Bipolar disorder thrust into spotlight


Ellis H. Katz, Ph.D., notes that identifying bipolar disorder in children can be challenging. (photo by Tom Croke)

By Phyllis Hanlon

Virginia Woolf, Sylvia Plath, Robin Williams, Vincent Van Gogh, and Beethoven have brought the word bipolar into the public lexicon. While their eccentric and sometimes dangerous behaviors make headlines, clearly identifying and appropriately treating bipolar in them - or any individual - presents a significant challenge.

The recent media attention to bipolar comes with both good and bad repercussions, according to Lucia Matthews, Ph.D., who has a private practice in Barrington, R.I. "The positive outcome is that people are talking about [bipolar]," she says. "The profession has become attuned to the subtleties. We are asking the right questions of our clients." She attributes this increased awareness to a better ability to "connect the dots" when it comes to diagnosing and treating bipolar disorder.

On the flip side, increased advertising for mood disorder medications is leading to an upsurge in demand from clients. "People are self-diagnosing," says Matthews. "When society focuses on something, it becomes the prevalent perspective."

However, the issue is not clear-cut. Clinicians have come to realize that this illness, while rooted in genetics, has an environmental component and often involves other diagnoses, such as anxiety and obsessive compulsive disorder (OCD). "When we talk about bipolar, we're talking about disregulation of chemistry," says Susan Sanders, Ph.D., of the Morning Bridge Center in Phillips, Maine.

The DSM-IV currently provides at least 10 different codes that can be used when diagnosing mood disorders. Bipolar falls into four general categories: depression, mania, hypomania and mixed mood. Recently, a new "catchall" code for bipolar spectrum disorder has been proposed, according to Sanders. She says the current system of categorizing - putting people into "little boxes" - is proving to be imprecise. "It's more useful and accurate to use a spectrum approach," she says, noting that the profession is undergoing a paradigm shift in its thinking about bipolar.

Ernie Downs, Ph.D., a private practitioner in Madbury, N.H., believes that a whole-person evaluation is the best way to diagnose bipolar disorder. "Within a session, I assess behavior, emotional reactivity and mood swings," he says. "I learn more by listening during the first session than by talking."

A history of extreme, cyclical behavior that affects relationships at home, school or in the workplace could lead to a bipolar diagnosis. "Pressured speech is the most obvious symptom," he says. "And the most reported symptom is thought bombardment." Downs adds that sleep difficulties and substance abuse issues are also contributing factors.

Admittedly, genetics plays a key role in bipolar. "We are drawn to someone whose temperament is like ours," Sanders says. She notes that if one parent has bipolar, there is a 15 to 30 percent risk of having a child with bipolar. If both parents have bipolar, the risk jumps to 50 to 75 percent.

Sanders explains that the treatment algorithm begins with mood stabilizing medication followed by talk or some other form of therapy. For instance, an OCD diagnosis responds to cognitive behavioral therapy (CBT). "But you can't treat someone with CBT whose mind is racing," she says. "Treatment occurs in layers." Sanders explains that once layers are peeled away, other diagnoses might be detected.

Matthews practices person-centered therapy in which she focuses on identifying a client's individual needs/wants. She teaches five skills that include distraction, toleration, acceptance and communication methods.

Borrowing a technique used in teaching children fire safety, Matthews also utilizes a "stop, drop and roll" system. She teaches the client to stop what he is doing, drop the urge to continue the behavior and roll out a new one. "By learning the skills, clients get confidence over controlling behavior," says Matthews, admitting that mastering the technique is not easy. She has successfully used this therapy for the last 10 years, but does not presume that her way is the best or only method.

Although bipolar usually develops in late adolescence or early adulthood, symptoms can appear much earlier, says Ellis H. Katz, Ph.D. A private practitioner, he also consults to an inner city school in Boston and in a hospital setting. "Usually the onset occurs during the 20s, but studies looking backward reveal that as many as half begin [to show symptoms] before the age of 18," he says.

While diagnosing bipolar in adults is difficult, identifying the illness in children presents an even bigger challenge. Katz says, "A lot of symptoms can be characteristic of typical behaviors of development at a certain age."

Many bipolar diagnoses in children begin as attention deficit hyperactivity disorder (ADHD) and Katz admits there can be overlap in diagnosis. Pervasive developmental disorders such as autism and Asperger's can also be confused with bipolar. Katz says, "It takes time to figure out the correct diagnosis."

Sanders reports that children may demonstrate prodromal factors such as sensitivity, irritability or regulatory difficulties, which are not diagnosable but suggestive of a potential problem.

Katz works closely with parents to determine a diagnosis and develop a treatment strategy. Depending on the symptoms, he coaches the parents and urges changes in eating and sleeping patterns. "Kids can have bipolar but having stability helps," he says. A regular bedtime, an orderly house, clear limits and reduced turmoil can create a more stable environment.

In addition to medication and talk therapy, Sanders reports that some success has been achieved through dietary changes, e.g., reducing sugar, caffeine, chocolate and carbohydrate intake. She also recommends the addition of omega-3 oils. "There are no real studies yet but you can notice a difference. Omega-3 oils have demonstrated usefulness in regulating brain functioning," she says. The evidence is anecdotal and caregivers should proceed with caution when administering omega-3 oils, particularly to children.

While some individuals with bipolar demonstrate creativity, energy, charisma and productivity, a therapist must make a connection with clients and individualize treatment, according to Downs. "One size does not fit all," he says, when dealing with a bipolar diagnosis.

The National Institute of Mental Health (NIMH) reports that approximately 5.7 million American adults, or 2.6 percent of the population over the age of 18, have bipolar disorder.

Bipolar disorder thrust into spotlight (March 2008 Issue)

Bipolar disorder thrust into spotlight
(March 2008 Issue)