Transcript Looking at the Bipolar Spectrum in Children and Adolescents

Bipolar Disorder in Children and
Adolescents: Some Tips for Parents and
Other Caregivers
David J. Miklowitz, Ph.D.
Professor of Psychiatry
Division of Child and Adolescent Psychiatry
UCLA Semel Institute and
Department of Psychiatry, Oxford University
Child and Adolescent Mood Disorders Clinic
www.semel.ucla.edu/champ
(310) 825-2836
Upon Hearing the Diagnosis of
Bipolar Disorder…
“The endless questioning finally ended. My
psychiatrist looked at me, there was no uncertainty
in his voice. “Manic-depressive illness.” I admired
his bluntness. I wished him locusts on his lands
and a pox upon his house. Silent, unbelievable
rage. I smiled pleasantly. He smiled back. The
war had just begun.”
--Kay Redfield Jamison
“An Unquiet Mind” (1993)
Thirty Years of research on
bipolar disorder has taught me
that….
managing bipolar disorder is
more than just taking
medicines.
Pediatric (under age 18) Bipolar Disorder
 About 2% prevalence across
nations1
 At risk for the 4 S’s2:
 School problems
 Substance abuse
 Suicide
 Social dysfunction
 High rate of familial transmission3,4
 Stronger genetic load in youth
than in adults4
 Early onset = poor prognosis5
1
Van Meter et al., J Clin Psychiatry 2011; 2Goldberg et al., J Nerv Ment Dis., 2004; 3Goodwin and Jamison, Manic-Depressive Illness, 1997;
et al., Biological Psychiatry, 2003; 5Leverich GS et al. (2007), J Pediatr 150(5):485-490
4Faraone
A 10-year Old Girl’s Description of
Bipolar Disorder
“When I feel happy, I get real bouncy… I’m hopping all
over the place, and my mind seems to be focused on one
thing for a short time. Sometimes, I don’t necessarily feel
bouncy, just kind of light and airy, like a butterfly. I sort of
flit and float from place to place, physically and in my
mind.
When I feel depressed, I’m like…dead. I just sit
there lifelessly, and my body just sort of flops around, like
a Beanie Baby. Also, my mind just sort of drifts away and
wanders aimlessly into space.”
Birmaher, B. 2004. Course and outcome of bipolar disorder in youth (COBY). NIMH Pediatric
Bipolar Disorders conference, Washington DC.
The 8 Family and Self-Care Principles for
Managing Bipolar Disorder
1.
2.
3.
4.
5.
6.
7.
8.
Monitor moods daily – know about early warning signs
Recognize and manage stress triggers
Stabilize sleep/wake rhythms
Know your position on medications
Develop a mania prevention plan
Work on family communication and problem-solving
Obtain reasonable accommodations at school or work
Get regular therapy or join a support group
From: Miklowitz DJ (2011). The Bipolar Disorder Survival
Guide, 2nd Ed
Principle #1
Monitor moods and know your child’s
early warning signs
Handout # 2
Increased
energy and
activity
Elated mood
Decreased need
for sleep
Symptoms of Mania
IRRITABILITY!
Being overconfident
or unrealistic
Increased
sexual thoughts
Talking fast
Loss of self-control
Easily distracted,
Racing Thoughts,
Lots of ideas
Handout # 2b
Low mood or sadness
Tearfulness
Low self-esteem
Trouble concentrating
Increase or Decrease
in Appetite
Crave Sweets or Carbohydrates
Symptoms of
Depression
Some people also:
• feel really tired or low
in energy
• wish they weren’t alive
• feel worthless or guilty
• talk or move slowly
• lack of thoughts
Sleeping too much
or too little
Loss of interest in
activities/boredom
Daily monitoring of mood symptoms
 Keep a daily mood chart
 “This is one of the things you can do in
addition to taking medications to gain more
control of your moods”
 How are your (your child’s) moods affected by
stress, alcohol, medications?
Week of Mar 3
HOW I FEEL
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Super-Hyper
X
Energized
X
X
X
Balanced
X
X
Down
X
Angry
I woke up at:
I went to bed at:
7
7
10
11
6
10:30
6
10:30
6
8
11
12
12
10
Examples of:
Super-Hyper
Feel good about myself
Talk faster
Like being high
Lots of ideas
Need less sleep
Down
Suicidal
Don’t want to go to school
Short-tempered
Stop eating or eat more
Want to be alone
Want to live in a bubble
Angry
Pissed off
Hate everyone
Irritable
Snap easily
Best Bipolar Apps
 iMoodJournal
 eMoods
 T2 Mood Tracker
 Moody Me
 iMind & Mood
 MoodTrack
Principle #2
 Recognize your stress triggers
Examples of Stress for Kids
 Loss of a loved one
 Family conflicts (between kid and sibling
or parent; between parents)
 High familial criticism
 Beginning of school year
 Events that change sleep cycles
 Bullying/peer problems
Factors Affecting Mood Swings
Genes
Stress
Possible Outcomes
Good
Okay
Poor
Managing Stress: The 3-Minute Breathing
Space
 Sit in comfortable chair with your back upright
 Close eyes or stare at an object. For 60 seconds, be aware of
noises in the room – acknowledge each sensation, thought, or
feeling, whether pleasant or unpleasant
 For 60 seconds, focus on in-breath and out-breath; if attention
shifts, gently escort yourself back to your breathing
 For 60 seconds, shift your attention to your entire body – notice
posture and sensations in different parts of the body as you
breathe in and out
 Slowly open your eyes and come back in contact with the room
Source: Segal, Williams, & Teasdale, 2001; Mindfulness-based
cognitive therapy for depression. NY: Guilford
Principle #3
 Stabilize your sleep/wake rhythms
Good Sleep Hygiene







Establish a regular bedtime and wake time
 Vary a maximum of 1 hour/day
 Avoid “sleep bingeing” on weekends
Separate kid from cell phone/IPAD, etc.
