Bipolar Disorder&

Post Traumatic Stress Disorder

Nancy Rappaport, MD

Harvard Medical School

Bipolar Disorder

• Also known as manic depression, a mental illness that causes a person’s moods to swing from extremely happy and energized (mania) to extremely sad (depression)

• Chronic illness; can be life-threatening

• Most often diagnosed in adolescence

Epidemiology of Bipolar Disorder

• Prevalence: 1% of population Adults = Adolescents

• Males = Females

• 2-3 million American adults are diagnosed with bipolar disorder

• NIMH estimates that one in very one hundred people will develop the disorder

Time Magazine, August 19, 2002

Nirvana’s LithiumI'm so happy 'cause today I've found my friends

They're in my head I'm so ugly, but that's okay, 'cause so are you...We've broken our mirrors

Sunday morning is everyday for all I care...And I'm not scared

Light my candles in a daze...'Cause I've found god - yeah, yeah, yeah

I'm so lonely but that's okay I shaved my head...And I'm not sad

And just maybe I'm to blame for all I've heard...But I'm not sure I'm so excited, I can't wait to meet you there...

But I don't care I'm so horny but that's okay...My will is good - yeah, yeah, yeah I like it - I'm not gonna crack

I miss youI'm not gonna crack

I love youI'm not gonna crack

I kill youI'm not gonna crack

Controversy

• Severity and duration

• Onset before puberty is estimated to be rare

• Developmental variability

• Retrospective study of adults

Vincent Van Gogh

“It isn’t possible to get values and color. You can’t be at the pole and the equator at the same time.  You must choose your own line, as I hope to do, and it will probably be color.”

Assessment/Diagnosis of Bipolar Disorder

• Often very complicated; it mimics many other disorders and has comorbidity (presents with other disorders)

• Alphabet soup diagnosis

• Half of bipolar children have relatives with bipolar disorder

Other Organic Diagnoses

• It is important to first rule out the possibility of any other organic diagnosis:– Thyroid disorder– Seizure disorder– Multiple sclerosis– Infectious, toxic, and drug-induced disorders

Genetics

• 30-70% Identical twins

• 75% Both parents bipolar

Mood history

• Mania– Giddy, goofy, laughing fits, class clown

– Explosive (how often, how long, how destructive and aggressive)

– Irritable, cranky, angry, disrespectful, threatening

– Grandiosity may present as EXTREME defiance and oppositionality

• Depression– Low frustration tolerance, self-destructive, no pleasure,

lower level of irritability

DSM Criteria

• A distinct period of abnormally and persistently elevated, expansive, or irritable mood

• DIGFAST acronym (at least 3 of 7 symptoms)

DIGFAST – Mental Status Exam

• Distractible• Increased activity/psychomotor agitation• Grandiosity/Super-hero mentality• Flight of ideas or racing thoughts• Activities that are dangerous or hypersexual• Sleep decreased• Talkative or pressured speech

Bipolar Disorder

• Significant functional impairment

• Bipolar I people go through cycles of major depression and mania

• Bipolar II similar to Bipolar I except that people have hypomanic episodes, a milder form of mania

• Rapid cyclers

Suicide Risk Factors

• 22% of adolescents with completed suicides had bipolar disorder

• Family history of suicide

• Substance abuse i.e. adolescent with impulse control disorder, depression, suicidality, substance use and access to a weapon is potential for lethality

• Major depression often presents first (estimated that 20 - 40% of children presenting with major depression within 5 years will be bipolar)

• Comorbidity

• 70 - 90 % of adolescents have other disorders

• ADHD, Conduct Disorder, Substance abuse

Pediatric-Onset Bipolar Disorder

• Geller (American Journal of Psychiatry, 2001) followed up 72 depressed prepubertal children into adulthood

• 48.6% (N=35) developed bipolar disorder by mean age 20.7 years

• Atypical presentation in juveniles-exacerbation of disruptive behavior, moodiness, low frustration tolerance, explosive anger and difficulty sleeping at night

• Comorbidity of ADHD/BPD more severe presentation, often severe affect dysregulation, marked impairment, violent temper outbursts

Pediatric-Onset Bipolar Disorder: Differential Diagnosis with ADHD

• ADHD confusion although identifying presence of mood disorder helpful in guiding treatment

Talkativeness

Physicalhyperactivity

Distractibility

• ADHD criteria does not include a mood component (usually comorbid ODD)

