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More Than Mood Swings: Bipolar Disorder in Teens

Parents are often exasperated by their moody teenage children. After all, teenagers are known to be irritable, to sleep a lot and to resist authority figures. So how can a concerned parent determine when a teenager is just being a typical teenager and when their child has a mental illness such as bipolar disorder?

In teenagers, symptoms of bipolar disorder can include dramatic mood changes within a single day and may have different symptoms than adults. Below, Barbara Geller, MD, a professor of psychiatry at Washington University in St. Louis, discusses how to recognize and treat bipolar disorder in adolescents.

What is bipolar disorder?
It's defined like other psychiatric disorders across the age span in a manual called the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The specific definition for what we now call bipolar disorder, but used to be called "manic-depressive" illness includes certain symptoms that patients must have to make a diagnosis.

People have to experience both depressed and manic episodes. For example, to fit the depressed part, they would need to be sad, to lose enjoyment in usual activities, to have trouble sleeping and eating, to be guilt-ridden, suicidal. To fit the manic part, they'd have to have elation: a mood of being happy as if the most wonderful thing in your life is happening except it's on a day that's like any other day. Families often describe it as Jim CarreyŚlike behaviors: silly, giddy, joking without an apparent reason.

People with bipolar disorder also get very grandiose. In adults, it may be developing business schemes that are unlikely to work so they wind up maxing-out credit cards. They have very active personal lives and may have multiple marriages. They seem to be able to go without sleep and are very social.

When does bipolar disorder usually first appear?
It's really only been in the last decade that people have started to pay attention to diagnosing bipolar disorder in young children and early adolescents. So many adults looking back can describe that they had the illness, but it may not have been recognized at that time. It's estimated from current studies that maybe as many as half of adults who have bipolar disorder had their onset before age 17.

How is the bipolar disorder different in younger children?
In adults, what people are used to thinking is that there will be a discrete episode with a clear onset and a clear offset. You generally have mostly a high or a low, and people function somewhat better between episodes.

What we see in the younger population is they have continuous illness for years, but on a daily basis, they can be both high and low. So they may spend four hours of the day high and giddy and silly, and it's very infectious and amusing, and maybe another four hours of the day morose, gloomy, not wanting to be with friends and thinking of hurting themselves. You see these very rapid cycles shifting from extreme high to extreme low on a daily basis, day in and day out, year after year.

And in children, the high manifests a little differently because children are not likely to max-out credit cards or have had four marriages by the time they're seven or eight. So what we look for in children is being super happy, as if it were Christmas morning or the day you're going to Disneyland, except it's the average day in school.

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What are some of the risk factors for bipolar disorder?
The biggest factor is that it seems to run in some families. Bipolar symptoms also can occur with use of certain prescription medications such as steroids, with some illicit drugs such as cocaine and with various brain diseases such as stroke, tumors and trauma.

What are some of the warning signs in teenagers?
What families may notice is an exaggeration of all the stereotypes of what we say teenagers do. So we think of teenagers as being irresponsible and being irritable, but the child with bipolar disorder may suddenly decide, "I'm not going to school. They're not teaching me anything. I'm going to be President of the United States anyway, why do I have to go to school?" They have very grandiose behaviors that are out of keeping with reality.

They can also get very hypersexual. We think of adolescents getting very interested in the opposite sex, but bipolar adolescents will feel an urgent need to have multiple partners. They'll begin using very sexy language in inappropriate places. At school, they may write it on the blackboard.

How can parents distinguish between a moody teenager and someone who might have a mood disorder?

It's extremely important for parents to get a professional evaluation if they have any suspicion. The worst that will happen, if it's unfounded, is they will have spent a little time and money. But if it is not evaluated, and you let it go on, it can devastate a child's life. There will be multiple suspensions from school. They can get sexually transmitted diseases because they have unsafe sex. They can very rapidly go into a depression and get very suicidal and act on it. So it's very important, especially in families where a family member has bipolar disorder or has depression, for parents to get consultations at the first sign of any suspicion.

Are teenagers with bipolar disorder more likely to have drug and alcohol problems?
There is a very high rate among people with bipolar disorder of using alcohol and drugs across the age span. Parents have to be very suspicious because a child who's using drugs may seem like they're just having "the normal moodiness of adolescence."

There are some common things to look for. For example, drugs cost money and the family may find that items are disappearing from the house. A child may ask to borrow Mom's jewelry, and it somehow gets lost. Or they borrow electronic equipment, and what they're doing is selling it so they can afford their drugs.

What treatment is recommended to teenagers with bipolar disorder?
There are three classes of medication that are used for bipolar illness across the age span. The antimania drug lithium is the mainstay, and lithium is especially good if somebody else in the family with bipolar disorder has responded to it. The second class of drugs is called anticonvulsants because they were originally developed to treat epilepsy. And the third class of drugs is called neuroleptics.

It's very important to educate the family about the illness and to let them grieve. The last thing they want is for one of their children to have the illness. Then you can help them adapt and take part in the child's treatment. You also have to educate personnel at the school so that the expectation about the amount of work that the child can do is geared toward what the child can manage.

How well does medication control the disease?
Some kids do very well and become indistinguishable from other children as long as they take their medication regularly. The medication essentially has to be taken indefinitely, as it is in adults. Most who take it regularly will have fewer hospitalizations and suicide attempts, and they will be able to hold jobs better and have more stable personal relationships. For others, bipolar disorder is very difficult to treat, and it can be months of trying to find the right combination of treatments.

Are there strategies for helping teenagers stay on their medication?
Strategies have really not been formally researched and developed. This is a very important area for future research. For example, will there be Web-based programs the patients can go to? One thing that we find very helpful to do with adolescents is to grieve with them. The way parents have to mourn the loss of a child who's well, the children themselves have to mourn the loss of their former well self.

But grief hurts a millimeter less every day, so we usually can tell them that six months from now, it'll be more automatic just to take the medication and go about your other business.

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