Bipolar disorder

Bipolar disorder (BD) is a condition in which a young person has extreme changes of mood - periods of being unusually happy (known as ‘mania’ or ‘hypomania’), and periods of being unusually sad (‘depression’).

It is sometimes called 'manic depressive disorder’, ’bipolar affective disorder’ or ‘bipolar mood disorder’.

The mood swings are way beyond what would be considered normal for a particular individual, and are out of keeping with their personality.

Bipolar disorder is extremely rare in young children, but there are quite a few studies that suggest that it may start in teenage years and in early adult life. It affects about one in 100 adults.

The condition can be hard to recognise in teenagers because more extreme behaviour can be part of this stage of life.

In bipolar disorder, a person can have:

• manic or hypomanic periods (or ‘episodes’)
• depressive periods
• mixed periods.

Below is a list of the symptoms in each episode. A young person needs to have at least one manic or hypomanic episode to be diagnosed with bipolar disorder.

• feeling incredibly happy or 'high' in mood, or very excited
• feeling irritable
• talking too much -increased talkativeness
• racing thoughts
• increased activity and restlessness
• difficulty in concentrating, constant changes in plans
• over confidence and inflated ideas about yourself or your abilities
• decreased need for sleep
• not looking after yourself
• increased sociability or over-familiarity
• increased sexual energy
• overspending of money or other types of reckless or extreme behaviour.

'Hypomania’ is a milder form of mania (less severe and for shorter periods). During these periods, people can actually become very productive and creative and so see these experiences as positive and valuable. However, hypomania, if left untreated, can become more severe, and may be followed by an episode of depression.

At the extreme end, some people also develop something called psychosis.  This is when someone has strong, bizarre beliefs e.g. that they have superhuman powers or are being watched or followed.

• feeling very sad most of the time
• decreased energy and activity
• not being able to enjoy things you normally like doing
• lack of appetite
• disturbed sleep
• thoughts of self-harm or suicide.

On the milder end, you may just feel sad and gloomy all the time. Here too, at the extreme end, some people can develop psychosis.

A mixture of manic symptoms and depressive symptoms at the same time.

The exaggerated thoughts, feelings and behaviours can affect many aspects of life and can lead to:

• problems in relationships with friends and family
• interference with concentration at school or work
• behaviour that places the young person's health or life at risk
• a loss of confidence and a loss of the sense of control the person feel over their life.

The longer the condition continues without treatment, the more harmful it is likely to be to the life of the young person and to their family.

The first step towards getting help is to recognise that there might be a problem. Seeking medical advice early on is very important. If the bipolar illness can be identified and treated quickly, this reduces its harmful effects.

You should contact your GP first. If necessary, they can then make a referral to your local child and adolescent mental health service (CAMHS), who can offer more specialist help

In the short term, depending on whether you are high or low and how severe it is, you may need different treatments.

When you have severe symptoms, you may need medications and also sometimes admission to hospital to help your symptoms and also keep you safe.

In the long term, the goal of treatment is to help you have a healthy, balanced and productive life. This would include understanding the condition, controlling the symptoms and preventing the illness from coming back.

Below we briefly describe each aspect of the treatment.

Medication

Medication usually plays an important role in the treatment of bipolar disorder, especially if episodes are severe. In the initial stages of the illness, medication helps to reduce the symptoms.

The choice of medication can depend upon the type of episode (manic or depressed). Everyone is different and so the type of medication that is recommended will also be different.

The three main types of medication that are helpful are:

• antipsychotic medication: risperidone, olanzapine and aripiprazole are types of antipsychotics.
• mood stabilizers: Lithium is a type of mood stabiliser.
• antidepressants:  fluoxetine is a type of antidepressant.

It is important that medications are not taken only when the problems are serious. If your child has had more than one severe episode of illness, staying on medication is important to reduce the risk of further episodes.

Medication may be needed for months or even years. Some people may, under medical supervision, be able to stop their medication when they have recovered and have felt well for a while.

They may need physical examinations and tests (like blood test) before starting or while on medication. It is important that if prescribed medication, you are regularly seen by your doctor or psychiatrist.

Side-effects of the medication can occur, some of which are quite serious. The psychiatrist will be able to advise about what they are and about what can be done to help. The risk of side-effects needs to be balanced against the risk of the damaging effects of the illness on a person's life.

No young person should be taking medication unless they are reviewed by a health professional regularly. This is to monitor the dose of the drug and to check for side-effects.

