Bipolar Disorder


Managing the highs and lows of bipolar disorder

Bipolar Disorder, also known as manic depressive illness, is a psychiatric disorder that involves changes in brain function leading to dramatic mood swings.

The unpredictability of extreme highs and lows and their intensity can disrupt daily functioning for patients and their family members alike. Some describe it as living on a continuous roller coaster.

An estimated 1 per cent of the population is affected by Bipolar Disorder, although the exact figure is difficult to determine as the disorder is often under-detected and thus not always treated.

There is no single proven cause, but many experts suggest that a variety of factors, such as heredity, psychological vulnerabilities, traumatic life experiences and substance abuse, may act together to produce the illness.

Bipolar disorder typically develops in late adolescence or early adulthood, although it can also manifest itself at an earlier age or in later life.

Over the course of the disorder, different kinds of recurrent mood episodes, lasting days, months or even longer, can occur:

- Mania: Heightened energy and creativity, euphoria, irritability, little need for sleep, increased talkativeness and faster speech, racing thoughts, distractibility, recklessness, inflated feelings of self-worth and grandiosity, and in some cases hallucinations;

- Depression: feeling sad, worthless and hopeless, losing interest in normal activities, low energy, loss of appetite, suicidal ideation, or problems with thinking, concentrating, and decision making;

- Hypomania: a mild to moderate form of mania. The person may feel better than normal and more productive, but does not have the marked impairment in social and occupational functioning. As these episodes feel generally good, there is a tendency to neglect medication. However, hypomanic episodes are rarely maintained and often turn into either manic or major depressive episodes;

- Mixed state: both mania and depressive episodes occur at the same time or alternate rapidly during the day

There is no established "cure" for Bipolar Disorder, but effective management can certainly minimize or eliminate problematic symptoms that interfere with normal functioning. Early and proper diagnosis, the right medication, effective psychotherapy, and support of family, friends, or self-help groups can all help people with this disorder to lead relatively healthy and productive lives.

Some recover completely between episodes and may go years without any symptoms, others continue to experience mild swings up and down.

In addition to pharmacological treatment, which is the mainstay of treatment for Bipolar Disorder, a variety of psychological interventions can also be very helpful (unless the person is in an acute manic state, in which case therapy is practically impossible and hospitalization is sometimes indicated). Especially cognitive- behavioral therapy has shown to be effective with bipolar clients.

In this approach, clients learn to keep track of their moods, recognize early warning signals, formulate and implement a relapse prevention plan, and cope with persistent symptoms. Other useful therapies include interpersonal therapy and family therapy.

The former is mainly geared towards improving interpersonal relationships and regularizing daily routines, which help minimize stress and instability.

The focus of family therapy is on educating the whole family about the disorder and its management, reducing their distress and the strain that the disorder often places on their relationships, helping them acquire new insights in family functioning, and improving communication skills and problem solving techniques.

Family members can also be pivotal in encouraging a patient to see a doctor, to stick with a medication or therapy treatment, or to recognize early warning signals.

Bipolar disorder comes with grim suicide statistics

Plagued by feelings of guilt, self-blame and hopelessness, death may seem a welcome escape for some afflicted with bipolar disorder, like the Kitchener father who killed his family and then took his own life last Thursday.

Friends and neighbours said Bill Luft suffered from the mood disorder.

The statistics are grim; about 15 per cent of people with bipolar disorder kill themselves, said Dr. Vijay Kumar, chief of psychiatry at Grand River Hospital.

"Sometimes the mental torment is so huge, death becomes a solution to the suffering,"Kumar said.

However, the majority of patients respond well to treatment with mood stabilizing drugs, such as lithium, and counselling, Kumar said. About 95 per cent experience varying degrees of relief from the extreme highs and lows, with almost a third enjoying a normal life.

But Kumar cautioned it's essential to continue treatment, often for the person's entire life.

A relapse can hit without warning when treatment is stopped suddenly, he said. And then it may be too late for anyone to help.

Also known as manic depression, bipolar disorder is characterized by episodes of mania and depression punctuated by periods of normal behaviour.

