Bipolar Disorder, Co-occurring Conditions, and the Need for Extreme Caution Before Initiating Drug Treatment
Rarely does bipolar disorder in children occur as a pure entity by itself. Rather it is often accompanied by clusters of symptoms that--when observed at certain points in a child’s life--suggest other psychiatric disorders, such as attention-deficit disorder with hyperactivity, depression, obsessive-compulsive disorder, oppositional defiant disorder, generalized anxiety disorder,conduct disorder, eating disorders, or Tourette’s syndrome.
The questions researchers are attempting to resolve are: Does bipolar disorder occur simultaneously with other psychiatric disorders making it possible for a child actually to have three or four diagnoses? Are these clusters of symptoms that suggest distinct disorders merely early precursors on a developmental continuum that eventually expresses itself as full-blown bipolar?
Are all these symptoms merely a more apt description of early-onset bipolar disorder?
The truth is no one knows for certain. And until research can provide clarification, parents are going to have to tolerate a great deal of diagnostic ambiguity. Yet a correct diagnosis is vital to a child’s well-being, for it is the proper diagnosis that guides the treatment and--equally important--prevents the child from being placed on medications that can considerably worsen the course of the disorder.
It is not uncommon for physicians to focus narrowly on one cluster of symptoms--often the ones that are most recognizable such as a depressed mood or hyperactive behavior. As a result, a child may be prescribed antidepressants such as Prozac, Paxil, Zoloft, Celexa and so on to treat the depressive symptoms, and stimulants such as Ritalin, Adderall and Cylert to treat what appears to be attention-deficit disorder with hyperactivity. Luvox, an antidepressant also in the selective serotonergic reuptake inhibitor (SSRI) category is commonly prescribed for symptoms of obsessive-compulsive disorder.
Yet data is emerging that is beginning to demonstrate the dangers of treating only the attentional, depressive, or obsessional symptoms, meantime overlooking the possibility of a bipolar condition.
The Overlap With ADHD
Perhaps the greatest source of diagnostic confusion in childhood bipolar disorder is that its symptoms overlap with many of the symptoms of attention-deficit disorder with hyperactivity. At first glance, any child who can’t sit still, who is fidgety, impulsive, easily distracted or emotionally labile is more likely to receive a diagnosis of ADHD than bipolar disorder. However, since over 80 percent of children with a bipolar disorder will meet full criteria for attention-deficit disorder with hyperactivity, ADHD should be diagnosed only after bipolar disorder is ruled out. While these two conditions seem highly co-morbid, stimulants unopposed by a mood stabilizer can have an adverse effect on the bipolar condition. 65 percent of the children in our study had hypomanic, manic and aggressive reactions to stimulant medications. Parents wrote to us and described some of their children’s reactions to stimulants. They said things like: "He got sky-high on Ritalin and then violent"; "Ritalin caused physical aggression"; "She got psychotic on stimulants"; "He got suicidal and tried to get run over by a car"; "He went bonkers..."
This past May, in a letter to the editor of the Journal of the American Academy of Child and Adolescent Psychiatry,Tomie Burke, founder of Parents of Bipolar Children, and Martha Hellander, Executive Director of the Child and Adolescent Bipolar Foundation addressed the issue of whether mania is mistaken for attention-deficit disorder with hyperactivity in children. They wrote: "Most of our children initially received the ADHD diagnosis, were given stimulants and/or antidepressants, and either did not respond or suffered symptoms of mania such as rages, insomnia, agitation, pressured speech, and the like. In lay language, parents call this ‘bouncing off the wall." First hospitalizations occurred often among our children during manic or mixed states (including suicidal gestures and attempts) triggered or exacerbated by treatment with stimulants, tricyclics, or selective serotonin reuptake inhibitors. Many of these same children are now doing well on lithium or other mood stabilizers, along with cautiously monitored adjunctive medications."
A First Episode of Depression
It is also not uncommon for the initial episodes of a developing mood disorder to present as major depression. But as clinical investigators follow the course of the disorder in children, a significant rate of switching to bipolar symptoms occurs. According to the American Academy of Child and Adolescent Psychiatry, a third of the 3.4 million children who first seem to be suffering with depression will go on to manifest the bipolar form of a mood disorder.
The only major epidemiological study of bipolar disorders in youth was conducted by Dr. Peter Lewinson and colleagues at the Oregon Research Institute, and they found that a significant percentage ( 61.1 percent) of the bipolar adolescents began their course of illness with either minor or major depressive episodes.
What are the possible predictors of a switch from a major depressive disorder to a manic-depressive course of illness? In the survey we conducted for our book, some of the common symptoms that preceded a bipolar course were depressions marked by a craving for sweets and carbohydrates, prolonged and aggressive temper tantrums, lethargy, oversleeping, separation anxiety, self-consciousness with others, and phobic anxiety.
