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 Lithium
I'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 you
I'm not gonna crack
I love you
I'm not gonna crack
I kill you
I'm not gonna crack
Controversy
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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:
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Thyroid disorder
Seizure disorder
Multiple sclerosis
Infectious, toxic, and drug-induced disorders
Genetics
• 30-70%
• 75%
Identical twins
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
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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 juvenilesexacerbation 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
Talkativeness
Physical
hyperactivity
Distractibility
• ADHD confusion although identifying presence
of mood disorder helpful in guiding treatment
• 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%
– 38%
– 38%
depakote
lithium
carbamazepine
Geller et al.
• High relapse rate
• Geller longitudinal study
– 1 year f/u recovery rate
– Relapse rate
37%
38%
Newer Agents
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Neurontin
Lamictal
Topamax
Gabatril
Atypical antipsychotics
Atypical Antipsychotics
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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
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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
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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)
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“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
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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
Guilt/Shame
Sadness/Depression
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 YourselfAll 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 Feelings
FEELINGS
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 Feelings
FEELINGS
ASK YOURSELF Related Thoughts
Guilt or shame
What bad thing have I
•I am not good enough
done?
•I am to blame for what
What is wrong with me? 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 SPECIAL
I 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.