During the manic stage, a person is euphoric or excessively "high" and also exhibits uncharacteristically poor judgment and irritability.

In the depressive episodes, irrational feelings of hopelessness, anxiety and sadness become overwhelming.

Unlike a common case of the blues, depression caused by bipolar disorder is long-lasting and not affected by a person's environment. Even a happy moment brings no joy to a person suffering from bipolar disorder.

One to two per cent of the population is affected by bipolar disorder, an early onset disease often first manifested during teenage years. Men and women are affected equally. The disorder is thought to be hereditary.

Changing moods: Children with mental health problems such as manic depression are often misdiagnosed with attention disorders

Mitzi Waltz's daughter Carmen was just seven when she told her mother about the hallucinations: "There's a witch flying around my room, Mom."

Ms. Waltz felt a fleeting panic. It's not something any parent wants to hear from their child, so she tried to come up with the first explanation she could think of.

"And the first thing that came to my mind was, `Well, you're probably having lucid dreams,"' says the Portland, Oregon journalist and author.

Her daughter didn't like the explanation and kept insisting the witch was really there, but Ms. Waltz closed the conversation and Carmen never brought it up again.

"She got the impression that's not something you mention to Mom because it freaks Mom out," Ms. Waltz says.

Only Carmen kept seeing things.

At age 11, Carmen -- the teacher's pet, the super student, "the whole deal" -- started having trouble in school. She got in a fight with her best friend, she talked back to her teachers and disrupted her class. Her mother, who was also dealing with an autistic toddler at the time, searched for an explanation.

"I thought `early puberty,' because she went through lots of days where she was just fine. It was easy to brush it under the rug until things got very out of hand."

By the time she was 12, Carmen was locking herself in her room. Her appearance changed, her school performance sank, her moods swung from rage to giddiness. She saw counsellors and school therapists, but nothing helped. Mitzi Waltz felt she was losing her daughter.

Then one night Carmen's brother walked into her room and saw his sister trying to cut her wrists.

"We thought, `OK, we'll get her to the experts,"' Ms. Waltz says, only it turned out to be another wrong turn. The doctors diagnosed simple depression and prescribed Carmen a drug that only made the mood swings worse.

When the hospital discovered the family's health insurance wasn't going to cover treatment, the "miracle cure" occurred, her mother says. "They said she was fine, and sent her home."

It would take another year and a half of substance abuse and running away from home before the correct diagnosis was finally made: bipolar disorder, a condition that, according to some estimates, may affect as many as one million American children and teens in the U.S. alone.

Until recently, bipolar disorders, a group of illnesses that include manic depression and seasonal affective disorder (SAD), "were almost never diagnosed in children and only rarely recognized" in teens, even though it's now emerging that up to 40 per cent of adults diagnosed with a bipolar disorder first began experiencing symptoms when they were children, writes Ms. Waltz in her new book, Bipolar Disorders: A Guide to Helping Children and Adolescents (O'Reilly & Associates, $36.95).

Not only can it be missed, psychiatrists acknowledge that a bipolar disorder can be misdiagnosed as ADHD, or attention deficit hyperactivity disorder. According to a recent study published in the Journal of the American Academy of Child and Adolescent Psychiatry, "23 per cent of children currently diagnosed with ADHD will eventually be diagnosed as having a bipolar disorder, either by itself or in combination with ADHD," Ms. Waltz reports. Other times it gets lumped into normal adolescent turmoil.

But there's nothing "normal" about the mood changes that accompany bipolar disorders, she says.

"Their moods swing low and keep dropping until life doesn't feel worth living anymore," Ms. Waltz writes. "They swing so high that they lose touch with reality, making rash decisions and behaving wildly."

Bipolar disorders are thought to be caused by a chemical imbalance in the brain, though research suggests genetics play a role because they tend to run in families.

The problem is that, like any mental illness, diagnosing a bipolar disorder "is not an exact science," Ms. Waltz says. There's no blood test or brain scan or questionnaire that can prove, with 100-per-cent accuracy, that a child is suffering.

