Understanding Bipolar Disorder
The following portraits will give you a vivid illustration of how differently bipolar disorder can appear in different children and at different ages. I will then go on to explain what connects these very different children to a single diagnosis of bipolar disorder.
Ralph, age eleven, was an excellent student and a creative, talented artist. He was also impulsive, overly excited in groups, often silly and goofy, and subject to sudden aggression. Ralph’s inappropriate behavior made him a target for teasing at school, while at home his difficulty in accepting limits was causing his relationship with his parents to deteriorate. His mother brought him to me primarily because he seemed depressed and had difficulty sleeping.
Jean was first seen at the age of twelve, because of complaints of depression. She cried frequently, had great difficulty sleeping, imagined herself dying, and had recently begun deliberately scratching herself superficially, enough to break the skin but not penetrate it. Jean also had periods of intense energy and high spirits during which she had unrealistically grand ideas. When I saw her, her speech was rapid and her thinking was scattered. While her developmental history was largely normal, she had experienced great difficulty with the word no when she was a toddler and had an episode of depression as early as the fourth grade.
Klaus was a handsome, sweet, blond six-year-old who was brought to me because of severe tantrums, as well as oppositional and bizarre behavior. He was also highly activated—becoming hyperactive and silly—when he ate sugar. Klaus had been started on Ritalin at age five for what was thought to be ADHD, but when I first saw him he was frankly psychotic: hyperactive, silly, grimacing, and talking incessantly. He drew several pictures in rapid succession in a wild and scribbling style. He had cut up his clothes with scissors after a dream in which he found himself in a “paper world” where a paper tiger had bitten off his head. He told me he cut up his clothes while trying to cut up the tiger that was attacking him. His reaction to the stimulant (and to sugar) made clear to me that his hyperactivity and inattention were symptoms of early onset bipolar disorder.
Each of these children suffers from bipolar disorder, a psychiatric condition characterized by dramatic movements between two poles or extremes of mood. As you may already know, a child with bipolar disorder can go from periods of being overly high or irritable (hypomania) to periods of despair and hopelessness (depression) and back again—sometimes within the space of just a few minutes. These mood changes (oscillations) can be startling and confusing, both to the child and those around him. He may feel happy and content one minute, then suddenly plunge into deep despair or intense rage. He may ricochet between a sense of well-being and personal power and a sense of hopelessness and depression, between feelings of creativity and energy and feelings of frustration and inertia. A manic silliness or an explosive irritability can suddenly be replaced by an anxious withdrawal from the world.
Mood swings can be triggered by stress, monthly or daily hormonal cycles, seasonal changes, variations in blood sugar, or the ups and downs of life. Although mood swings affect all children to some extent, they can be disabling for a child with bipolar disorder. Once set in motion, these swings can develop a life of their own—they can build up a biological head of steam, a momentum that carries well beyond the original insult and cannot be quelled by typical parenting.
Bipolar disorder is also characterized by intensity: intense energy, activity, imagination, anxiety, anger, stubbornness, irritability, shyness, sensitivity, silliness, or restlessness. These two traits—oscillation and intensity—may be present very early in life, appear at a particular developmental stage, or occur in response to certain stressors.
Because of their intense energy, creativity, and perceptiveness, bipolar kids can be wonderfully engaging, inspiring joy and pride in you as a parent. But their intensity and changeability can also make them unpredictable, oppositional, and at times inconsolable. Tasks that are routine for other children—making friends, obeying rules, staying asleep at night, performing well at school, and feeling comfortable in the world—can be very difficult for them, and for you as a parent.
Some Basic Terms
attention deficit disorder (ADD). A condition in which a person has unusual difficulty staying focused on a subject or an activity. A person with ADD often loses track of what she is asked to do or where she has put things, or what she meant to do a moment ago.
attention-deficit/hyperactivity disorder (ADHD). A person with ADHD has the same problems as a person with ADD but is also restless, impulsive, talkative, and in constant motion.
bipolar I. This is classic manic depression with episodes of both highly elevated and depressed mood. It must include at least one episode of full-blown mania (defined below) and usually more frequent depressions. Although manic episodes and depressions can be extremely disabling, this condition is also often characterized by unusual imagination, productivity, artistic talent, or inventiveness.
bipolar II. This is a less flagrant (although no less dangerous) condition. It consists of hypomanic episodes and recurrent depressions. The hypomanic episodes may be more irritable than elated and may appear as explosions of temper as well as an increase in activity. The hypomanic episodes may also be characterized by a driven pursuit of some goal, real or imaginary. Although bipolar II is not characterized by the extreme moods seen in bipolar I, it can disable a person’s ability to function personally or professionally, and it carries a significant risk for suicide.
bipolar III. This is a more recent term (not yet accepted by all psychiatrists), which refers to a person who appears to be normal or simply depressed but has a manic or hypomanic response to an antidepressant. In children it can include a child who appears to have ADHD but becomes manic, hypomanic, or depressed when treated with a stimulant.
depression. The central feature of depression is an inability to experience pleasure. It is usually accompanied by negative and self-critical or self-destructive thoughts. Depression can also cause crying; irritability; rage; anxiety; fatigue; and disturbances in sleep, appetite, thinking, and movement (usually a slowing but sometimes agitation).
grandiosity. Thinking or behavior that is based on a grossly exaggerated sense of one’s power, importance, intelligence, or ability to succeed.
