ADHDFamilies

What is Bipolar?
What does it look like in a person?
What are the different states?
Information is provided in both layman terms and also DSM-IV.Here is a fairly complete list of symptoms of depression that bipolars have described: Reduced interest in activities

• Indecisiveness
• Feeling sad, unhappy, or blue (pervasive attitude that life sucks)
• Irritability
• Getting too much (hypersomnia) or too little (insomnia) sleep
• Loss of concentration
• Increased or decreased appetite
• Loss of self-esteem, such as one’s belief that they suck
• Decreased sexual desire (probably not really prevalent in junior high kids)
• Problems with memory
• Despair and hopelessness
• Suicidal thoughts
• Reduced pleasurable feelings
• Guilt feelings
• Crying uncontrollably and/or for no apparent reason
• Feeling helpless
• Restlessness, unable to sit still
• Feeling disorganized, unable to keep track of assignments or tasks
• Difficulty doing things
• Lack of energy and feeling tired
• Self-critical thoughts
• Moving and thinking slowly
• Feeling that one is in a stupor, or that one’s head is in a fog
• Speaking slowly
• Emotional and/or physical pain
• Hypochondriac worries; fears or illnesses which prove to be psychosomatic
• Feeling dead or detached
• Delusions of guilt or of financial poverty
• Hallucinating

Criteria for Manic Episode (DSM-IV, p. 332)

1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
   1. Inflated self-esteem or grandiosity
   2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
   3. More talkative than usual or pressure to keep talking
   4. Flight of ideas or subjective experience that thoughts are racing
   5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
   6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
   7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
3. The symptoms do not meet criteria for a Mixed Episode.
4. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
5. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatments) or a general medical condition (e.g., hyperthyroidism).

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

Okay, here is the above in a plain-English version:

• Decreased need for sleep
• Restlessness
• Feeling full of energy
• Distractibility (what was that?)
• Increased talkativeness
• Creative thinking
• Increase in activities
• Feelings of elation
• Laughing inappropriately
• Inappropriate humor
• Speeded up thinking
• Rapid, pressured speech
• Impaired judgment
• Increased religious thinking or beliefs
• Feelings of exhilaration
• Racing thoughts, which can’t be taught, and can’t be bought, although they ought, you might get caught.
• Irritability
• Excitability
• Inappropriate behaviors
• Impulsive behaviors
• Increased sexuality (also known as “platoon-of-Marines-on-shore-leave syndrome”) * * “Clang associations” (the association of words based on their sound, a possible reason so many poets are bipolar, also why we have pun fun)
• Decreased interest in sex, or any other interpersonal relationships, due to obsessive interest in some other subject or activity
• Inflated self-esteem (so prove I’m NOT the world’s leading authority!)
• Financial extravagance
• Grandiose thinking
• Heightened perceptions
• Bizarre hallucinations
• Disorientation
• Disjointed thinking
• Incoherent speech
• Paranoia, delusions of being persecuted
• Violent behavior, hostility
• Severe insomnia
• Profound weight loss
• Exhaustion

What is Hypomania? (Hypomania means, literally, “mild mania.”)

It’s sometimes difficult to draw a distinct line between “manic” and “hypomanic,” as “marked impairment” is a necessarily subjective evaluation.
Also, one of the reasons that bipolar disorder often has a delayed diagnosis may be that hypomanic episodes are often overlooked amid the chaos of adolescence and early adulthood.
The associated features of mania are present in Hypomanic Episodes, except that delusions are never present and all other symptoms are “generally” less severe than they would be in Manic Episodes.

Criteria for Hypomanic Episode (DSM-IV, p. 338)

1. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non-depressed mood.
2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
   1. Inflated self-esteem or grandiosity
   2. More talkative than usual or pressure to keep talking
   3. Flight of ideas or subjective experience that thoughts are racing
   4. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
   5. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
   6. Excessive involvement in pleasurable activities that have a high potential for painfulconsequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
3. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
4. The disturbance in mood and the change in functioning are observable by others.
5. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
6. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

What is the difference between euphoria and dysphoria?