Avoid caffeine and other stimulants at night
Avoid alcohol, illicit drugs, or activating
over-the-counter medications
Exercise early in the day, not right before bed
Avoid working in bedroom before bed
When traveling, normalize sleep/wake rhythms as
soon as possible
Principle #4
 Know your position on medications
Therapies With Bipolar Disorder
Indications: Adults
Therapy
Valproic acid (Depakote)
Lithium
Carbamazepine (Tegretol)
Divalproex (Depakote)
Bipolar
Mania
√
√
√
√
Lamotrigine (Lamictal)
Aripiprazole (Abilify)
Olanzapine (Zyprexa)
√
√
Olanzapine+fluoxetine (OFC)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
Asenapine (Saphris)
Bipolar
Depression
Maintenance
Relapse
Prevention
Yes
No
No
No
Yes
No*
Yes
No
No
No
Yes
No
No
No
No
No
Yes
No
Yes
No
Yes
No
Yes
No
No
√
√
√
√
√
√
√
√
√
√
Yes
Yes
√
√
Yes
Yes
Yes
No
No
Yes
No
No
Yes
No
No
No
Yes
No
No
No
Yes
No
No
No
Yes
Physicians’ Desk Reference®. 59th ed. Montvale, NJ: Medical Economics Co; 2010
FDA Approval 2011
Medication
Lithium
Mania
Yes
Ages
Other Approval
12 - Adult
Divalproex
Partial, absence >10
Carbamazepine
Seizures, migraines 2-15
Lamotrigine
Seizures >2
Aripiprazole
Yes
10-17
Schizophrenia
Quetiapine
Yes
10-17
Schizophrenia
Olanzapine
Yes
13-17
Schizophrenia
Risperidone
Yes
10-17
Schizophrenia
Clozapine
Ziprasidone
Troubleshooting Medication
Adherence
 Discuss side effects with doctor
 Develop strategies for pill storage and use
 Role of medications in family:
 Does kid feel she’s taking meds for herrself or others?
 Pressures from family members to discontinue
medications?
 What is the symbolic significance of taking medications
(loss of creativity? Giving up emotions)?
 “Grieving over the lost healthy self”
1Miklowitz
2Frank
DJ & Goldstein MJ. Bipolar Disorder: A Family-Focused Treatment Approach. NY: Guilford Press, 1997.
E, et al. Biol Psychiatry 48(6):593-604, 2000.
Who Should be in Charge of My
Child’s/Teen’s Medications?
 If kid is to take responsibility, he or she must buy into
the diagnosis and treatment plan
 The kid must be cognitively able to handle the dosing
requirements
 Issue of boundaries - is kid more or less likely to take
meds. if parents take a directive role?
 Older kids are more likely to be able to take
responsibility than younger kids
 Make sure that medications do not become the
battleground in which autonomy battles are fought
Principle #5
 Develop a mania prevention plan
The Mania Prevention
Contract
 List prodromal signs
 List circumstances in which, historically, these
have been most likely to occur
 What can you do?
 What can your spouse/parents/siblings do?
 The psychiatrist? Therapist?
 Have all emergency contact info in one place
27
Handout #11
Prevention Action Plan
Stressors or Triggers
1
2
3
4
5
6
7
8
9
10
Early
Warning
Signs
Coping Skills
Overcoming
Obstacles
Things to do to Reduce
Chances of Mania
 Contact physician for medication
change
 Avoid driving
 leave credit cards at home
 Take someone who you trust along with
you when going out at night
 For life decisions: use the 2-person rule
and the 48 hr rule
Relapse Prevention Plan for Phil, age 17
Early Warning Signs
•Sleeps less, gets up more during night
•Gets irritable, cranky, reacts to everything
•Obsessed with video games and pornography websites
•Talks loudly about elaborate money-making schemes
Recent Stressful Events
•Family conflict (ongoing)
•Fired from job (1 month ago)
•Dog died (2 months ago)
Coping Strategies
• Contact Dr. Benson for medication check
•Try to have the same bedtime as rest of the family
•Talk about family problems with Pete (brother)
•Stay away from friends who make me want to smoke weed
Principle #6
 Work on communication and problemsolving
A mother’s
perspective….
