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Bipolar Disorder & Post Traumatic Stress Disorder Nancy Rappaport, MD Harvard Medical School.

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Presentation on theme: "Bipolar Disorder & Post Traumatic Stress Disorder Nancy Rappaport, MD Harvard Medical School."— Presentation transcript:

1 Bipolar Disorder & Post Traumatic Stress Disorder Nancy Rappaport, MD Harvard Medical School

2 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

3 Epidemiology of Bipolar Disorder Prevalence: 1% of population Adults = Adolescents 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

4 Time Magazine, August 19, 2002

5 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

6 Controversy Severity and duration Onset before puberty is estimated to be rare Developmental variability Retrospective study of adults

7 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 color.”

8 Assessment/Diagnosis of Bipolar Disorder 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

9 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

10 Genetics 30-70%Identical twins 75%Both parents bipolar

11 Mood history Mania –Giddy, goofy, laughing fits, class clown –Explosive (how often, how long, how destructive and aggressive) –Irritable, cranky, angry, disrespectful, threatening –Grandiosity may present as EXTREME defiance and oppositionality Depression –Low frustration tolerance, self-destructive, no pleasure, lower level of irritability

12 DSM Criteria A distinct period of abnormally and persistently elevated, expansive, or irritable mood DIGFAST acronym (at least 3 of 7 symptoms)

13 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

14 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

15 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

16 Major depression often presents first (estimated that % of children presenting with major depression within 5 years will be bipolar) Comorbidity % of adolescents have other disorders ADHD, Conduct Disorder, Substance abuse

17 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

18 Atypical presentation in juveniles- exacerbation of disruptive behavior, moodiness, low frustration tolerance, explosive anger and difficulty sleeping at night Comorbidity of ADHD/BPD more severe presentation, often severe affect dysregulation, marked impairment, violent temper outbursts

19 Pediatric-Onset Bipolar Disorder: Differential Diagnosis with ADHD ADHD confusion although identifying presence of mood disorder helpful in guiding treatment Talkativeness Physical hyperactivity Distractibility

20 ADHD criteria does not include a mood component (usually comorbid ODD) Look for family history data to help with diagnosis of bipolar disorder Nonverbal learning disorders overlap

21 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

22 Prioritizing Target Symptoms 1.Treat mania and/or psychosis 2.Treat depression 3.Anxiety and ADHD

23 Medications Mood Stabilizers Lithium Divalproex Sodium (Depakote) Carbamezapine

24 Improvement is seen when mood stabilizers are used Kowatch et al (JAACAP 2000) Response rates: –53%depakote –38%lithium –38%carbamazepine

25 Geller et al. High relapse rate Geller longitudinal study –1 year f/u recovery rate37% –Relapse rate38%

26 Newer Agents Neurontin Lamictal Topamax Gabatril Atypical antipsychotics

27 Atypical Antipsychotics Risperidol Olanzapine (Zyprexa) Quetiapine (Seroquel) Abilify Geodon

28 Atypical Antipsychotics (ctd.) Increasingly used because they can cause rapid patient stabilization Zyprexa can help with depression, mania and psychosis Weight gain

29 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.

30 Multiple Modalities Psychotherapy Psychoeducation/Support School Support/Consultation Residential Placement, Acute Hospitalization Mood Charting Teach Good Sleep Hygiene Legal intervention Hope

31 The Explosive Child Ross Greene, PhD The Basket Model

32 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)

33 Entering the Baskets Basket A: “No”, “You must,” “You can’t” Basket B: Empathy, problem, invitation Basket C: I didn’t bring it up

34 Basket Model (ctd.) Basket A: He did what I said Basket B: We worked it out, we solved the problem. Basket C: I didn’t bring it up

35 Treatment Objectives Reduce meltdowns Teach lacking skills Flexibility Frustration tolerance

36 Reminder!! Meltdowns are 99.9% predictable

37 Post Traumatic Stress Disorder Impact of traumatic experiences affects capacity to function in school Physical abuse Sexual abuse Domestic violence

38 PTSD 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

39 Trauma and Immigration Escaping political terror or ethnic persecution Cumulative losses Staggered patterns of entry

40 PTSD - Symptoms Hyperarousal (most common symptom; startled response, behavioral irritability, sleep disturbances, regulatory functions off, hypervigilance, emotional numbing, or dissociation) Nightmares Flashbacks Upsetting reminders and triggers

41 Active Avoidance Passive Avoidance

42 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 impertinence) Freezing: hyperarousal, dissociation response seen as oppositional

43 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

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

45 Impact of Trauma on Learning (ctd.) Interference with cognition and information processing Difficulty processing verbal information with a disproportionate emphasis on nonverbal clues

46 Difficulty regulating emotions and differentiating emotions Language used to distance people Locus of control gives up easily

47 PTSD Secondary attachment figure Pianta’s work “Banking” Error history - disorganized attachment Islands of competency

48 PTSD (ctd.) No particular medication Low doses of SSRI if depression and anxiety present Risks/benefits

49 Exercise: The 5 Steps of Cognitive Restructuring 1.SITUATION Ask yourself: What happened that made me upset?” Write down a brief description of the situation. Situation: _________________________

50 2. FEELING Circle your strongest feeling (if more than one applies, use a separate sheet for each feeling): Fear/AnxietySadness/Depression Guilt/ShameAnger

51 3. THOUGHT 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 below. THOUGHT: _______________________ __________________________________

52 If it applies, circle your common style of thinking: Again and Again Too Much Risk Must/Should/NeverEnd of the World Always Blaming YourselfAll or None Thinking on the Downside Thinking With Your Feelings

53 4. CHALLENGE YOUR THOUGHT 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: ______ ________________________________________

54 5. OUTCOME 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 evidence.

55 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 thought. New Thought: __________________________ ______________________________________

56 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 below. Action Plan: _________________________

57 YES, my thought is supported by the evidence. 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: _____________________________ ________________________________________

58 Guide to Thoughts and Feelings FEELINGS ASK YOURSELF Related Thoughts Fear, nervousness, anxiety What bad thing do I expect to happen? What am I scared is going to happen? Something terrible is going to happen I am going to be attacked or hurt I am going to be rejected or abandoned I am going to lose control or go crazy Sadness or depressionWhat have I lost? What is missing in me or in my life? I am not worth anything I don’t have anyone I can depend on Nothing will ever get better Life is not worth living

59 Guide to Thoughts and Feelings FEELINGS ASK YOURSELF Related Thoughts Guilt or shameWhat bad thing have I done? What is wrong with me? I am not good enough I am to blame for what happened to me I am a bad person I am a failure AngerWhat is unfair about the situation? Who has wronged me? I am being treated unfairly I am being used The situation is unfair Someone has done something wrong to me

60 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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