Even the "bible" doctors turn to to diagnose mental illness, the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV, consists of criteria that were developed for adults, not children.

And knowing when to treat and how to separate kids who have bipolar disorder

from those who may have ADHD or another behaviour disorder is proving controversial.

"Say you've now labelled a kid of five years of age with having manic depression. That has its own implications," says Dr. Robert Milin, acting clinical director, child and adolescent program, at the Regional Children's Mental Health Centre at the Royal Ottawa Hospital.

"What if you're wrong, and you put this kid on lithium or epival (an anti-seizure drug used to treat mood disorders) for his whole life, or an unknown period?

"If we were able to be very specific and say, `we aren't going to make any false errors here, we're going to be pretty good (diagnosing) 90 per cent of these kids and maybe we're only going to put a few kids, who might not actually be bipolar on a medication,' OK," Dr. Milin says.

"The issue is, we aren't very specific."

But Ms. Waltz argues that children and their families pay a huge toll when these disorders aren't recognized and treated early. "Suicide is a common outcome," she says. So are dropping out of school, poor job prospects and a life dependent on welfare.

The disorder doesn't discriminate. It occurs in all ethnic groups, in rich families and poor, she says. And it can surface starting in early infancy.

Ms. Waltz says many parents of bipolar children and teens said they knew their child was "different" from the moment they were babies. They were more difficult to care for, took longer to get into a regular sleep schedule, resisted weaning "and violently disliked transitions and new situations." They may have cried more than other babies, and had more tantrums.

"These are kids who would throw a tantrum for 3 1/2 hours at a level of intensity you just can't believe. They would attack a parent, or a sibling or a pet," Ms. Waltz says.

The earlier the onset, she says, the worse the disorder can be.

But there can be more subtle signs, and, in many cases, parents miss the sometimes cyclical pattern of a bipolar disorder.

"For some people, it has to do with the time of year." It can be a seasonal affective depression, where mood changes as the hours of daylight diminish.

She says the pattern may be hormonal in women. "We may blow it off as PMS (pre-menstrual syndrome), but a particular type of very severe PMS may actually be in the bipolar disorders family.

"This was certainly true for my daughter. The only medication she's on now is Depo-Provera -- not for birth control, for mood control -- and it's been really effective for her."

A bipolar disorder can be misdiagnosed as ADHD because there's so much overlap between the two, she says. But there are telltale differences.

For example, temper tantrums can occur for hours in a child with a bipolar disorder, compared to 30 to 40 minutes for a child with ADHD.

Kids with ADHD "tend to bounce out of bed, ready to take on the world with an overabundant supply of energy," Ms. Waltz says. Bipolar children, on the other hand, are harder to wake up, and slower to get going. They also tend to complain of stomachaches, headaches and other "phantom illnesses."

And unlike children with ADHD, bipolar children are also less likely to be diagnosed with a learning disability. "Many are early talkers and readers and use language with special skill," Ms. Waltz says.

But they're also more likely to behave recklessly because of "grandiose thinking" she says -- "leaping from the playground climbing structure because they believe they can fly."

Ritalin is the drug of choice for treating ADHD. If the child has a bipolar disorder instead, "Ritalin itself won't do anything," Ms. Waltz says.

"But the thing that does cause problems is that a lot of doctors are now prescribing Prozac for younger kids, and for a kid with a bipolar disorder, medications like Prozac and Paxil and Zoloft can cause mood swings -- and that can be dangerous."

It's not clear just how prevalent are bipolar disorders in children. Dr. Milin, of the Regional Children's Mental Health Centre, says it's still an uncommon illness in children, but one whose frequency rises in later adolescence. "It's an understudied area that we're now making more efforts to understand."

He says extreme irritability with a fluctuating mood is one of the most common symptoms -- so much irritability that it's affecting the child's school work, or preventing a child from playing hockey, or interfering with their life in some other way, what the doctors call a "functional impairment."

Ms. Waltz says it's crucial parents try to find an expert who has seen bipolar disorders in children before, "and to give them as much information as you can.