• Look for family history data to help with diagnosis of bipolar disorder

• Nonverbal learning disorders overlap

Developmental Variability

• Discrete episodes may be difficult to delineate more CHRONIC COURSE

• Children with bipolar disorder are more likely to present with aggressive temper outbursts or affective storms rather than euphoric presentation

Prioritizing Target Symptoms

1. Treat mania and/or psychosis

2. Treat depression

3. Anxiety and ADHD

Medications

• Mood Stabilizers

• Lithium

• Divalproex Sodium (Depakote)

• Carbamezapine

• Improvement is seen when mood stabilizers are used

• Kowatch et al (JAACAP 2000)

• Response rates:– 53% depakote– 38% lithium– 38% carbamazepine

Geller et al.

• High relapse rate

• Geller longitudinal study– 1 year f/u recovery rate 37%– Relapse rate 38%

Newer Agents

• Neurontin

• Lamictal

• Topamax

• Gabatril

• Atypical antipsychotics

Atypical Antipsychotics

• Risperidol

• Olanzapine (Zyprexa)

• Quetiapine (Seroquel)

• Abilify

• Geodon

Atypical Antipsychotics (ctd.)

• Increasingly used because they can cause rapid patient stabilization

• Zyprexa can help with depression, mania and psychosis

• Weight gain

Key Point

• Just because a child improves on a mood stabilizer does not prove the diagnosis. Mood stabilizers have been used for a long time to help with aggression in children.

Multiple Modalities

• Psychotherapy• Psychoeducation/Support• School Support/Consultation• Residential Placement, Acute Hospitalization• Mood Charting• Teach Good Sleep Hygiene• Legal intervention• Hope

The Explosive Child

Ross Greene, PhD

The Basket Model

Common Approaches to Problems/Unmet Expectations

• Basket A: Impose adult will

• Basket B: Collaborative problem solving (work it out); problem-invitation

• Basket C: Drop it (for now, at least)

Entering the Baskets

• Basket A: “No”, “You must,” “You can’t”

• Basket B: Empathy, problem, invitation

• Basket C: I didn’t bring it up

Basket Model (ctd.)

• Basket A: He did what I said

• Basket B: We worked it out, we solved the problem.

• Basket C: I didn’t bring it up

Treatment Objectives

• Reduce meltdowns

• Teach lacking skills

• Flexibility

• Frustration tolerance

Reminder!!

• Meltdowns are 99.9% predictable

Post Traumatic Stress Disorder

• Impact of traumatic experiences affects capacity to function in school

• Physical abuse

• Sexual abuse

• Domestic violence

PTSD

• Nature, duration, severity, and history of exposure is critical in shaping the brain response. Children reflect the world in which they are raised.

• Dramatic, unpredictable, threatening changes in the environment

• Stress response

Trauma and Immigration

• Escaping political terror or ethnic persecution

• Cumulative losses

• Staggered patterns of entry

PTSD - Symptoms

• Hyperarousal (most common symptom; startled response, behavioral irritability, sleep disturbances, regulatory functions off, hypervigilance, emotional numbing, or dissociation)

• Nightmares• Flashbacks• Upsetting reminders and triggers

Active Avoidance

Passive Avoidance

Fight or Flight

• Fight or Flight response alarm reaction then fear (experience in the high school, sometimes inappropriate escalating behavior by adults to child’s apparent impertinence)

• Freezing: hyperarousal, dissociation response seen as oppositional

Trauma: Common Ways of Thinking (Automatic)

• “All or nothing”

• “Again and Again”

• “Must”, “Should”, or “Never”

• “End of the world”

• Always blaming yourself

• Thinking on the downside

Impact of Trauma on Learning

• Hypervigilant

• Highly aroused

• High speed “on” or “off”

Impact of Trauma on Learning (ctd.)

• Interference with cognition and information processing

• Difficulty processing verbal information with a disproportionate emphasis on nonverbal clues

• Difficulty regulating emotions and differentiating emotions

• Language used to distance people

• Locus of control gives up easily

PTSD

• Secondary attachment figure

• Pianta’s work “Banking”

• Error history - disorganized attachment

• Islands of competency

PTSD (ctd.)

• No particular medication

• Low doses of SSRI if depression and anxiety present

• Risks/benefits

Exercise: The 5 Steps of Cognitive Restructuring

1. SITUATION

Ask yourself: What happened that made me upset?” Write down a brief description of the situation.

