Thursday, March 8, 2012

Can We Prevent Bipolar Disorder?

There’s good news for many children who were once labeled with bipolar disorder. Research shows that many kids who look bipolar as a child do not grow up to have bipolar disorder as an adult. Instead, they may have unipolar depressive disorders or generalized anxiety disorders. This encouraging research introduces many theories.

Many believe that one of the reasons for this occurrence is that some children have been misdiagnosed with bipolar disorder, instead these kids have a different illness altogether. In response, the American Psychiatric Association is creating a new diagnosis that will appear in the DSM-5 guide called Disruptive Mood Dysregulation Disorder, for labeling kids that don’t fit under the “classic adult symptoms” of bipolar disorder.

I don’t doubt the above theory of why some “bipolar” kids don’t grow up to have bipolar disorder, but I also wonder if in addition, there’s another factor to consider.

Is it possible that our kids are showing the early signs of bipolar disorder, but because of early treatment with medication and therapy, their brains are rewired as they develop. I’ve been told many times that it’s hard to diagnose children since their brains are still growing and changing and many kids experience less severe symptoms as they grow older. Is it too far of a stretch to ask the question, “Are we able to change the course of early onset bipolar disorder in children with early treatment?”

Some would argue that bipolar disorder can not be cured or altered for once an adult is diagnosed, it stays with them for a lifetime. But we’re talking about “adult brains” that are already complete in their development. Is it possible that the illness can be altered in children?

I don’t claim to know the answers, I’m just curious and wonder what your thoughts are? As far as I’m concerned, we’re years away from having the research to provide us the answers. Even with a new diagnosistc label, I believe we’ll still have confusion. For example, if most “bipolar kids” grow up to have unipolar depressive disorders or generalized anxiety disorders, then how is the Disruptive Mood Dysregulation Disorder label going to fix this? Won’t we now have kids with Disruptive Mood Dysregulation Disorder growing up to have depression or anxiety? How do we know what meds are right? What if our kids are responding to bipolar medication?

I read in the DSM-5 Development guide the following research:
The only treatment trial of SMD used lithium and did not show efficacy vs. placebo (Dickstein et al, 2009). 
SMD (Severe Mood Disorder) is the former name for Temper Dysregulation Disorder which is now Disruptive Mood Dysregulation Disorder. (confused yet?)

So if we consider our son’s positive response to Lithium, does that disqualify him from the new Disruptive Mood Dysregulation Disorder diagnosis? What about all his other symptoms that aren’t included under the new label? Even though there’s a new diagnosis, we still find our son’s illness outside the diagnostic statistical manual. Where do we go from here? Wait for yet another new label?

It all seems so complicated, I don’t know what the answers are, I just have more questions. What about you, do you think the course of early onset bipolar disorder can be altered with early treatment? Is bipolar disorder an extreme form of a mood disorder illness on a spectrum of other illnesses, many yet undefined? Why isn’t a Bipolar 2 diagnosis applied to children that look bipolar but don’t have clear mania? Is it really as cut and dry as the diagnostic statistical manual makes it?

Whatever the answers are, I hope my son is one of the lucky ones who doesn’t have bipolar disorder as an adult. As in the case for all of us, only time will tell.

As a final note, I thought I would share what Dr. Kiki Chang said in a Frontline documentary filmed in 2007 called The Medicated Child:
These medications have effects on the brain directly—that’s how they work. But some of the effects on the brain could also be protective. In animal studies and cell-line studies, there’s some evidence that suggests that these medications have what we call neuroprotective qualities. They actually protect the brain against injury and insult. They may even help with healthy neuronal growth in certain areas. If that’s the case, perhaps finding the right medication early on can protect a brain against all these further insults of kindling later on and maybe even directly have some sort of neuroprotective effect, so that these children never do progress to full bipolar disorder. 
Source:
http://www.pbs.org/wgbh/pages/frontline/medicatedchild/interviews/chang.html#5

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Please notes that the American Psychiatric Association does recognize that there are real cases of bipolar disorder in children, this proposed diagnosis does not deny the existence of bipolar disorder in children.

Also I think it’s important to note that the guide also clarifies that youth with SMD (now Disruptive Mood Dysregulation Disorder) are as severely impaired as those with BD.


DSM-5 Proposed Justification for Disruptive Mood Dysregulation Disorder (Once called Temper Dysregulation Disorder with Dysphoria)
http://www.dsm5.org/Proposed%20Revision%20Attachments/Justification%20for%20Temper%20Dysregulation%20Disorder%20with%20Dysphoria.pdf

Disruptive Mood Dysregulation Disorder:
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=397#

The Medicated Child Frontline Interview Transcript:
http://www.pbs.org/wgbh/pages/frontline/medicatedchild/interviews/chang.html

13 comments:

  1. Both my daughter's therapist AND psychiatrist have said they've seen kids cured due to intensive therapy and meds. Kids brains are still growing and preventing mood episodes does make a difference. I am also curious about SMD, as it more accurately describes my daughter. I hope there are more medicines and studies for our kids with each passing year.
    Cathy

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    1. Very interesting Cathy. I too hope that we’ll discover more with more studies, I hope it’s in their lifetime.

