Nirvana’s LithiumI'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 youI'm not gonna crack

I love youI'm not gonna crack

I kill youI'm not gonna crack

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

Mood Disorders

AKA: Affective Disorders

Affect – “emotion” or “mood”

Unipolar & Bipolar Depression

Unipolar Bipolar

Depressive Disorder, NOSDysthymiaMajor Depression

-Single Episode-Recurrent

- - -Seasonal Affective

Disorder (SAD)Postpartum Depression

Mood Disorder, NOSCyclothymiaBipolar II DisorderBipolar I DisorderBipolar Disorder, NOS

Mania/Hypomania

-Extreme euphoria

-Lack of need for sleep

-Inflated Ego and Self-Esteem

-Loose Associations/Flight of Ideas

(from topic to topic)

-May become psychotic when in episode

(in mania only)

Continuum of Causes of Affective Disorders

Biological Bipolar

Major Depression

Environmental Dysthymia

Genetics

30-70% Identical twins 75% Both parents bipolar

Mood Disorders

Growing consensus that Bipolar is organically based with a notable genetic factor

Like Major Depression, Bipolar Disorder linked to low serotonin activity

Theory: low serotonin dysregulation of other important neurotransmitters, e.g., norepinephrine

Etiology of Bipolar Disorder

Mood Disorders“Defective Membrane” Theory of

Bipolar Disorder

1. Nerve impulse moves along neuron electro-chemically

2. Impulse carried via exchange of Na & K ions across neural membrane

NaK

3. Defect in process impulse carried too quickly or too slowly

GRK3 regulates sensitivity to neurotransmitters

Decreases the sensitivity of neurons to neurotransmitters

Acts as a brake to stress Maintains balance in the brain

GRK3 is a Gene For Bipolar Disorder GRK3 is inherited with bipolar disorder GRK3 is turned on by amphetamine A mutation in GRK3 increases risk to

bipolar disorder 3 fold

Mood Disorders

Genetic studies, especially of twins, indicate a genetic predisposition for bipolar disorder

40% of identical twins concordant, vs. 5 to 10% of fraternal twins

Etiology of Bipolar Disorder

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

Controversy 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

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

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 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 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

Pediatric-Onset Bipolar Disorder: Differential Diagnosis with ADHD

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

Talkativeness

Physicalhyperactivity

Distractibility

Time Magazine, August 19, 2002

Time Magazine, August 19, 2002

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% depakote 38% lithium 38% carbamazepine

Geller et al. High relapse rate Geller longitudinal study

1 year f/u recovery rate 37% Relapse rate 38%

Newer Agents Neurontin Lamictal Topamax Gabatril Atypical antipsychotics

Atypical Antipsychotics Risperidol Olanzapine (Zyprexa) Quetiapine (Seroquel) Abilify Geodon

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