Situation: _________________________

2. FEELING

Circle your strongest feeling (if more than one applies, use a separate sheet for each feeling):

Fear/Anxiety Sadness/Depression

Guilt/Shame Anger

3. THOUGHT

Ask yourself: “What am I thinking that is leading me to feel this way?” Identify the thought that is most strongly related to the circled feeling. Write down your thought below.

THOUGHT: _______________________

__________________________________

__________________________________

If it applies, circle your common style of thinking:

Again and Again Too Much Risk

Must/Should/Never End of the World

Always Blaming Yourself All or None

Thinking on the Downside

Thinking With Your Feelings

4. CHALLENGE YOUR THOUGHT

Rewrite thought from Step 3: __________

Now ask yourself: “What evidence do I have for this thought? Is there an alternative way to look at the situation? How would someone else think about the situation?” Write down the answers that DO and DO NOT support your thought:

Things that DO support my thought: __________

________________________________________

Things that DO NOT support my thought: ______

________________________________________

5. OUTCOME

Next, ask yourself: “Overall, does the evidence support my thought or not?” Look at all the things that support your thought and balance them against all the things that do not support your thought. Check the box below to see whether your thought it supported by the evidence or not:

No, my thought is not supported by the evidence.

If your thought is NOT supported by the evidence, come up with a new thought that is supported by the evidence. These thoughts are usually more balanced and helpful. Write your new, more helpful thought in the space below. And remember, when you think of this upsetting situation in the future, replace your unhelpful, automatic thought with the new, more accurate thought.

New Thought: __________________________

______________________________________

In some cases, even if you decide that your thought is not supported by the evidence, or is only partially supported, you may want to come up with an action plan. Typically this is to help you cope with upsetting feelings that arise even though you have come up with a more balanced thought. If you have an action plan for the situation, write it below.

Action Plan: _________________________

YES, my thought is supported by the evidence.

If your thought IS supported by the evidence, decide what you need to do next in order to deal with the situation. Ask yourself: “Do I need to get more information about what to do?” “Do I need to get some help?” “Do I need to take steps to make sure I am safe?” Write down your action plan to deal with the upsetting situation below.

Action Plan: _____________________________

________________________________________

Guide to Thoughts and FeelingsFEELINGS ASK YOURSELF Related Thoughts

Fear, nervousness, anxiety

What bad thing do I expect to happen?

What am I scared is going to happen?

•Something terrible is going to happen

•I am going to be attacked or hurt

•I am going to be rejected or abandoned

•I am going to lose control or go crazy

Sadness or depression What have I lost?

What is missing in me or in my life?

•I am not worth anything

•I don’t have anyone I can depend on

•Nothing will ever get better

•Life is not worth living

Guide to Thoughts and FeelingsFEELINGS ASK YOURSELF Related Thoughts

Guilt or shame What bad thing have I done?

What is wrong with me?

•I am not good enough

•I am to blame for what happened to me

•I am a bad person

•I am a failure

Anger What is unfair about the situation?

Who has wronged me?

•I am being treated unfairly

•I am being used

•The situation is unfair

•Someone has done something wrong to me

I AM SPECIALI am special. In all the world there is nobody like me.Since the beginning of time, there has never been another person like me. Nobody has my smile. Nobody has my eyes, my nose, my hair, my voice. I am special.No one can be found who has my handwriting. Nobody anywhere has my tastes - for food or music or art. No one sees things just as I do.In all of time there has been no one who laughs like me, No one who cries like me. And what makes me laugh or cry will never provoke identical laughter and tears from anybody else, ever.

No one reacts to a situation just as I would react. I am special. I am the only one in all creation who has my set of abilities. Oh, there will always be somebody who is better at one of the things I am good at, but no one in the universe can reach the quality of my combination of talents, ideas, abilities and feelings. Like a room full of musical instruments, some may excel alone, but no one can match the symphony sound when all are played together. I am a symphony.Through all of eternity no one will ever look, talk, walk, think or do like me. I am special. I am rare. And in rarity there is a great value. Because I am rare, I need not attempt to imitate others. I will accept and even celebrate my differences.

I am special. And I am beginning to realize it is no accident that I am special. I am beginning to see that I was made for a very special purpose. There must be a job for me that no one else can do as well as I. Out of all the billions of applicants, only one is qualified, only one that has the right combination of what it takes.That one is me. Because…I am…special.