Chapter One
Understanding Bipolar Disorder
The following portraits will give you a vivid illustration of how differently bipolar disorder can appear in different children and at different ages. I will then go on to explain what connects these very different children to a single diagnosis of bipolar disorder.
Ralph, age eleven, was an excellent student and a creative, talented artist. He was also impulsive, overly excited in groups, often silly and goofy, and subject to sudden aggression. Ralph's inappropriate behavior made him a target for teasing at school, while at home his difficulty in accepting limits was causing his relationship with his parents to deteriorate. His mother brought him to me primarily because he seemed depressed and had difficulty sleeping.
Jean was first seen at the age of twelve, because of complaints of depression. She cried frequently, had great difficulty sleeping, imagined herself dying, and had recently begun deliberately scratching herself superficially, enough to break the skin but not penetrate it. Jean also had periods of intense energy and high spirits during which she had unrealistically grand ideas. When I saw her, her speech was rapid and her thinking was scattered. While her developmental history was largely normal, she had experienced great difficulty with the word no when she was a toddler and had an episode of depression as early as the fourth grade.
Klaus was a handsome, sweet, blond six-year-old who was brought to me because of severe tantrums, as well as oppositional and bizarre behavior. He was also highly activated--becoming hyperactive and silly--when he ate sugar. Klaus had been started on Ritalin at age five for what was thought to be ADHD, but when I first saw him he was frankly psychotic: hyperactive, silly, grimacing, and talking incessantly. He drew several pictures in rapid succession in a wild and scribbling style. He had cut up his clothes with scissors after a dream in which he found himself in a "paper world" where a paper tiger had bitten off his head. He told me he cut up his clothes while trying to cut up the tiger that was attacking him. His reaction to the stimulant (and to sugar) made clear to me that his hyperactivity and inattention were symptoms of early onset bipolar disorder.
Each of these children suffers from bipolar disorder, a psychiatric condition characterized by dramatic movements between two poles or extremes of mood. As you may already know, a child with bipolar disorder can go from periods of being overly high or irritable (hypomania) to periods of despair and hopelessness (depression) and back again--sometimes within the space of just a few minutes. These mood changes (oscillations) can be startling and confusing, both to the child and those around him. He may feel happy and content one minute, then suddenly plunge into deep despair or intense rage. He may ricochet between a sense of well-being and personal power and a sense of hopelessness and depression, between feelings of creativity and energy and feelings of frustration and inertia. A manic silliness or an explosive irritability can suddenly be replaced by an anxious withdrawal from the world.
Mood swings can be triggered by stress, monthly or daily hormonal cycles, seasonal changes, variations in blood sugar, or the ups and downs of life. Although mood swings affect all children to some extent, they can be disabling for a child with bipolar disorder. Once set in motion, these swings can develop a life of their own--they can build up a biological head of steam, a momentum that carries well beyond the original insult and cannot be quelled by typical parenting.
Bipolar disorder is also characterized by intensity: intense energy, activity, imagination, anxiety, anger, stubbornness, irritability, shyness, sensitivity, silliness, or restlessness. These two traits--oscillation and intensity--may be present very early in life, appear at a particular developmental stage, or occur in response to certain stressors.
Because of their intense energy, creativity, and perceptiveness, bipolar kids can be wonderfully engaging, inspiring joy and pride in you as a parent. But their intensity and changeability can also make them unpredictable, oppositional, and at times inconsolable. Tasks that are routine for other children--making friends, obeying rules, staying asleep at night, performing well at school, and feeling comfortable in the world--can be very difficult for them, and for you as a parent.
