Bipolar Disorder Post Traumatic Stress Disorder

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					       Bipolar Disorder
Post Traumatic Stress Disorder
      Nancy Rappaport, MD
      Harvard Medical School
          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
 Epidemiology of Bipolar Disorder

• Prevalence: 1% of population Adults =
• 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
Time Magazine, August 19, 2002
   Nirvana’s 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
•   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
  Assessment/Diagnosis of Bipolar
• 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
        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

• 30-70%   Identical twins
• 75%      Both parents bipolar
                 Mood history
• Mania
  – Giddy, goofy, laughing fits, class clown
  – Explosive (how often, how long, how destructive and
  – Irritable, cranky, angry, disrespectful, threatening
  – Grandiosity may present as EXTREME defiance and
• 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
• DIGFAST acronym (at least 3 of 7
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
• 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
• 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
• ADHD criteria does not include a
  mood component (usually
  comorbid ODD)
• Look for family history data to
  help with diagnosis of bipolar
• Nonverbal learning disorders
     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
  Prioritizing Target Symptoms

1. Treat mania and/or psychosis
2. Treat depression
3. Anxiety and ADHD
• Mood Stabilizers
• Lithium
• Divalproex Sodium
• 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
  Atypical Antipsychotics (ctd.)
• 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
 The Explosive
 Ross Greene,

The Basket Model
     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)
        Entering the Baskets
• Basket A: “No”, “You must,” “You can’t”
• Basket B: Empathy, problem, invitation
• Basket C: I didn’t bring it up
         Basket Model (ctd.)
• Basket A: He did what I said
• Basket B: We worked it out, we solved the
• Basket C: I didn’t bring it up
          Treatment Objectives

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

• Meltdowns are 99.9%
 Post Traumatic Stress Disorder

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

• Escaping political terror or ethnic
• Cumulative losses
• Staggered patterns of entry
          PTSD - Symptoms
• Hyperarousal (most common symptom;
  startled response, behavioral irritability,
  sleep disturbances, regulatory functions off,
  hypervigilance, emotional numbing, or
• Nightmares
• Flashbacks
• Upsetting reminders and triggers
Active Avoidance
   Passive Avoidance
             Fight or Flight
• Fight or Flight response alarm reaction then
  fear (experience in the high school,
  sometimes inappropriate escalating
  behavior by adults to child’s apparent
• Freezing: hyperarousal, dissociation
  response seen as oppositional
      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
 Impact of Trauma on Learning

• Hypervigilant
• Highly aroused
• High speed “on” or “off”
  Impact of Trauma on Learning

• Interference with cognition and information
• Difficulty processing verbal information
  with a disproportionate emphasis on
  nonverbal clues
• Difficulty regulating emotions
  and differentiating emotions
• Language used to distance
• Locus of control gives up easily

•   Secondary attachment figure
•   Pianta’s work “Banking”
•   Error history - disorganized attachment
•   Islands of competency
              PTSD (ctd.)

• No particular medication
• Low doses of SSRI if depression and
  anxiety present
• Risks/benefits
      Exercise: The 5 Steps of
      Cognitive Restructuring

   Ask yourself: What happened that made
   me upset?” Write down a brief description
   of the situation.
   Situation: _________________________
  Circle your strongest feeling (if more than
  one applies, use a separate sheet for each

  Fear/Anxiety        Sadness/Depression
  Guilt/Shame         Anger
  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
  THOUGHT: _______________________
If it applies, circle your common style of

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
   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: ______
  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
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
New Thought: __________________________
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
Action Plan: _________________________
    YES, my thought is supported by the
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: _____________________________
    Guide to Thoughts and Feelings
FEELINGS                ASK YOURSELF Related Thoughts

Fear, nervousness,      What bad thing do I     •Something terrible is
anxiety                 expect to happen?       going to happen
                        What am I scared is     •I am going to be attacked
                                                or hurt
                        going to happen?
                                                •I am going to be rejected
                                                or abandoned
                                                •I am going to lose control
                                                or go crazy

Sadness or depression   What have I lost?       •I am not worth anything
                        What is missing in me   •I don’t have anyone I can
                        or in my life?          depend on
                                                •Nothing will ever get
                                                •Life is not worth living
    Guide to Thoughts and Feelings
FEELINGS         ASK YOURSELF Related Thoughts

Guilt or shame   What bad thing have I  •I am not good enough
                 done?                  •I am to blame for what
                 What is wrong with me? happened to me
                                        •I am a bad person
                                        •I am a failure

Anger            What is unfair about the   •I am being treated
                 situation?                 unfairly
                 Who has wronged me?        •I am being used
                                            •The situation is unfair
                                            •Someone has done
                                            something wrong to me
                           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. Because…I am…special.

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