hypomania. A state of arousal with some of the characteristics of mania but not to a degree that is necessarily disabling: increased energy, imagination, productivity, grandiosity, silliness or wittiness, pressured speech, increased motor activity, or irritability. People who are hypomanic may or may not have impaired judgment (if they do, it is less severe than with mania). Some bipolar I patients, when they are hypomanic, seem larger than life or infectiously amusing. Bipolar II patients when they are hypomanic can be frighteningly irritable or destructive.
mania. True mania is a disabling condition of arousal that usually requires hospitalization. It consists of rapid pressured speech, racing thoughts, extreme impulsivity (usually a form of pleasure seeking but sometimes an attempt to escape an irrational danger), hypersexuality, decreased sleep, increased energy, decreased appetite, grandiose thinking, hallucinations, and delusions. Mania is always accompanied by gross deficits in judgment.
oscillation. A movement up and down, as with the movement of a wave or a spring. One can talk of mood oscillations, hormonal oscillations, oscillations of blood sugar, or seasonal oscillations.
What Causes Bipolar Disorder?
Bipolar disorder is an inherited condition, like hair color or intelligence. There are almost certainly several genes involved, and a child can inherit some from one parent and some from the other. Probably some bipolar patients have a different set of inherited genes than others. In some children I have seen, I don’t recognize the disorder in either parent, although there are traces of it in grandparents, uncles, aunts, or cousins. As with other medical conditions, such as cardiovascular disease or emphysema, what is probably inherited is a biological vulnerability that appears more or less severely depending on the influence of environmental stress or biological risk factors.
The first sign of the disorder is often depression, unaccompanied by mood elevation, appearing before or during puberty. The depression may come about in response to a personal loss or a social setback (an environmental stress), or it can begin in response to a recreational or prescribed drug (a biological risk factor). In younger children, however, the disorder can appear in forms of increased arousal: severe temper tantrums, unusual anxiety, intense silliness, or an early sleep disturbance.
How Do I Know If My Child Is Bipolar?
A reliable diagnosis of bipolar disorder requires a thorough psychiatric evaluation, including an examination of the child, a description of current symptoms, history of symptoms, developmental history, and family history. Even then a diagnosis may be tentative, depending on a child’s course over time. There are, however, things you can look for.
Contrary to what many people think, bipolar disorder is not just another name for manic depression—although the concept arose from earlier understandings of manic depression, and bipolar disorder includes manic depression. What unites other forms of bipolar disorder with manic depression is the characteristic movements between depression and a state of arousal—irritability, silliness, anxiety, a driven or obsessive pursuit of a particular goal, hypersexuality, or other kinds of compulsive pleasure seeking. Like manic depression, other forms of bipolar disorder also can react unpredictably to some medications used for depression or ADHD. What separates these other forms of bipolar disorder from classic manic depression is the variety and subtlety with which the symptoms can appear.
Surprisingly, bipolar disorder isn’t a specific diagnosis: it is not, like other medical diagnoses, the result of a single underlying physical condition. Rather, it is a syndrome, a recognizable group of symptoms that can arise as a result of different underlying physical (in this case neurological) conditions. We know that the underlying biology of various patients must be different because bipolar patients with similar symptoms can react differently to the same medication. In fact, two people can react oppositely to the same medication.
Although our recognition of the disorder is based on a recognizable pattern of symptoms, there isn’t one particular disposition or behavioral pattern that immediately pinpoints this disorder. That’s because there can be a variety of symptoms in different combinations appearing at different ages. Nor is there yet any blood test or brain scan that confirms the disorder. The term bipolar can be applied to a large number of children, including some who appear to be normal and high functioning and others who are more seriously affected. An accurate assessment of a child ultimately rests on three sources of information: current symptoms, developmental history going back to infancy, and family history.
Although no single characteristic in the checklists below is by itself an absolute sign of bipolar disorder, a number of them occurring together with particular severity should serve as a red flag warning that a child may be disposed to developing bipolar disorder. Notice also that some of these indicators can be recognized only in retrospect. There is no way a parent could appreciate their significance at the time they first appear.
____ extreme anxiety
____ marked irritability
____ marked impulsivity
____ high level of activity
____ excessive talkativeness
____ rapid speech
____ racing or rapidly changing thoughts
____ auditory or visual hallucinations
____ intense oppositional behavior (trouble accepting the word no)
____ deliberate destructiveness
____ extreme silliness
____ separation anxiety
____ sensory hypersensitivity
____ florid imagination and prominent creativity
____ an early or prolonged sleep disturbance
____ vivid nightmares that include violence and death
____ frequent night terrors
____ movement between depression and an elevated mood
____ a prominent rebound reaction, or a sleep disturbance during treatment with any medication used for ADD or ADHD
____ a worsening of symptoms in response to treatment with an antidepressant
____ hypersexuality in the absence of sexual abuse
The symptoms that bring a child to psychiatric attention may be obvious, such as a depression or a manic episode, or they may be less definitive, such as a behavioral disturbance, an anxiety attack, hyperactivity at home or in school, or problems with peer relationships. It is also true that in toddlers and latency-age children (ages eight to twelve), symptoms of mania and depression often occur simultaneously. Even when there are no clear signs of mania or depression, severe irritability or anxiety can be a marker for the increased arousal typical of this disorder. It often takes an experienced clinician to recognize a significant pattern.
Copyright © 2006 by Gregory T. Lombardo, M.D., Ph.D. All rights reserved.