated, displays poor judgment, and cannot realize that his behavior is irrational. But depression and bipolar are not the same thing and should be treated differently.

The base causes of bipolar disorder are not known, but experts believe there is a genetic component. The disorder does run in families, but most people with bipolar don’t have a family history, and most who do, though they’re at higher risk, won’t develop the disorder. Certain medical conditions, specifically thyroid disease, put people at risk of depression and mania.

The standard for a diagnosis of bipolar disorder is the presence of a manic episode, though the vast majority will experience depression as part of the disorder.

A manic episode is a sustained period of “abnormally and persistently elevated, expansive, or irritable mood” in a distinct shift from normal functioning—not just “10 minutes of feeling super-good,” as one clinician puts it, but a pattern of behavior. Some of the following symptoms are also usually present: grandiosity; decreased need for sleep; increased talkativeness; racing thoughts; scattered attention; drive to achieve goals; and risk-taking behavior. The behaviors must significantly interfere with normal activities—social life, school, work—or a psychotic episode must be present.

A teenager in a major depressive episode will display either depressed or irritable mood most of the time, or lose interest or pleasure in things he once enjoyed. In addition, he’ll show some of the following symptoms: marked weight loss or gain; sleeping too much or too little; restlessness or lethargy; fatigue; feelings of hopelessness, helplessness, worthlessness, or excessive or inappropriate guilt; cloudy or indecisive thinking; and a preoccupation with death, plans of suicide, or an actual suicide attempt.

This section describes the most severe form of the condition, called bipolar I disorder. Some are also diagnosed with bipolar II disorder, in which less severe episodes of hypomania replace manic episodes.

Medication is essential to the treatment of bipolar disorder, as is the involvement of the whole family. Psychotherapy can be of help in limiting and managing manic and depressive episodes and their consequences, which can severely affect a young person and all those around him. Even with an effective course of medication, people with bipolar can have “breakthroughs,” or relapses, so a support network of family, friends, and professionals who monitor the young person’s behavior is vital.

 

Psychotherapeutic: Bipolar is often treated with cognitive behavioral therapy in addition to medications. CBT helps children and adolescents understand what triggers their episodes, how their thoughts influence their feelings, and how to control and manage them. Family therapy is often employed to engage the family in keeping track of symptoms and managing stress levels in the home, which can lead to episodes.

 

Some other therapies that have been shown to help include “prodrome detection,” which encourages early detection and prevention of a budding episode, and social rhythm therapy, which uses a codified daily schedule to head off mania or depression.

 

Pharmacological: The first-line medication used to treat bipolar disorder is often a mood stabilizer. This class includes lithium and various anticonvulsants, which are generally effective at treating manic symptoms and lowering the frequency and severity of both manic and depressive episodes. A young person diagnosed with bipolar disorder might take lithium for the rest of his life. Other drugs can be prescribed to treat symptoms like psychosis (antipsychotics) or trouble sleeping (anti-anxiety drugs). If a mood stabilizer does not adequately address depressive symptoms, a doctor may prescribe an antidepressant, but will do so with extreme caution and almost always in conjunction with a mood stabilizer, as antidepressants can trigger a manic episode.

 

Many people with bipolar disorder take more than one medication and the medications can have complex interactions, leading to significant side effects if they are not well controlled.

 

Electroconvulsive Therapy: In some cases where medication and therapy aren’t providing the hoped-for result, electroconvulsive therapy, or ECT may be considered. This is not the “shock therapy” of old; in ECT, the patient is anesthetized briefly while electrical current is passed through a part of the brain. This causes a seizure, though there are few, if any, external signs of a seizure, and no danger to the patient, who has also been given a muscle relaxant. ECT is rarely used in adolescents, and there is little information about its use in pre-pubertal children, but the therapy is effective in treating both manic and depressive symptoms of bipolar disorder.

Children and adolescents diagnosed with bipolar disorder often have ADHD as well, and they are also at elevated risk for anxiety disorders and alcohol and substance dependencies. 

Children and adolescents with bipolar disorder are at increased risk of committing suicide—the third leading cause of death among adolescents and young adults aged 15 to 24. Never ignore signs of suicidal behavior or ideation, which include: drastic changes in eating habits, sleep patterns, or personality; marked neglect of personal appearance; giving away personal belongings; sudden happiness after a period of depressed mood; and, of course, talk of suicide or of “going away” or “not being a problem anymore.”

If you think your child or adolescent is suicidal, you can call the National Suicide Prevention Lifeline at 1-800-273-8255 or 911 if there is an emergency. Don’t hesitate—the risk of suicide in children and adolescents is all too real.

Is it my fault?
Bipolar disorder isn’t the result of bad parenting, nor can the best parenting prevent it. It is suspected that a complex combination of genetic and environmental factors is involved in bipolar disorder. Whatever the cause, early diagnosis and treatment is all important; the sooner your child begins to control the disorder, the better off he will be down the road.

Are the drugs safe?
If used properly and managed closely, the medications used to treat bipolar disorder are safe. But you should make sure to listen to the doctor who prescribes the medications and never start, stop, or change a course of medication without the clinician’s instruction.
Will my child outgrow bipolar disorder?
That’s unlikely. But while bipolar disorder is a chronic illness, with medication and vigilance, most people with the disorder are able to manage it effectively.

How does it affect school?
The “poles” of bipolar obviously affect children and adolescents differently. In a depressive episode, kids may find it difficult or impossible to go to school, and may also avoid socializing with friends. In a manic episode, your child could become an abnormally high achiever, but the reckless risk-taking and bloated self-importance also associated with mania could just as well land him in hot water.

What is my role in treatment?
Vital. Many of the latest treatments for bipolar put a premium on education—teaching a child with the disorder to keep a keen eye out for the onset of a manic or depressive episode so she can attempt to counteract it, or to understand how daily routine, sleep cycle, and relationships impact the disorder. The family is integral in helping a bipolar child commit seriously to behavioral therapies so they yield the best results, and in monitoring the child for signs of relapse.

How long does treatment last?
Experts agree—bipolar can always come back. Though the intensity and type of treatment can vary, it is a lifelong affair.