"Doctors have told me that a lot of parents aren't really forthcoming with information. They're worried about wasting their time because we're so used to the five-minute appointment. But for something like this tell the doctor you want to book a long amount of time just to talk. And tell them as much as you can about your child. If you're not comfortable talking to your doctor, write it out."

She says parents shouldn't make the mistake of shutting down the lines of communication.

"It can take a while to come to a diagnosis, and I think it's important, as long as you're not in crisis -- you don't have suicide (attempts) or substance abuse happening right now -- to take as much time as you can, educate yourself, especially about the treatment options," she says, which include lithium and anti-seizure drugs that, for reasons doctors don't fully understand, help reduce the mercurial mood swings of bipolar illness.

Until medical science comes up with better tools for recognizing bipolar disorders in children earlier, "diagnosis will remain a difficult and uncertain process," Ms. Waltz predicts.

But there is hope. A bipolar disorder isn't something you outgrow, she says. "It's a chronic health condition. It doesn't go away." But as children get older, their symptoms get better, and they learn more coping skills.

Today, Carmen holds down a full-time job as a department store manager. She's travelled to England on her own to study.

"It's just a wonderful thing to see where she is now, compared to where she was just a few years ago," her mother says.

"It really gives me a lot of hope for other people's kids."

Coping with the 'wigglies' in a child's head: Bipolar disorder used to be an adult affliction, but doctors are finding it more often in children

Helpless and isolated. That's how St. Catharines resident Sarah Cannon felt as she watched her five-year-old daughter flounder through the darkness of an undiagnosed mental illness.

At the worst of times, the "wigglies" in Emily's head tormented her without mercy.

The beautiful, blond-haired child would beg her mother to leave the volume on the television turned up loud to block out the voices that wouldn't leave her alone. She would tremble violently at the thought of bedtime, lying wide-eyed and awake at night, or finding refuge on the floor of the bathroom where the men in the chimney didn't like to go.

Perhaps most painful of all, the gentle girl who loved to show love to everyone would fly into unexpected rages over something as simple as an unwanted meal. "She'd be fine, and then all of a sudden she'd look at the plate and start screaming that she hated the food, that she hated us for trying to make her eat the food," recalls Cannon, her eyes tearing up at the memory. "Why? There really was no why. We gave her lunch."

The occasional imaginary friend, bad dream or unprovoked temper tantrum are something most kids experience, but for Emily, the episodes were frighteningly real and much more extreme. "Everything's always to the extreme," said her mother. "She loves to the extreme, plays to the extreme, reacts to the extreme."

Dr. Maria Becker, a Niagara-based child and adolescent psychiatrist, said emotional roller-coaster rides are just a part of the heavy burden children are forced to bear when they are afflicted with bipolar disorder. Known in the past as manic depression, bipolar disorder is a genetic brain illness characterized by wild mood swings that until recently was thought to occur only rarely in children.

An estimated one to two per cent of the adult population suffers from bipolar disorder, but the average age of onset for the disease has dropped from the early 30s to the teens in the span of a single generation. Some experts estimate close to 50 per cent of bipolar children haven't been diagnosed.

Becker said medical experts are split on why the number of child bipolar diagnoses seem to be on the increase. Some fear the disease is becoming more common, while others argue doctors are simply getting better at recognizing the problem.

Becker, who has diagnosed "dozens" of bipolar children and teens, counts herself among the latter group. "When I was in med school, I got in trouble for diagnosing a 15-year-old with bipolar," she said. "Attitudes have changed, and I think we're realizing the condition is a lot more common than people think."

Despite this, diagnosing the disease in children is still universally described as "controversial and new."

Part of the difficulty is that symptoms of the disorder in children are radically different from those in adults. While a bipolar adult's cycle of depression and mania often stretches over months, Becker explains bipolar children will often bounce back and forth between emotional highs and lows several times a day.

Uncontrollable, unpredictable anger is the "core symptom" most parents will notice in a bipolar child, said Becker.

"It's like the thermostat isn't working in the brain," she said. "It's either too hot or too cold, and the child doesn't know how to make it better."