There are two basic types of mania or hypomania: euphoric and dysphoric. A person can experience both types when they have bipolar disorder.
In euphoria, a person is high, in love with the world, one with the world, feeling boundless energy, talking a mile a minute, mind is racing, deluded with grandiose thoughts, etc. This kind of mania is generally the kind described in the popular literature.

Dysphoria is another type of mania. In dysphoria one is “high” but in a different sense: agitated, destructive, full of rage, talking a mile a minute, mind racing, deluded with grandiose thoughts, paranoid, full of anxiety, panic-stricken. In addition, dysphoria can also come into the depressive side. These are often referred to as “mixed episodes.” Mixed episodes are quite dangerous; suicidal ideation often accompanies this state.

What’s the difference between agitated depression and dysphoric (hypo)mania?

Dr. Ivan Goldberg (psydoc@netcom.com) explains: “While folks in an agitated depression show increased motor activity, they never show increased sociability, increased creative thinking, joking and punning that may be seen in someone experiencing a dysphoric (hypo )manic state.”
What are delusions and hallucinations?

What are delusions?

Delusions are, in general, “false beliefs.” The DSM-IV (p. 763) defines a delusion as: A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. People who are in a manic or depressed episode may have delusions. Some of these might include delusions of reference, where the individual feels like events, objects, or other persons have a particular and unusual significance. The individual may also have grandiose delusions or delusions of persecution (such as paranoia). It’s important to note that delusions must be diagnosed in terms of cultural, social, and religious norms. A belief that one is in direct communication with God, for example, might be either a delusion or an expression of certain kinds of religious faith.

Can people with bipolar disorder have hallucinations?

Most certainly. The DSM-IV (p. 766) defines a hallucination as: A sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ. Hallucinations should be distinguished from illusions, in which an actual external stimulus is misperceived or misinterpreted. Some people know that they are having hallucinations, and others do not. Most people who have bipolar disorder realize that the hallucinations are not actual perceptions of reality. However, this realization does not keep them from occurring.

What kind of hallucinations are there?

Hallucinations may occur in any of the senses: auditory (for example, hearing voices or music), gustatory (for example, unpleasant tastes), olfactory (for example, unpleasant smells), somatic (for example, a feeling of “electricity”), tactile (for example, a sensation of being touched, or “skin crawling” sensations), visual (for example, flashes of light, colors, images on the periphery).

What medications are commonly used in treatment?

There are three types of medications commonly used in treating Bipolar Disorder:
mood stabilizers, antidepressants, and antipsychotics.

Other medications may be given to help you sleep or to treat anxiety and/or panic attacks if you have them. Because many people need a combination of two or three drugs to get stable, it can take quite some time to find the right medications (and the right dosages of each.) This is usually on the order of magnitude of weeks or months… but it’s been known to take “years” to find the exact combination and dosages that work. If the first medication does not help, it “does not mean” a person is untreatable! Some drugs can potentially cause relatively severe side-effects. In particular, mood stabilizers and antipsychotics in high doses can make you very tired and slowed down and “zombie-like.” We’re listing potential side effects below, as we discuss each drug. Our objective here is not to frighten, but to inform and share experiences. Everyone is different; some people will take these meds and experience no side effects; some people will experience side effects that aren’t listed here.

Mood Stabilizers

Mood stabilizers are the primary treatment for most people. They are supposed to level your moods, so that a person is neither too low (depressed) or too high (manic). In practice, they work much better at treating mania than depression, and may have a mood-dampening effect, so that a patient may get more depressed on a mood stabilizer than they were before. Mood stabilizers take a week or two to get a therapeutic blood level and then it may take a few more weeks to get the full effect of the drug.

Carbamazepine (Tegretol)

Tegretol is another anti-convulsant. Side effects of Tegretol are generally more severe than for lithium or Depakote, but some patients who cannot tolerate lithium do fine on Tegretol. Tegretol is also especially effective for rapid cyclers.

