Definition

Bipolar disorders is the name given to a group of mental disorders characterized by extreme fluctuations in mood. People diagnosed with bipolar disorders experience moods ranging from deepest depression to mania, often with periods of less extreme moods, or even emotional stability, in between.

Description

Individuals diagnosed with bipolar disorders experience fluctuations in mood over which they have no control. All of the bipolar disorders cause great emotional distress. Even the state of elevated mood, or "mania," might sound as if it would feel good; but it is, in fact, a painful, pressured feeling that is not at all pleasurable. People with mania find their thoughts running at an unstoppable pace; they cannot sleep, often for many nights at a time. Their speech may become rapid, and they may have grandiose ideas. Often people in manic states spend money they do not have, and make important but disastrous life decisions.

Individuals in the depressed mood state experience loss of interest in activities and people. They also experience loss of appetite, difficulty sleeping, lack of sexual desire, and an extreme loss of general energy. The ability to concentrate and think clearly is also compromised. Work, social, and family relationships are always impaired. Feelings of worthlessness and helplessness are common, as is the feeling that nothing will every improve. While depressed individuals may or may not report feeling "down" or "depressed," the feelings they do experience are very painful.

The handbook used by mental health professionals to diagnose mental disorders is the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, also known as the DSM-IV-TR. It includes four basic types of bipolar disorder : Bipolar I Disorder, Bipolar II Disorder, Cyclothymia, and Bipolar Disorder Not Otherwise Specified.

Bipolar I disorder is characterized by one or more manic episodes, or so-called "mixed" episodes, which involve both manic and depressive feelings alternating rapidly, often within the same day or week. Individuals with Bipolar I disorder may also experience one or more major depressive episodes. Suicide occurs in 10-15% of individuals with this disorder.

Bipolar II disorder is characterized by the occurrence of one or more major depressive episodes, interspersed with periods of mild manic episodes referred to as "hypomania." Hypomanic episodes are similar to manic ones, but are far less intense and less severe in their consequences. In fact, individuals may not see their hypomanic episodes as a problem, feeling, instead, that they have bursts of energy in which they can accomplish a great deal.

Cyclothymic disorder is a chronic, low-level disturbance of mood, punctuated by periods of depressive symptoms and periods of hypomanic symptoms. Cyclothymia often begins early in life, and people with the disorder may not know they have it; they may simply think of themselves as sadder and/or less energetic than other people, with occasional bursts of energy.

Bipolar disorder not otherwise specified is the term used in the DSM-IV-TR for individuals who do not meet the criteria for one of the other three diagnoses, but who nevertheless experience patterns of mood swings alternating between depression and mania.

Bipolar Disorder in Childhood and Early Adolescence

There has been substantial controversy in the mental health field about the existence and diagnostic boundary of childhood (i.e., early-onset) bipolar disorder. Although it is now accepted that symptoms of mania can be manifested in children and adolescents (see National Institute of Mental Health Research Roundtable on Prepubertal Bipolar Disorder, 2001, Journal of the American Academy of Child and Adolescent Psychiatry, 40, 871-878), many questions remain about the diagnosis, natural history, neurobiology, and treatment of early-onset bipolar disorder. The book Bipolar Disorder in Childhood and Early Adolescence is an edited collection of 15 chapters that address these questions as well as a range of other aspects of early-onset bipolar disorder. The authors of the chapters are established scientists whose work in this area is recognized as "state of the art."

The first 4 chapters of the book address the diagnosis and phenomenology of bipolar disorder in children and adolescents. In chapter 1, Peter Lewinsohn and his colleagues describe the epidemiology, clinical characteristics, and longitudinal course of early adolescent bipolar disorder. Chapter 2, by Barbara Geller and her colleagues, discusses a recently developed diagnostic instrument for pediatrie bipolar research and presents data that help to clarify the diagnostic boundary between attention deficit/hyperactivity disorder (ADHD) and early-onset bipolar disorder. In chapter 3, Sandra Dejong and Jean Frazier review phenomenological characteristics, diagnostic issues, and pharmacological treatments for children and adolescents with co-occurring pervasive developmental disorders and early-onset bipolar disorder. Chapter 4, by Demitri Papolos, examines the common comorbidities (e.g., ADHD, conduct disorder, substance use disorder) associated with early-onset bipolar disorder. In chapter 5, Kiki Chang and Hans Steiner review studies about offspring of parents with bipolar disorder and describe early manifestations of bipolar disorder in children.