Complicating matters is that bipolar symptoms in children resemble those in other disorders, such as attention-deficit/ hyperactivity disorder -- meaning misdiagnosis is also common. "Doctors tend to diagnose what is most visible," said Becker, adding sometimes a child may be suffering from multiple disorders and be receiving treatment for only one.

These problems translate into confusion and grief for parents, most of whom have little chance of recognizing the disorder for what it is.

The Cannons understand fully.

Sarah and her husband spent three years watching their daughter cycle through periods of rage, fear and the inability to eat or sleep before Emily was accurately diagnosed.

"We went to a neurologist, a geneticist, they all said the same thing. 'We know something's wrong, but we don't know what,' " she said.

It's difficult for the mother of two to express how frustrated and alone she and her family felt in their battle with Emily's unknown malady. Her attempts to find a reason for Emily's outbursts ranged from MRI brain scans to occupational therapy to banning her from watching television.

"When there's something wrong with a child that young, bipolar disorder certainly isn't the first thing you think of," she said. "I didn't know what to do or who to talk to."

The good news is that thanks to an ever increasing arsenal of medication, treatment for bipolar disorder is improving steadily. In the past few months, a cocktail of the anti-convulsant Tegretol and the anti-psychotic Risperdal have worked wonders for Emily. But drugs are only part of the equation.

Becker said family members and their ailing loved ones need to be taught how to negotiate the bipolar minefield.

Lack of sleep, stress and conflict are just a few of the factors that could trigger a manic cycle. Bipolar teens are also particularly susceptible to becoming addicted to drugs and alcohol. That's especially dangerous, according to Becker, since even relatively benign stimulants such as caffeine and chocolate have the potential to push an ill person's mood into dangerous territory.

The consequences of ignoring these added stresses are severe: the suicide rate among bipolar patients is close to 20 per cent.

Vivid memories of her own struggle to understand the illness have prompted Cannon to form a support group for parents of bipolar children in Niagara.

She hopes the group will provide referrals, information and a place for parents to share both their trials and successes.

Dan Silver, executive director of Community Support Services Niagara, said the group will address a "tremendous" need in the community.

Silver said he took more than 1,800 calls from parents looking for mental-health support services last year, and 20 per cent of those were from parents with kids under the age of 10. "It's so easy for parents and children to become overwhelmed when faced with an incomprehensible mental illness," he said. "

In the year-long period since Emily began receiving treatment, the atmosphere in the Cannon household has changed "completely."

"We're not as stressed, were not playing the blame game. We can work with her now, rather than fighting against her," Sarah said.

Emily has just completed "a really wonderful, really successful" year of junior kindergarten and Cannon feels better prepared now to face the inevitable challenges that will surface as Emily grows into adolescence.

But one thing Cannon still fears is the stigma that surrounds mental illness. As an advocate for changing attitudes towards mental illness, Cannon said she would love to have a picture of her "beautiful, caring" daughter in The Standard to show people the "true face" of bipolar disorder, but as a mother she is scared.

She worries about her daughter being labelled by classmates, or treated differently by uninformed teachers. She feels people have difficulty "wrapping their mind around" the idea of a child afflicted with an "adult" disease.

"It's unfortunate, but I believe if things were different, there would be a lot more help available for anyone suffering through a situation like this," she said.

Becker said it's important for teachers to realize the unique talents and limitations of bipolar children, and to work with them accordingly.

"As a rule, they're generally very bright children, very creative, some of them quite gifted," she said. "They're also very sensitive to what's going on around them and they often have specific learning challenges, like problems with planning and problem solving."

Sometimes teachers only see a bright child who doesn't appear to be giving a full effort, but Becker emphasized that nothing could be farther from the truth.

"These things have to be seen as part of the illness, rather than as a lack of caring or effort ... they don't want it to be that way, these kids desperately want to learn."

Cannon said she has learned more from Emily over the past few years than her daughter has from her, and the experience has made her fiercely determined to dispel the stigma surrounding the disease.

"I want this to be a message to Joe Q. Public. These children are special, they're fighting valiantly against a terrible illness and they should be applauded, not scowled at," she said.

"I want to tell parents not to lose sight of who their children are."