Bipolar Disorder and Adolescence

1. Bipolar Disorder and Adolescence Ralph Orland M.D. Clinical Associate Professor Loyola University Medical Director – Genesis Clinical Services 630-653-6441; rorland59@yahoo.com 12/04/09

2. Overview • Diagnosis of Bipolar • Severity of Bipolar • Outcomes and treatments • School Interventions • Resources • Questions and discussion

3. DSM IV Manic Episode • A Distinct Period of Abnormally and Persistently Elevated, Expansive, or Irritable Mood, Lasting At Least One Week (or any duration if hospitalization is necessary) • At Least Three: (or 4 needed if mood is irritable alone) • Inflated self Esteem or Grandiosity • Decreased Need for Sleep • More Talkative Than Usual • Flight of Ideas or Racing Thoughts • Distractibility • Increase in Goal Directed Activity or Psychomotor Agitation • Excessive Involvement in Pleasurable Activities Potential for Painful Consequences • Causes a Marked Impairment in Occupational or Social Functioning

4. Mania In Children • Many Daily Mood Swings • Complex Cycling Pattern • "Affective Storms" • Aggressive Behavior • Highly sexualized • Irritability • Belligerence • Euphoria is Not As Common

5. Mania In Adolescents • Markedly Labile Moods with Mixed Features • Extreme Irritability • Severe Deterioration in Behavior – destructive behaviors, vandalism, reckless driving, sexual promiscuity • Substance Abuse • If Mania Progresses • Psychosis • Grandiosity • Paranoia • Thought Disorder

6. Depressive Episode Preschool-Age children Sad, limited verbal communication and appear slowed down. School –Age Children Depress mood, trouble concentrating, poor performance in school, irritability, crying and suicidal thoughts. Somatic symptoms Headache Abdominal pain

7. AdolescentBipolar Depression Anhedonia Diurnal variation Hopelessness Psychomotor retardation Delusions Hypersomnia Weight changes Drug abuse Suicidal ideation Boredom, apathy and socially withdrawn Lonely Unloved Negative self esteem Poor school performance

8. Mixed Episode Rapidly alternating mood with symptoms of mania and major depression Duration for 1 week Ultrarapid cycling common on children Impairment in functioning Psychotic features

9. BPD II Disorder • One or More HypomanicEpisodes- same criteria as manic symptoms but less severe ( no impairment or distress) only need 4 days of duration • One or more Depressive episodes • Prevalence–0.5% of population • Studies suggest that long term prognosis just as rocky as Bipolar I

10. Bipolar NOS May include a much wider range of individuals –5% of the population (Bipolar Spectrum Unmasked with medication; family histories; poor responses to usual treatments Major overlap with personality, temperament, developmental issues Pediatric Criteria???

11. Characteristics of Bipolar Disorder in youth at some point • Mixed Mania – 51% • Rapid cycling – 81% • Grandiosity – 47% • Psychotic processes – 25% • Suicidality – 23% • Co morbid ADHD – 20%

12. ADHD Before age 7 Clinically significant impairment (social, academic and occupational) Symptoms worsen in unstructured, bored, minimally supervised or sustained attention. Motivation and Immediate gratification

13. ADHD Epidemiology • Elementary School 17% Boys 8% Girls • Adolescent 11% Boys 6% Girls • Out patient 30-50% • Inpatient 40-70%

14. Bipolar Epidemiology • 1% of the population-disease starts for 60% in teenage years • 1 million kids with this – 50% or more are undiagnosed • 40 fold increase in diagnosis in children last ten years; 2 fold increase in diagnosis in adults – • Reasons: Identification, education, prevalence, influence of mass media, parents, pharmaceutical companies?

15. Trends • Median age of onset has changed from late 20’s to late teens in past 20 years • 25% of adults with Bipolar –state that symptoms were present by age 13 – 50% by age 18 • Increase in both MDD and Bipolar with each cohort since 1940 onward: genetics, stress, vulnerability to illness, diet, lack of sleep • Bipolar NOS category (5% of population?) – adds to the burden substantially

16. Stats • Earlier age of onset- more difficult course:episodes,rapid cycling, substance abuse, suicide attempts, “normal days” • After 8 year follow up- children were symptomatic 67% of the days with either depressed/mixed/manic symptoms-highly variable course – the illness or misidentified treatment?

17. Stats • If clear mania or hypo mania – took on average 9 months to stabilize • If rapid cycling (most adolescence) – took on average 2.75 years to stabilize • a lot of time to lose track of normalcy, identity formation, and to keep on the straight and narrow course • Case example: Dawn

18. Co morbidities in Bipolar Youth • 36% have 2 or more medical issues vs. 8% -cardiac,GI,neurological, muscular,female reproductive, respitory • Reasons: medication toxicity,unhealthy life choices, poor health care access, biological susceptibility • Substance use very common • Social anxiety, panic attacks more common

19. Onset later –puberty but can be at 6-7 years Fluctuating course Decreased sleep Hyper verbal, flight of ideas, pressured Increased self esteem Good students when stable Should be seen by age 7y/o Constant issues in school or home Intact or mildly disturbed sleep Speech- normal Low self esteem Learning disabilities Bipolar vs. ADHD

20. Benefits of School • Structure of daily routine • Attempt at stabilizing sleep structure • Regularity of classes/lunches/PE helpful • Center for focus – organization, reasoning, goals – rather than disorganization and distractibility • Healthy peer relationships