While it is so tempting to want to rescue a child from depression with an antidepressant, bipolar children often have terrible and bizarre reactions to these medications. In our study, over 80 percent of the children now diagnosed as bipolar had manic, hypomanic, violent, and suicidal reactions to these medications. Often the child seemed to do well at first, but after weeks and even months of treatment (we heard the time period three months quite often) a deterioration seemed to take place and the child became: "nasty and had vicious"; "giddy and silly"; "activated, aggressive, and agitated"; and we heard reports of "increased cycling"; "She began to cut herself"; "He destroyed my entire porcelain collection with a baseball bat and then came at me with a knife. I had to call the police and they put my beloved 13-year-old in jail."
Obsessive-compulsive symptoms may also occur in tandem with a bipolar disorder and, again, it is risky to treat just the obsessional symptoms. Last year, Dr. Frances S. Go and colleagues at the Department of Psychiatry at the University of Pittsburgh Medical Center treated a sample of 20 adolescents (ages 11-17) diagnosed with OCD and mood disorders and reported that 30 percent of the patients--6 out of the 20--treated with SSRIs developed mania or hypomania. The symptoms included impulsivity, grandiosity, pressured speech, and disinhibition and emerged despite a gradual dose elevation and conservative dosing. The authors advise clinicians to "be aware of the risk and to be vigilant in monitoring manic and hypomanic behaviors when using SSRIs to treat OCD in youth..."
The Big Picture
How, then, does a clinician make a diagnosis of bipolar disorder with all the co-morbid conditions? The family history is an important clue. If the family history reveals mood disorders, suicide, or alcoholism coming down one or both sides of the family tree, red flags should appear in the mind of the diagnostician. The illness has a strong genetic component although it can skip a generation.
It is obvious that the diagnosis of mood disorders in children is extremely complex. While the perplexing questions raised by the frequency of co-morbid diagnoses cannot be resolved at this time, researchers have begun to define a syndrome that encompasses symptoms of a number of childhood psychiatric disorders but also has unique features of its own. Ranging from "very common" to "common," the symptoms and behavioral traits that have consistently observed in children with early-onset bipolar disorder include:
Separation anxiety Rages and explosive temper tantrums lasting up to several hours Irritability Oppositional behavior Rapid cycling (frequent mood swings, occurring within an hour, a day, or several days) Distractibility Hyperactivity Impulsivity Restlessness/fidgetiness Silliness, giddiness, goofiness Racing thoughts Aggressive behavior Grandiosity Carbohydrate cravings Risk-taking behaviors Depressed mood Lethargy Low self-esteem Difficulty getting up in the morning Social anxiety Oversensitivity to emotional or environmental triggers
Bedwetting (especially in boys) Night terrors Rapid or pressured speech Obsessional behavior Compulsive behavior Excessive daydreaming Motor and vocal tics Learning disabilities Poor short-term memory Lack of organization Fascination with gore and morbid topics Hypersexuality Manipulative behavior Extremely bossy behavior with friends/bullying Lying Suicidal thoughts Destruction of property Paranoia Hallucinations and delusions
Now understanding that early-onset bipolar disorder is frequently co-morbid with other childhood psychiatric conditions, doctors and parents should be concerned that a medication used to treat these other conditions may "flush out" a previously quiescent bipolar gene that can significantly worsen the course of illness and potentially wreak havoc with that child’s life. It is therefore vitally important that parents learn everything they can about their family histories, and if mood disorders (depression or manic-depression), suicide, or alcoholism come to light, treatment should proceed very cautiously. Mood stabilizers should perhaps be the first line of treatment (and it may take two such medications to stabilize the child), and attentional, obsessional, or depressive symptoms be treated only after a therapeutic dose of the mood stabilizer is achieved.
Papolos, Demitri and Janice Papolos. The Bipolar Child. New York: Broadway Books, December, 1999.
Go, Frances S. Erin E. Malley et al. "Manic Behaviors Associated with Fluoxetine in Three 12-18-year-olds with Obsessive Compulsive Disorder." Journal of Child and Adolescent Psychopharmacology 8 (1998):73-80.
Hellander, Martha E. and Tomie Burke. "Children With Bipolar Disorder (letter to the editor)" Journal of the Academy of Child and Adolescent Psychiatry 38 (May 1999): 495.
Lewinson, Peter M, Daniel N. Klein, and John R. Seely. "Bipolar Disorders in a Community Sample of Older Adolescents: Prevalence, Phenomenology, Comorbidity, and Course." Journal of the Academy of Child and Adolescent Psychiatry 34 (April 1995):454-463.
This newsletter will be published regularly and will attempt to be responsive to specific questions that are pertinent to families. Please send in your comments and suggestions to firstname.lastname@example.org which can also be reached through our web site at www.bipolarchild.com. Please feel free to forward the newsletter to others you think may find it helpful.
We continue to collect research data on clinical symptomatology and ask that those that are interested and have not already enrolled in the research program you may do so at the web site.
If you have received this newsletter from a friend, family member or colleague and want to subscribe yourself, please go to http://www.bipolarchild.com/contact.html.
Click here to view Bipolar Disorder Fact Sheet published by Healthline on April 5, 2012.
Return to FAS Community Resource Center