The second section of this book discusses the genetic, biological, and neurological causes and correlates of early-onset bipolar disorder. Chapter 6, by Nuri Farber and John Newcomer, examines how problems in brain maturation and development might lead to abnormalities in neuronal functioning that underlie symptoms of bipolar disorder. In chapter 7, Melissa DelBello and Robert Kowatch review data from neuroimaging studies (e.g., computed tomography, magnetic resonance imaging, single-photon emission computed tomography) and conclude that children and adolescents with bipolar disorder exhibit frontal-subcortical brain abnormalities. In chapter 8, Robinder Bhangoo and her colleagues discuss the physiological correlates of emotion that are especially relevant to early-onset bipolar disorder. Chapter 9, by Ohel Soto and Tanya Murphy, uses the example of pédiatrie autoimmune neuropsychiatrie disorders associated with streptococcus (PANDAS) to explain how immune system dysfunction can produce psychiatric symptoms, including mania and depression. In chapter 10, Uma Rao discusses EEG sleep pattern disruptions underlying bipolar disorder and suggests possible mechanisms (e.g., circadian dysregulation) related to these disruptions. Chapter 11 is an interesting review of findings from family, twin, and adoption studies in which the author, Judith Badner, provides evidence for a genetic basis for early-onset bipolar disorder; she also suggests that familial factors for childhood-onset and adult-onset bipolar disorders are similar.

The third and final section of this book focuses on biological and psychosocial interventions for children and adolescents with bipolar disorder and their families. In chapter 12, Neal Ryan reviews the scant empirical literature on pharmacological treatment options for childhood and early adolescent bipolar disorder. Chapter 13, by Jill Goldberg-Arnold and Mary Fristad, provides a detailed description of a family group treatment that focuses on social skills development and symptom management for children with early-onset bipolar disorder. Chapter 14, also by Fristad and Goldberg-Arnold, provides practical information that therapists and parents can use to manage family, school, and peer difficulties among children with bipolar disorder. In the final chapter, Martha Hellander and her colleagues discuss the potential of the Internet in creating and sustaining support groups for parents of children and adolescents with bipolar disorder.

This book provides some very useful information on the burgeoning area of early-onset bipolar disorder. A clear strength of the book is that it addresses some of the more controversial aspects of the disorder, including issues related to comorbidity and the differing clinical manifestations in children versus adults. Another strength of the book is that it discusses the latest empirical findings in this area and provides some clues about etiology and prognosis. The book also provides clinicians with preliminary but helpful treatment protocols for working with families of children with bipolar disorder.

Although this book conveys some of the most recent developments about bipolar disorder in children, the relative lack of empirical knowledge on this disorder is apparent. Moreover, although early-onset bipolar disorder likely has a strong genetic and biological basis, the research presented in this book fails to consider psychosocial factors that might precipitate the onset of the disorder or that might mediate the impact of genetic and biological factors. Another limitation of the book is that the chapters are rather loosely organized and are not well integrated with each other. The book could have benefited from a concluding chapter in which the editors synthesized the contributions of the different authors and delineated important areas for research and clinical practice.

Overall, this book provides a thorough representation of recent research on early-onset bipolar disorder and may serve as a helpful reference for researchers and practitioners who wish to understand the phenomenology and biological factors associated with this disorder. Although more research is needed in the area of treatment, the book may serve as a preliminary guide for therapists working with children and adolescents with manic and depressive symptoms. This book is a valuable addition to the field of child psychiatry, child clinical psychology, and related disciplines.

[Author Affiliation]

Columbia, MO CHARLES M. BORDUIN, PH.D.

AMY L. DAMASHEK, M.A.

See also Affect; Bipolar disorder; Cognitive-behavioral therapy; Cyclothymic disorder; Depression and depressive disorders; Dysthymic disorder; Lithium carbonate; Manic episodes

Resources

BOOKS

American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Kaplan, Harold I., MD and Benjamin J. Sadock., MD Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 8th edition. Baltimore, MD: Lippincott Williams and Wilkins, 1998.

Barbara Sternberg, Ph.D.