“That’s me on that string…my son is like a big baby
puppeteer, keeping us all on a string with his vicious mood
swings. Worst of all he seems delighted that he can do it.”
Five Stages of Parental Acceptance of Bipolar
Disorder in an Offspring
1. “It’s just growing pains”
2. “I’m going to put my foot down”
3. “Tough love”
4. “It’s just a brain disorder”
5. Achieving balance between accepting
the disorder and not letting it rule one’s
life
How Can The Family Help?
•Help child get treatment and support services (e.g., IEP)
• Support use of medication
• Maintain tolerant and calm home atmosphere
(What behavior is controllable and what isn’t)?
• Have fair expectations for performance after an episode
•Make sure the needs of healthy siblings are recognized
•Keep regular family routines
•Maintain“substance-free homes”
• Know your own limits
The Four Basic Communication Skills
• Expressing Positive Feelings
• Active Listening
• Making Positive Requests for Change
• Expressing Negative Feelings about Specific
Behaviors
Active Listening
• Look at the Speaker
• Attend to What is Said
• Nod Head, Say “Uh-Huh”
• Ask Clarifying Questions
• Check Out What You Heard
Making a Positive Request
• Look at the Person
• Say Exactly What You Would Like Him or Her to
Do
• Tell Him or Her How You Would Feel When S/He
Did That
• In Making Positive Requests, Use Phrases Like:
•“I would like you to _____ .”
• “I would really appreciate it if you would _____ .”
• “It’s very important to me that you help me with _____ .”
Principle #7
 Obtain “reasonable accommodations” at
school
Reasonable Accommodations in the
School Setting
 Develop an IEP plus monitor follow-up
 Help teachers distinguish bipolar disorder from ADHD
 Develop plan to manage behavioral problems
 Allow later starts to the school day
 Allow more frequent breaks, time outs
 Have “escape hatches” for child during periods of escalation
(e.g., in-school counseling)
 Reducing overstimulation in classroom
 Excused absences for medical appointments
 Alternative school environments
Note: make sure kid is on board with changes!
Disclosure and Stigma:
How Much Should We Tell
Others About What’s Going On?
 What’s the purpose of the disclosure? What do you
expect to achieve?
 Who should be told – teacher, friends’ parents?
What do you want them to do with the information?
 Is purpose of disclosure primarily to alleviate your
own distress? If so, consider support group as
alternative setting
Principle #8
 Get regular therapy or join a support
group
 Should have a “psychoeducational” focus
 Weekly or biweekly is optimal
Family-Focused Therapy (FFT)
Family-Focused Treatment (FFT)
of Bipolar Disorder




12 outpatient sessions over 4 months
Assessment of patient and family
Engagement phase
Psychoeducation about bipolar disorder (symptoms,
early recognition, etiology, treatment, selfmanagement)
 Communication enhancement training (behavioral
rehearsal of effective speaking and listening
strategies)
 Problem-solving skills training
Miklowitz DJ. The Bipolar Disorder Survival Guide: What You and Your Family Need to Know. Second Edition. New York, NY: The Guilford
Press; 2010.
The STEP-BD Multisite Program (15 sites, N=293)
(Miklowitz et al., 2007; Arch Gen Psychiatry)
2(3) = 8.02, p = 0.046
Hazard Ratios (vs CC)
CBT: 1.34, p = .12
FFT: 1.87, p = .013
IPSRT: 1.48, p =.048
Cumulative Proportion Not Recovered
Time to Recovery in Youth at Risk for Bipolar Disorder
χ2(1) = 3.96, P = .047
Time to Recovery from Symptoms at Entry, weeks
Miklowitz et al., 2014; J Am Acad Child and Adol Psychiatry
I cannot imagine leading a normal life without
both taking lithium and having had the benefits
of psychotherapy…ineffably, psychotherapy
heals. It makes some sense of the confusion,
reigns in the terrifying thoughts and feelings,
returns some control and hope and possibility of
learning from it all…It is where I have believed –
or have learned to believe – that I might
someday be able to contend with all of this.”
-Kay Jamison, Ph.D., An Unquiet
Mind, 1995
Summary: The 8 Self-Care Principles
1.
2.
3.
4.
5.
6.
7.
8.
Monitor moods daily – know about early warning signs
Recognize and manage stress triggers
Stabilize sleep/wake rhythms
Know your position on medications
Develop a mania prevention plan
Work on family communication and problem-solving
Obtain reasonable accommodations at school or work
Get regular therapy or join a support group
From: Miklowitz DJ (2011). The Bipolar Disorder Survival
Guide, 2nd Ed
UCLA Child and Adolescent Mood Disorders Program (CHAMP)
www.semel.ucla.edu/champ
(310) 825-2836