Side effects:

• Nausea
• Cognitive slowing
• Dizziness
• Confusion
• Tremor
• Loss of coordination
• Sores in mouth & gums,

AntidepressantsAntidepressants (ADs) are part of most people’s treatment if their disease includes severe depression. However, they must be used cautiously by bipolars. Although ADs normally do not cause folks to get high even when taken in larger doses than needed, for a significant number of bipolars. ADs can cause mania or hypomania and/or may trigger rapid cycling. This is most frequently reported with the older tricyclic ADs (like nortriptylene) and apparently least likely to occur with the AD Wellbutrin. Usually these undesirable effects can be avoided by using an “AD + mood stabilizer” combo, but even this does not eliminate the risk entirely. Antidepressants come in several flavors:

Tricyclics
Common tricyclics include: Norpramin ( desipramine), amitriptylene, nortriptylene, Sinequan, Elavil, Anafranil, Doxepin, Imipramine.

The side effects are the same as for SSRIs–supposedly more severe. The tricyclics are generally more sedating than the SSRIs, and are often used as sleeping pills. They also tend to cause weight gain. Tricyclics are quite toxic in overdose, and there is a danger of accidental overdose, especially when used as a sleeping pill “as needed.”

SSRIs
“SSRI” means Selective Serotonin Reuptake Inhibitor. These are the newest class of ADs and tend to be the first drugs used these days, although there is no evidence that they work better than tricyclics or MAOls. The SSRIs are: Prozac, Paxil, Zoloft, Luvox, Effexor (partly)

The SSRIs can cause rather extreme side-effects if they make you manic (or induce rapid cycling), but they are not very toxic so they are safest to use with a suicidal patient.

MAO/s or “MAOIs”
“Monoamine Oxidase Inhibitor.” Common MAOls are: Nardil (phenelezine) and Pamate. Side effects: Same as above, weight gain. MAOls are safer for your heart than tricyclics, so they are safer to use with elderly patients or patients with heart problems. MAOls may be effective in patients who don’t respond to SSRIs or tricyclics. They are thought to be especially helpful for people who are very tired and numb when depressed and who can be cheered up/made more active by outside stimulation.

Other medications

Benzodiazepines or “minor tranquilizers”
These drugs are used to treat anxiety and panic attacks, or as sleeping pills. Common benzos are: Valium (diazepam), Ativan (lorazepam), ProSom (estazolam), Restoril (temazepam), Klonopin (clonazepam). Side effects are drowsiness and nausea.

How do I help someone I know who has bipolar?

Bipolar Disorder doesn’t just affect the person who’s diagnosed with it, unfortunately. In this section, we talk about some things that friends, family members, loved ones, co-workers, peers, and teachers can do to cope and help when someone is diagnosed.

What to do (and what not to do) when you are living or working
with a Bipolar person:

Twelve things to do if your friend, student, or loved one has manic-depression:

1. Don’t regard this as a family disgrace or a subject of shame. Mood disorders are biochemical in nature, just like diabetes, and are just as treatable.
2. Don’t nag, preach or lecture to the person. Chances are he/she has already told him or herself everything you can tell them. He/she will take just so much and shut out the rest. You may only increase their feeling of isolation or force one to make promises that cannot possibly be kept. (I promise I’ll feel better tomorrow honey; I’ll do it then, okay?)
3. Guard against the “holier-than-thou” or martyr-like attitude. It is possible to create this impression without saying a word. A person suffering from a mood disorder has an emotional sensitivity such that he/she judges other people’s attitudes toward him/her more by actions, even small ones, than by spoken words. It is important to remember that bipolars are acutely sensitive to words, emotions, and actions.
4. Don’t use the “if you loved me” “or if you really wanted to do well in school/job” appeal. Since persons with mood disorders are not in control of their affliction, this approach only increases guilt. It is like saying, “If you loved me, you would not have diabetes.”
5. Avoid any threats unless you think them through carefully and definitely intend to carry them out. There may be times, of course, when a specific action is necessary to protect a child. Idle threats only make the person feel you don’t mean what you say.
6. If the person uses drugs and/or alcohol, don’t take it away from them or try to hide it. Usually this only pushes the person into a state of desperation and/or depression. In the end he/she will simply find new ways of getting more drugs or alcohol if he/she wants them badly enough. This is not the time or place for power struggle. (This is typically not a problem with younger children and experiences with young adolescents are just now being made known.)
7. On the other hand, if excessive use of drugs and/or alcohol is really a problem, don’t let the person persuade you to use drugs or drink with him/her on the grounds that it will make him/her use less. It rarely does. Besides, when you condone the use of drugs or alcohol, it is likely to cause the person to put off seeking necessary help. (Again, this statement would apply to older adolescent or adult.)
8. Don’t be jealous of the method of recovery the person chooses. The tendency is to think that love of home, family, friends, activities is enough incentive to get well. Frequently the motivation of regainjng self respect is more compelling for the person than resumption of responsibilities.
9. Don’t expect an immediate 100 percent recovery. In any illness, there is a period of convalescence. There may be relapses and times of tension and resentment.
10. Don’t try to protect the person from situations, which you believe they might find stressful or depressing. One of the quickest ways to push someone with a mood disorder away from you is to make them feel like you want them to be dependent on you. Each person must learn for himself or herself what works best for them, especially in social situations. If, for example, you try to “shush” people who ask questions about the disorder, treatment, medications, etc., you will most likely stir up feelings of resentment and inadequacy. Let the person decide for HIM OR HERSELF whether to answer questions, or to gracefully say “I’d prefer to discuss something else, and I really hope that doesn’t offend you.” On the other hand, when a person is being bombarded, or appears to be having some difficulty dealing with a situation, it is okay to step in and try to provide and “out” for the person.
11. Don’t do for the person that which he/she can do for himlherself. You cannot take the medicine for himlher; you cannot feel his/her feelings for himlher, and you can’t solve his/her problems for himlher; so don’t try. Don’t remove problems before the person can face them, solve them or suffer the consequences. However, make sure the consequences of an action will not make the illness worse, i.e., assigning extra math work with a child is having difficulty focusing on the work they are doing is completely inappropriate.
12. Do offer love, support, and understanding.

