Arun Singh is going through a difficult period. His ten-year-old son, Rakesh, is undergoing treatment for bipolar disorder. Arun starting noticing changes in Rakesh's mood from about three months back. Rakesh would suddenly exhibit extreme mood swings – energetic one day and dull the next day. Arun did not think this was out of the normal. However, Rakesh's mood swings more extreme and severe day-by-day. It was only after a visit to the doctor that Arun found out that his son was suffering from bipolar disorder.
There are many young boys and girls in and around Rakesh's age who suffer from bipolar disorder. If you see your son exhibiting extreme mood swings, do not dismiss it and try to get to the cause.
What is bipolar disorder?
Bipolar affective disorder (BPAD), also known as manic-depressive illness, is a disorder that is characterized by symptoms, which include mood disturbance (depression or elation) accompanied by related cognitive, psychomotor, behavioural or interpersonal difficulties. This causes significant impairment in the patient and family’s quality of life. It is now widely accepted that BPAD occurs in children and adolescent also. Studies have shown a drastic increase in diagnoses of BPAD in the youth over the last 20 years.
A recent meta-analysis showed that overall rate of BPAD in youth is 1.8 per cent. It is now increasingly recognized as a significant health problem.
Studies also show 10-20 per cent had the onset of this condition before the age of 10 and 60 per cent had the onset before the age of 20. Early onset is associated with a severe course and a poor outcome if not treated properly. In clinically based studies conducted at NIMHANS (National Institute of Mental Health and Nero Science) Bangalore, the prevalence rate is 3-6 per cent. It affects males and females equally.
There are many causes of BPAD such as:
- Psychosocial factors: Stressful life events, loss of a parent, use of drugs or alcohol.
- Genetic factors: Do play a role in developing this disorder. But psychosocial causes or the environment in which the child is brought up play a major role.
- Bipolar Disorder I: A classic form of cyclic change between mania and major depressive episodes.
- Bipolar Disorder II: Is characterized by episodes of major depression with hypomania.
Children with juvenile BPAD are often misdiagnosed as suffering from other condition such as ADHD or a conduct disorder. This can be a mistake. Often symptoms of bipolar disorder include:
1) Elated mood: Excessive and developmentally inappropriate excitability, silliness, uncontrollable laughter and excessive joking. Feeling “overwhelmed” or “top of the world”.
2) Unstable self-esteem and grandiosity: Make a statement that indicates increased self-esteem or grandiosity beyond what is expected of him or her.
3) Decreased need for sleep: Refusal to go to bed and desire to play, sing, or watch television throughout the evening or early morning.
4) Hypersexuality: Pleasure-focused sexual behaviour that is either developmentally atypical or unusual. Engaged in porn video watching.
5) Pressured speech and racing thoughts: Children may complain that a lot of ideas are running in their mind, which results in non-stop talk. Parents may describe this situation as one that is characterized by constant talking, dominating a conversation, constantly seeking attention by talking or “entertaining” excessively at home or school.
6) Restless activity: Constantly fiddling with everything at home.
7) Irritability: The chronic presence of irritability has been recently conceptualized as the core feature of BPAD. Irritable mood or aggressive, hostile behaviour if present indicate the severity of the disorder.
In a study conducted at NIMHANS, Bangalore, the most common symptom was pressure of speech, irritability, elation, distractibility, increased self-esteem, expansive mood and flight of ideas.
Depression in child and adolescent is often under-recognized. Clinic-based population from India report a prevalence rate of 9.2 per cent. Sex ratio is equal. Studies show that depression in adults often begins in adolescene.
This phase is characterized by symptoms like prolonged periods of sadness, loss of energy, inability to get pleasure from everyday activities, and complaints of a backache, headache, stomach ache, nausea, vomiting and diarrhea.
Treatment for BPAD involves a combination of therapies that include medications as well as physical and psychological interventions. It is to be noted that the patient will continue to experience mood changes, but the symptoms will become more manageable.
Psychoeducation: Family members and the patient should be educated about the cause, symptoms, course, different treatment of BD. In addition, restoration of hope and reversal of demoralization for the child and their parents, and case management may be necessary.
Sleep: Sleep deprivation can lead to worsening of mood symptoms. Ensuring a stable sleep pattern is needed to have a positive effect on physiology and daily functioning. To ensure this, certain measures have to be followed like:
- A fixed sleep schedule where the patient goes to bed and wakes up at fixed timings.
- Naps during the day should be avoided, as far as possible.
- Avoiding staying awake in bed for more than 5-10 minutes. Phones to be strictly switched off.
- No watching of television or tablets, reading in bed.
- Beverages like coffee to be strictly avoided
- The bedroom should have dim lights and preferably in a quiet section of the house.
Mood stabilizers, antipsychotics, antidepressants are given by the doctor to control symptoms. The choice of medicine, psychotherapy or combined treatment depend on the severity of symptoms, chronicity, comorbid disorder, child age, family and environment circumstance.
Note: Medication should always be done in the presence of a qualified doctor.
Bipolar disorder is a serious mental illness that requires early diagnosis and treatment. If left untreated, it can destroy relationships and affect one’s behavioural problem, result in chronic mood symptom, impaired family and peer relationship; poor academic performance, use of alcohol or drugs, and even suicide attempts.
The author is Director, Clinical Operation and Consultant Psychiatrist at Gautam Hospital & Research Center, Jaipur.
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