A diagnostic roller coaster
It can take ‘a decade and three different doctors’ to get children treatment for bipolar disorder as their symptoms may be mistaken for other conditions
I was doing research and interviews on bipolar disorder when notices appeared in my New York City neighborhood about a 21-year-old man who had been missing for a week. He was described as “bipolar” and “may be experiencing a manic episode.”
It took me back nearly seven decades when the state police in Texas called my father to say they had found his brother wandering on a highway. How he got there from New
York we never learned. He had apparently suffered a psychotic break and ended up in a New York state mental hospital that administered electric shock treatments but did little else to help him reenter society effectively.
Not until decades later did he receive a correct diagnosis of manic depression, now known as bipolar disorder. Characterized by extreme shifts in mood, “manic-depressive illness” was officially recognized by the American Psychiatric Association in 1952. But it would be many years before an effective treatment, the drug lithium, which acts on the brain to help stabilize debilitating episodes of severe mania and depression, was available to help my brilliant uncle resume a reasonably normal life.
Bipolar disorder typically runs in families, with different members experiencing symptoms to a greater or lesser degree.
If a parent has the disorder, a child’s risk can rise to 10%. My uncle’s only child displayed some minor behavioral characteristics of bipolar disorder, such as rapid speech and frenetic activity, but was able to complete two advanced degrees, marry, be a parent and succeed in an intellectually demanding career.
Bipolar disorder is most often diagnosed in the later teen years or young adulthood, affecting some 4% of people at some point in their lives. But in recent decades, diagnosis of the disorder has soared in children and adolescents, although some experts believe the condition is overdiagnosed or overtreated with potent psychiatric drugs.
Symptoms in children may initially be mistaken for other conditions, such as ADHD (attention deficit/hyperactivity disorder) or oppositional defiant disorder, and young people may suffer serious distress at home and in school for years. As David Miklowitz, professor of psychiatry at UCLA School of Medicine, told me, there is still “an average lag of 10 years between the onset of symptoms and getting proper treatment.”
Based on studies of patients’ histories, Dr. Boris Birmaher, professor of psychiatry at the University of Pittsburgh School of Medicine, reported, “In up to 60% of adults with bipolar disorder, onset of mood symptoms occurred before age 20. However, pediatric bipolar disorder is often not recognized, and many youth with the disorder do not receive treatment or are treated for comorbid conditions rather than bipolar disorder.”
Yet, Birmaher, who specializes in early onset bipolar disease, argues: “Pediatric bipolar disorder severely affects normal development and psychosocial functioning, and increases the risk for behavioral, academic, social and legal problems, as well as psychosis, substance abuse and suicide. The longer it takes to start appropriate treatment, the worse the adult outcomes.”
With early detection, which is most likely to occur when there is a family history of bipolar disorder, some affected young people may respond well to family and behavioral therapy that obviates the need for medication, Miklowitz suggested.
There is often resistance to treating children with drugs. Terence Ketter, retired professor of psychiatry at Stanford University, said one problem is that “faced with a bunch of badly behaved children, authorities want to give them antipsychotics to make them behave, but if they’re overtreated, they can become like zombies.” In agreement with Miklowitz, he said, “On average it takes about a decade and three different doctors to get children the right diagnosis and treatment.”
Another challenge to proper diagnosis and treatment stems from the boundless energy and extraordinary productivity and creativity that can accompany bouts of mania. Not until the mania reverts to severe depression or psychosis might a young person with bipolar disorder be likely to receive needed medical attention.
When depression is the symptom that brings patients to professional attention, the correct diagnosis can be especially tricky. As Ketter explained, depressed individuals may be unable to recall previous episodes of mania that occurred when they were not depressed.
Miklowitz said one of the first signs of bipolar disorder is “mood dysregulation — the child is angry or depressed one moment, then is excited and happy and full of ideas moments later.”
He listed characteristics of mania that can help parents distinguish them from normal teenage highs and lows. The symptoms can include “grandiose thinking, decreased need for sleep, rapid or pressured speech and/or flight of ideas, racing thoughts, distractibility, excessive goal-driven activity, and impulsive or reckless behavior,” Miklowitz said.
With depressive symptoms, he suggests looking for “an impairment in functioning — suddenly not going to school or going late, not finishing homework, sleeping through classes, a drop in grades, not wanting to eat with anyone else, talking about suicide, self-cutting.”
Depending on the severity of a child’s impairment, if nonlife-threatening symptoms are caught in the early teens, Miklowitz said it may be possible to start with psychotherapy and avoid medication, which has side effects.
“But if the child’s life is at risk, if he can’t function at home or at school, medication may be the answer,” he said. “There are risks to not medicating.”
When medication is necessary, he said, the dosage should be just high enough to control symptoms and not be overly sedating.