Some Basic Terms
attention deficit disorder (ADD). A condition in which a person has unusual difficulty staying focused on a subject or an activity. A person with ADD often loses track of what she is asked to do or where she has put things, or what she meant to do a moment ago.
attention-deficit/hyperactivity disorder (ADHD). A person with ADHD has the same problems as a person with ADD but is also restless, impulsive, talkative, and in constant motion.
bipolar I. This is classic manic depression with episodes of both highly elevated and depressed mood. It must include at least one episode of full-blown mania (defined below) and usually more frequent depressions. Although manic episodes and depressions can be extremely disabling, this condition is also often characterized by unusual imagination, productivity, artistic talent, or inventiveness.
bipolar II. This is a less flagrant (although no less dangerous) condition. It consists of hypomanic episodes and recurrent depressions. The hypomanic episodes may be more irritable than elated and may appear as explosions of temper as well as an increase in activity. The hypomanic episodes may also be characterized by a driven pursuit of some goal, real or imaginary. Although bipolar II is not characterized by the extreme moods seen in bipolar I, it can disable a person's ability to function personally or professionally, and it carries a significant risk for suicide.
bipolar III. This is a more recent term (not yet accepted by all psychiatrists), which refers to a person who appears to be normal or simply depressed but has a manic or hypomanic response to an antidepressant. In children it can include a child who appears to have ADHD but becomes manic, hypomanic, or depressed when treated with a stimulant.
depression. The central feature of depression is an inability to experience pleasure. It is usually accompanied by negative and self-critical or self-destructive thoughts. Depression can also cause crying; irritability; rage; anxiety; fatigue; and disturbances in sleep, appetite, thinking, and movement (usually a slowing but sometimes agitation).
grandiosity. Thinking or behavior that is based on a grossly exaggerated sense of one's power, importance, intelligence, or ability to succeed.
hypomania. A state of arousal with some of the characteristics of mania but not to a degree that is necessarily disabling: increased energy, imagination, productivity, grandiosity, silliness or wittiness, pressured speech, increased motor activity, or irritability. People who are hypomanic may or may not have impaired judgment (if they do, it is less severe than with mania). Some bipolar I patients, when they are hypomanic, seem larger than life or infectiously amusing. Bipolar II patients when they are hypomanic can be frighteningly irritable or destructive.
mania. True mania is a disabling condition of arousal that usually requires hospitalization. It consists of rapid pressured speech, racing thoughts, extreme impulsivity (usually a form of pleasure seeking but sometimes an attempt to escape an irrational danger), hypersexuality, decreased sleep, increased energy, decreased appetite, grandiose thinking, hallucinations, and delusions. Mania is always accompanied by gross deficits in judgment.
oscillation. A movement up and down, as with the movement of a wave or a spring. One can talk of mood oscillations, hormonal oscillations, oscillations of blood sugar, or seasonal oscillations.
What Causes Bipolar Disorder?
Bipolar disorder is an inherited condition, like hair color or intelligence. There are almost certainly several genes involved, and a child can inherit some from one parent and some from the other. Probably some bipolar patients have a different set of inherited genes than others. In some children I have seen, I don't recognize the disorder in either parent, although there are traces of it in grandparents, uncles, aunts, or cousins. As with other medical conditions, such as cardiovascular disease or emphysema, what is probably inherited is a biological vulnerability that appears more or less severely depending on the influence of environmental stress or biological risk factors.
The first sign of the disorder is often depression, unaccompanied by mood elevation, appearing before or during puberty. The depression may come about in response to a personal loss or a social setback (an environmental stress), or it can begin in response to a recreational or prescribed drug (a biological risk factor). In younger children, however, the disorder can appear in forms of increased arousal: severe temper tantrums, unusual anxiety, intense silliness, or an early sleep disturbance.
How Do I Know If My Child Is Bipolar?
A reliable diagnosis of bipolar disorder requires a thorough psychiatric evaluation, including an examination of the child, a description of current symptoms, history of symptoms, developmental history, and family history. Even then a diagnosis may be tentative, depending on a child's course over time. There are, however, things you can look for.
Contrary to what many people think, bipolar disorder is not just another name for manic depression--although the concept arose from earlier understandings of manic depression, and bipolar disorder includes manic depression. What unites other forms of bipolar disorder with manic depression is the character...
![[Start the discussion]](http://g-ecx.images-amazon.com/images/G/01/x-locale/communities/discussion_boards/start-new-discussion-sec._V192250339_.gif){kind=small}