Bipolar is a life-long illness, just as diabetes or thyroid malfunction, etc. The person doesn’t choose to have the illness and life’s events did not bring it on. It is important to remember that they are human beings.

Teaching a Bipolar Child

When teaching a bipolar child, it is often difficult to see how the illness is effecting their lives. Behavioral difficulties are typically worse at home than in school; however, as the child begins to rely more on peers, it may worsen at school. The reasoning is that bipolars have the most difficulty under conditions of intense affect which is present in the most intimate relationships. At school the focus may be more on work, thus lowering the intensity of the interactions.

Bipolar children have many symptoms that interfere with their ability to work: distractibility, irritability, impulsivity, flight of ideas, racing thoughts, dissociative symptoms (a feeling of being outside one’s body - robot like behavior), quick mood changes, intense energy or lack of energy, etc. These are just the symptoms of the illness. Now, add to it the symptoms of the medication, which are memory loss, lack of organizational skills, spacey feelings, nausea, difficulty digesting foods, etc. As grown-ups we would not wish to endure these symptoms and nearly a11 adult bipolars often go off medication simply because of the side effects of the medication. Please remember this when you’re wondering why a bipolar child isn’t performing at “normal” mode.

Finally, bipolar children are highly sensitive and want very much to be just like every other child. It is even more important to be watchful of the way you address the bipolar child. Remember, talk to them in the manner you would want someone to talk to you. Don’t be condescending or talk down to them. Don’t use comments (either verbally or on paper) like, “I already went over that material, weren’t you listening?” Of course they were listening, sometimes it just doesn’t all come through. Remember, if you wouldn’t want it said to you, don’t say it to a child. In accordance with state and federal laws, no bipolar child should ever be kept from an activity such as music, physical education, field trips, etc. as discipline for incomplete work, behavior difficulties, etc. It is expected that the teacher will allow the child to finish the work at another time or at home. Notification of the parents should be taken when a child is not meeting the deadlines for work.

Bipolar children will expend a great deal of energy just trying to maintain a “normal” profile in order to keep anyone from knowing they are bipolar.

Often bipolar children can not admit to a teacher they are getting behind. It is important for teachers to continually monitor their progress and make sure they are keeping up with work. When a bipolar child is getting behind it is highly important to immediately notify the parents in order to make concessions to bring the child up to speed. Additionally, there will be times (quite often) when a bipolar child needs more time to absorb information. For that reason, no work should ever be graded lower because it is late. It is important to work with the child and parents to assure the child is on task (to the best of his /her ability).

Most important, if the child is getting out of control contact the parents immediately. Don’t assume that this is just a typical “acting-up” situation. More often then not, it is a serious problem.