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  2. Mama Bear,
    Possibly. But also brain adults can be altered. Often, the illness progresses because of self medication with narcotics and alcohol.
    I have ADHD, I was managed without meds as a child but I started to desperately need them at adult age. I couldn't function or I could barely function. It was very hard to get the proper diagnosis and medicine.
    I can function, I can be more independent, I can think about my future.
    Adult brain can also be altered, and not only in the worst scenario case.


    What I also can say is that : we don't know, research has to tell us more. Because we have so much to learn about these illnesses.
    What I think that now, the most important is recognizing that there is a problem and find a treatment plan which works for each person : the treatment plan X which makes wonders for a child may be a disastrous plan for another child.
    And like with medicines, I know that I need a combo of therapies to get better : talk therapy, CBT and DBT are not as antagonist as we can think, they complete each other.
    I need the tools of CBT to manage my symptoms daily, but I also need the talk therapy to know why these symptoms occur. Because talk therapy is useful for certain areas, but it doesn't solve everything, like CBT helps but doesn't solve everything.
    Each therapy has its interests and its limits, and the fight between psychanalysis and behavioral therapies are, in my patient's eyes, useless, tiring and they don't bring anything to anyone. It's only a fight in order to grab the most power, but at the end, patients have no profit, even....
    Both complete themselves in their antagonisms, so opposing themselves is the most useless strategy we can use.

    About the diagnosis, what I say is that it figures out the problem, so we can find a solution.
    I have "only" ADHD, but if they were calling this diagnosis "purple face with yellow polka dots", call it whatever they want as long as they give me the right treatment and the right tools to manage my problem in life !
    A diagnosis doesn't make the prognosis, it just figures out the problem so we can find how to solve it.
    But the most important is : how do you respond to the treatment ? So if your child responds to the treatment and you have two different diagnosis but which gathers the same symptoms, I don't think that dwelling on that will change the course of the history for your child. Also because the terminology can change over the time, with the research who discovers new elements.
    We have no crystal balls to know what the future can hold us. If the child is cured for bipolar, it's always great. But we can't know yet, because there are many, many years, and even the top world physician can't tell you what the future holds : he has no more crystal ball to predict the future than you or someone else.

    My best advice as a patient is : focus on the present, what can we do to make us get better.
    A prognosis worthes what it worthes, so never take a prognosis for granted. It's not a definitive sentence about what your child's life will be.
    And we have so much to learn about mental health :D

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    1. Hmmm... I never thought about the adult brain being altered. you’re advice is good... “focus on the present”.

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    2. Sorry for the question, but what do you exactly mean "I never thought about the adult brain being altered" ? Because I'm not sure to have exactly understood what do you mean.

      But even adult brains can be altered. When you take recreational drugs + alcohol as an adult, you create damage on your brain. So you alter your brain.
      When you catch up missing sleep as an adult, you alter your brain.
      In a sense or another, you alter the brain as an adult.

      Of course, altering a child and an adult brain gives different outcomes.
      It's more difficult to make changes as an adult than as a child, but it's not impossible. Nothing is lost before even trying.

      But researchers discovered that we don't lose neuronal connexions (except in illnesses like Alzheimer disease or dementia). The most important is the quality of neuronal connexions : if connexions are good, then you keep your brain up.
      If you have a healthy lifestyle to prevent a cardiovascular diseases, the same holds true for brain diseases. Even if you stop smoking at 50 yo and start exercise at 60 yo, it's never too late to take up any step to become healthier. :)

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    3. I see your point about alcohol altering the brain etc. I guess I was referring to mental illness being improved because the brain itself has changed, not because of medications keeping the brain well, but an actual physical change in the brain such as a person with depression no longer needing treatment since their brain became restored.

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    4. Not only. When you get therapy and medicines to manage your mental illness, you alter your brain.
      A mental illness can sometimes heal, but not always. We don't know yet.

