Bipolar Disorder & Post Traumatic Stress Disorder

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Bipolar DisorderPost Traumatic Stress Disorder

• Nancy Rappaport, MD
• Harvard Medical School

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Bipolar Disorder

• Also known as manic depression, a mental illness
  that causes a persons moods to swing from
  extremely happy and energized (mania) to
  extremely sad (depression)
• Chronic illness can be life-threatening
• Most often diagnosed in adolescence

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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

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Time Magazine, August 19, 2002
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Nirvanas 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

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Controversy

• Severity and duration
• Onset before puberty is estimated to be rare
• Developmental variability
• Retrospective study of adults

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Vincent Van Gogh

• It isnt possible to get values and color. You
  cant 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.

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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

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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

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Genetics

• 30-70 Identical twins
• 75 Both parents bipolar

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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

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DSM Criteria

• A distinct period of abnormally and persistently
  elevated, expansive, or irritable mood
• DIGFAST acronym (at least 3 of 7 symptoms)

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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

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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

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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

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• 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

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Pediatric-Onset Bipolar Disorder

• Geller (American Journal of Psychiatry, 2001)
  followed up 72 depressed prepubertal children
  into adulthood
• 48.6 (N35) developed bipolar disorder by mean
  age 20.7 years

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• 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

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Pediatric-Onset Bipolar Disorder Differential
Diagnosis with ADHD
Talkativeness
Physical hyperactivity
Distractibility

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

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• 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

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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

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Prioritizing Target Symptoms

• Treat mania and/or psychosis
• Treat depression
• Anxiety and ADHD

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Medications

• Mood Stabilizers
• Lithium
• Divalproex Sodium (Depakote)
• Carbamezapine

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• Improvement is seen when mood stabilizers are
  used
• Kowatch et al (JAACAP 2000)
• Response rates
• 53 depakote
• 38 lithium
• 38 carbamazepine

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Geller et al.

• High relapse rate
• Geller longitudinal study
• 1 year f/u recovery rate 37
• Relapse rate 38

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Newer Agents

• Neurontin
• Lamictal
• Topamax
• Gabatril
• Atypical antipsychotics

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Atypical Antipsychotics

• Risperidol
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Abilify
• Geodon

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Atypical Antipsychotics (ctd.)

• Increasingly used because they can cause rapid
  patient stabilization
• Zyprexa can help with depression, mania and
  psychosis
• Weight gain

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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.

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Multiple Modalities

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

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The Explosive ChildRoss Greene, PhD
The Basket Model
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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)

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Entering the Baskets

• Basket A No, You must, You cant
• Basket B Empathy, problem, invitation
• Basket C I didnt bring it up

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Basket Model (ctd.)

• Basket A He did what I said
• Basket B We worked it out, we solved the
  problem.
• Basket C I didnt bring it up

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Treatment Objectives

• Reduce meltdowns
• Teach lacking skills
• Flexibility
• Frustration tolerance

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Reminder!!

• Meltdowns are 99.9 predictable

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Post Traumatic Stress Disorder

• Impact of traumatic experiences affects capacity
  to function in school
• Physical abuse
• Sexual abuse
• Domestic violence

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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

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Trauma and Immigration

• Escaping political terror or ethnic persecution
• Cumulative losses
• Staggered patterns of entry

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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

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• Active Avoidance
• Passive Avoidance

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Fight or Flight

• Fight or Flight response alarm reaction then fear
  (experience in the high school, sometimes
  inappropriate escalating behavior by adults to
  childs apparent impertinence)
• Freezing hyperarousal, dissociation response
  seen as oppositional

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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

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Impact of Trauma on Learning

• Hypervigilant
• Highly aroused
• High speed on or off

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Impact of Trauma on Learning (ctd.)

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

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• Difficulty regulating emotions and
  differentiating emotions
• Language used to distance people
• Locus of control gives up easily

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PTSD

• Secondary attachment figure
• Piantas work Banking
• Error history - disorganized attachment
• Islands of competency

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PTSD (ctd.)

• No particular medication
• Low doses of SSRI if depression and anxiety
  present
• Risks/benefits

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Exercise The 5 Steps of Cognitive Restructuring

• SITUATION
• Ask yourself What happened that made me upset?
  Write down a brief description of the situation.
• Situation _________________________

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• 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

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• 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 _______________________
• __________________________________
• __________________________________

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• 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

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• 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 ______
• ________________________________________

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• 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.

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• 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 __________________________
• ______________________________________

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• 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 _________________________

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• 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 _____________________________
• ________________________________________

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Guide to Thoughts and Feelings
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Guide to Thoughts and Feelings
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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. BecauseI amspecial.