Talking treatments (also known as ‘psychotherapies’)

It is crucial that drug treatments are combined with practical help for the young person and their family.

Help with understanding the illness (psycho education)

It is very important that the young person with bipolar disorder and their family are helped to understand the condition, how best to cope and what to do to reduce the chances of it recurring.

The young person and their family may notice particular ‘triggers’ to their episodes and/or early warning signs that an episode may be starting - being aware of these can help reduce the chance of episodes occurring, and getting help in the earliest stages of an episode can stop it from escalating.

Family-focused treatment

Stress at home can worsen the situation and can even trigger an episode of the illness. Talking therapy in which the whole family is helped to find ways of reducing stress, solving problems and communicating more effectively has been shown to help young people with bipolar disorder get better, and stay well.

Cognitive-behavioural therapy (CBT)

This is another type of talking therapy in which the young person, sometimes with their family, learns to understand the links between their feelings and thoughts and how this affects their behaviour.

Some young people may need to go into hospital for intensive support if the symptoms are severe.

Recovery

It is important for the young person to recognise that they are not alone and to keep up hope.

Many people only have a few mood swings and then the problem goes away. For others, it becomes a lifelong pattern which they learn to live with and manage.

An episode of bipolar disorder can interfere with education because it is difficult to learn when they are unwell. An important part of recovery is to begin to plan returning to education or to think about work.

I was a happy, confident person studying for 11 GCSEs, and enjoying a good social life with a large circle of friends. All seemed well in my life.

Rachel is fifteen-year-old girl who has suffered episodes of depression in the past. Two months ago she started to talk very quickly and seemed to have lots of energy. She was excited about everything and was making all her friends laugh a lot.

Over a three-day period Rachel barely slept or ate and started to say things that did not really make sense; for example, she told friends that was a princess in Taiwan. She also started swearing and became extremely flirtatious, which was out of character. She is quoted as saying, "I've never felt so great - I'm flying. I'm eleven on a scale of one to ten."

Rachel's parents were very worried and on the fourth night of her not sleeping, they took her to the local A&E department, where she was seen by a psychiatrist who arranged for her to stay in hospital. A diagnosis of bipolar disorder was confirmed and treatment was given to bring Rachel's mood back to normal. She now has treatment to help prevent episodes of both depressed and abnormally high mood in the future.

She has been working with a community psychiatric nurse to improve her ability to recognise her own mood state and take measures to protect herself from further episodes."

Extract from The Young Mind: an essential guide to mental health for young adults, parents and teachers

Bipolar UK - Supports people with a diagnosis of bipolar disorder and their families.

Rethink mental illness - A national charity that helps people affected by a severe mental illness to recover a better quality of life.

SANE - A national charity which improves the quality of life for people affected by mental illness.

YoungMinds - Provides information and advice on child mental health issue and a Parents'Helpline:0800 802 5544.

Further reading

National Institute for Health and Clinical Excellence (2006). The management of bipolar disorder in adults, children and adolescents, in primary and secondary care. Patient version. www.nice.org.uk

• Leibenluft E & Dickstein DP (2008). Bipolar disorder in Children and Adolescents. In: Rutter M et al. (eds) (2008) Rutter’s Child and Adolescent Psychiatry (5th edn). Oxford: Blackwell. pp894-905.
• Merikangas KR, Akiskal HS, Angst J, Greenberg PE, Hirschfeld RMA, Petukhova M & Kessler RC (2007). Lifetime and 12-month prevalence of bipolar spectrum disorder in the national comorbidity survey replication. Arch Gen Psychiatry;64:543-552.
• Fristad MA (2006). Psychoeducational treatment for school-aged children with bipolar disorder. Development and Psychopathology: 18:1289–1306.
• Miklowitz DJ, Axelson DA, Birmaher B, George EL,Taylor DO, Schneck CD, Beresford CA, Dickinson LM, Craighead WE, Brent DA (2008). Family-focused treatment for adolescents with bipolar disorder: results of a 2-year randomized trial.Archives of General Psychiatry; 65(9):1053–1061.
• Carr A (2009). Bipolar disorder in young people: description, assessment and evidence-based treatment. Developmental Neurorehabilitation; 12(6): 427–441.
• Fristad MA, Verducci JS, Walters K, Young ME (2009). Impact of multifamily psychoeducational psychotherapy in treating children aged 8 to 12 years with mood disorders. Archives of General Psychiatry; 66(9):1013-1021.