      But it's not because the illness is incurable that we have to lose hope. Let think about celebs with a mental illness, like Ty Pennington with ADHD, or Glenn Close with bipolar.
      Mental illness mustn't bar ourselves from success. But we have to manage it t best.
      Too bad that I still haven't found no good pdoc and have to rely on my GP (it's better than nothing, of course. For the pdoc I had, I had to never hope for anything better than sheltered work for all my life. Don't get me wrong, if the person is happy in a sheltered work and finds a balance for herself, nothing to be ashamed of. The problem here is that that presented the sheltered work as a punishment, that "since I don't do like everyone else, my punishment is going to a sheltered work. Starting studies after 25 years old is too late and without diploma, you have no competences to do anything and you deserve nothing else than unqualified jobs, you deserve only to stay in poverty". The problem is that I'm not interested in a sheltered work, also because I love law, writing and such. Sheltered work don't absolutely match my interests, I don't go there just for a pdoc's love, it would be a complete non sense. Go there if it's something which suits your needs, not because someone told you to do so).

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  3. Hmmm, okay here are my thoughts... 40 years ago my uncle was acting out as a child. He was uncontrollable. At that point in time, his parents tried Ritalin. It made things worse. His father beat the crap out of him, trying to make him "stop". It didn't work but he learned to lie, to hide what he felt. Then when he got old enough that no person could control him, he went out of control. He was in jail, he was homeless, a drug user, even suicidal at times. Finally in his 40s, he was diagnosed with Bipolar Disorder and Schizoeffective disorder. When I spoke with my son's Psych about it, I said I felt that previous generations had not been allowed to work out their issues, but bottled them up inside because of beatings, and physical abuse. She agreed. We are in an age where corporal punishment is frowned on. Shoot, my dad got paddled in school! Today there is so much more knowledge. Do I believe the symptoms go away? No, but I think that because we use different techniques with our kids, they can learn to manage their symptoms better, instead of pretending they aren't there.
    Label wise? I guess I really don't care too much what the label is, as long as the treatment works! I hear they are trying to take aspergers off the list as well. We just got our diagnosis back in November! As parents I guess we all know there is something there, and we at least have found some others to that are going through the same thing.

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    1. Thanks for sharing your personal story, you bring an interesting perspective with it.

      I get so frustrated with how the media claims there’s a impossible increase in mental illness in kids-yet your story is a perfect example of how mental illness was present in children years ago, but kids were abused or parents just thought they were a bad kid or maybe blamed themselves as being bad parents. There are so many stories of adults claiming to have symptoms as kids, yet the data doesn't tell this story since kids didn't receive treatment until they were an adult. I think most of us would agree that therapy for children was almost unheard of years ago, this too also explains why the numbers of illness has increased, kids are now getting treatment where in the past they didn't, they were just struggling with mental illness on their own.

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  4. I think there is just so much that we don't understand yet about how the brain functions or how the brain develops that as a society we can't answer the question of whether bipolar (or other mental illness) can be cured if treated in childhood. I'd like to think so. And certainly medicine has learned that if surgery is performed on a child with a cleft palate at the right time developmentally, that child won't suffer the effect of a cleft pallet--I don't see why that type of things couldn't also be true for the brain.

    And while adult brains are certainly plastic, I think they are less plastic than children's brains. As adults we can change our skeleton in small ways by taking up a new sport, but we can't really change our stature. I suspect that brains are like that too.

    And at this point, because we have so little data on childhood mental illness--we just don't know. (and I find that so frustrating.)

    Heather

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    1. Heather,
      About adult's size, I can tell you : yes and no. Yes, we can change adult's size with GH and surgeries. But we have to be extra careful that it doesn't make more harm than good.
      Some people suffering from acromegalia continue to grow up past after the usual age of end to grow up.
      But does it mean that it's a desirable possibility ? When can we say that it makes more harm than good ? Does it mean that we have to erase any difference in this world ?

      To continue the thread of my reasoning, adult brains can also be very plastic.
      I remember that my ENT doctor wouldn't have expect that with my BAHA hearing aid (for my Single Sided Deafness), I would have located sounds, neither I would have been able to locate in a home without my hearing aid.
      So the fact that adult brain cannot be very plastic becomes increasingly called on question. Everything we thought to know about brain is getting casted on doubt.

      The only thing that I can reply to you is that what you are saying is what we thought as absolutely true and inquestionable.
      But researchers realize that it's not as true as we thought in the past. Because brain is much more plastic as we thought before. Because we realize that we don't lose neurones with age, except in conditions like Alzheimer.


      And for all the reasons I gave you, I agree with your last sentence.
      I will go even further that we don't know much more about adult mental illnesses, because what we thought as undoubtfully true is increasingly put in doubt. So even for adult mental illness, we know so little yet, even when thinking we know everything.

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  5. What an interesting post. My son was recently diagnosed with bipolar disorder and it is difficult to find information about bipolar in children because the main focus is on adults. One site I found that was specifically geared toward understanding bipolar in children is http://onlineceucredit.com/edu/social-work-ceus-bc. I hope this is helpful for other parents with bipolar kids as well.

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  6. I want to thank you for sharing it, your Post is great and very helpful

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