21. Struggles within school • 50% have impairment within family and social functioning • Unstable mood contributes to school failure (even if depressed – 67% have manic type symptoms preventing concentration and focus – racing thoughts, agitation, distractibility) • Bipolar disorder creates subtle but sustained impairments in “working memory” (math, sciences)– this is a neurodegenerative disease if left untreated

22. Struggles within school • Often feel best and most awake in the late PM so they stay up late (disrupted circadian rhythm) – often don’t have insight into its effect on them –”that’s just me” • Alienation of friends: when depressed – isolate,loss of interests, unmotivated • when manic – irritable, outbursts, excessive talking, irrational actions, unpredictability – friends gradually avoid them

23. Struggles within school • Medication side effects: decreased concentration, alertness, motor coordination • Weight gain and other physical changes: embarrassment or impairment – tremor, sleepiness, hair loss, slurring of words • Psychiatrists often reactionary to symptoms and don’t consider the whole person, family, and quality of life issues

24. Medication cornucopia • Mood stabilizers: lithium, depakote, lamotrigine, carbamzepine, gabapentin • Atypical antipsychotics: Serequel, Resperidal, Geodon, Zyprexa, Abilify • Antidepressants: Lexapro, Zoloft, Paxil, Effexor, Cymbalta, Pristiq • Stimulants: Ritalin, Adderal • Whatever else works

25. Medications • This is neurobiological illness • Medications are absolutely essential and mood stabilization is the goal • However the individual response is much more variable than in depression and so the combinations are quite extreme • Average adult Bipolar is on 4 –5 different medications for their condition • Expect not to get a response with just one agent

26. Other struggles • Hypo manic symptoms create envy • Greater energy, achievement, perseverance, heightened perceptual sensitivity, exuberance and playfulness, optimistic, social and sexually provocative, decreased sleep • Bipolar is the only illness more common in the upper income brackets and is commonly connected to creativity • Leads to denial of illness and perpetuating of illness as patients want to continue to feel this way and don’t want to lose the euphoric productive times

27. Other struggles • Patients have seen the previous high levels and miss these • Loss of idealism of achievement and professional possibilities • Leads to a potential cycle of failures as they constantly have to be lowering their expectations

28. Other struggles • Stigma of illness • Initial stabilization is easy as compared to long term maintenance • Possibility of return of symptoms leading to distractibility, impulsivity – job loss, failure at school, social calamity • Case example: Amy

29. What can be done at the school? • Establish a relationship with open communication about the illness – medications, other therapeutic interventions that are occurring; being able to bring in reality testing with them (you are talking to loud; slow down, that’s your mania-you don’t want that consequence etc.) – directive approach • If illness is suspected – educate students and parents – use examples from classroom, peer interaction, self observations

30. School interventions • Monitoring of mood – encourage mood journals and expression of moods • Emphasize regularity and consistency: sleep, meal times, exercise times, attendance at class, keeping those schedules on weekends, structuring their day outside of school • Healthy life style choices: peers, substances, activities

31. Access to treatment • Like many illness if the patient or family feel that things are stabilized they cut back on visits and interventions which are needed for future stabilization (this is a life long illness)- • Over reliance on medications • Poor response to traditional supportive or insight oriented treatments

32. Therapies that work • Family involvement is crucial (but goes against the traditional adolescence needs to gain independence therapy)-psycho educational and to lesson family resistances • Social rhythm therapy • Dialectic behavioral therapy • Solution focused therapies (focus on strengths)

33. Basic caveats to being a school professional • Need to follow the districts guidelines on how and when to intervene with students involving any mental health issues • Bipolar disorder is common and disruptive and due to the nature of the illness often kids have no insight or clue as to what is happening (most can recognize depression but not the significance of irritability etc.)

34. School health professional’s information for parents • Observations about the student’s academic and/or functional performance, or behavior in the classroom or school; • Modifications being made to address the student's academic and/or functional performance; • Options for referring students for an educational and/or health care evaluation, according to school policy; • If things do not improve, schools should follow local procedures to ensure that the student is provided with specialized educational services, consistent with section 504 of the rehabilitation act and the Individuals with Disabilities Education Act (IDEA); and • Provide parents with resources to help them better understand IDEA and 504 accommodations.

35. Early signs to be evaluated Decline in school performance Persistent difficulty with peers Poor grades despite strong efforts Constant worry or anxiety Persistent somatic complaints School refusal or loss of interest in usual activities Persistent and disruptive hyperactivity Inability to focus or concentrate Repeated disrupted sleep patterns Continuous or frequent aggression, “acting out” or oppositional behavior Persistent sadness and/or irritability

36. Concerns on labeling • Remove feelings of blame or guilt about a child’s mental health concerns • Recognize and acknowledge that parental denial and anger may exist • Communicate empathy and compassion for the parents’ circumstances • Recognize that stigma continues to be associated with mental health related issues • Provide parents with resources and share with them that education is the key to understanding mental health related concerns • Take a problem-solving approach to addressing mental health concerns • Recognize the value of parents and schools working together as a team

37. Resources and References • NAMI • DBSA – www.dbsalliance.org - includes charts, calendars, information • NIMH – LCM(life chart method) • Childhood onset of bipolar – the perfect storm, Post, RM ;Psychiatric Annals, Oct 2009; 39(10) p 879-886. • Helping you Bipolar patients stay in school or employed, Bowden,CL; Current Psychiatry, Sep 2009; 8(9) p 17-22.