The Bi | Polar Puzzle

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Image: Gerald Slota, The New York Times Magazine.

A couple days ago, I heard an interview with Jennifer Egan on WNYC about her upcoming article in tomorrow's New York Magazine about bipolar disorder, often known as manic-depressive illness, "The Bi | Polar Puzzle." It's long but well-written and definitely worth reading. In this touching and informative piece, Egan primarily addresses several questions; whether bipolar disorder exists in children, what it looks like and whether children with undiagnosed/untreated bipolar disorder will grow up to be bipolar adults. I've summarized it here, along with a few of my own comments, for those of you who cannot access it.

Egan begins by discussing whether bipolar disorder exists in children and what it "looks like" in children. She briefly -- perhaps too briefly -- explores the difficulty of diagnosing it in children and how bipolar disorder differs from other childhood mental health issues, particularly the confusingly similar Oppositional Defiant Disorder (ODD) and Attention Deficit Hyperactivity Disorder (ADHD). Obviously, this is a real problem, for reasons that will be explained further in this summary, and because of this, the professionals are addressing it.

One of the research scientists that Egan interviewed, Ellen Leibenluft, who runs the pediatric bipolar-research program at the National Institute of Mental Health, told her; "There definitely will be -- and needs to be -- more description of what bipolar disorder looks like in children, how one diagnoses it and some of the challenges."

But why bother to diagnose bipolar disorder in children? Because it is devastating, that's why. In short, this disorder can interfere with educating the child, prevent that child from being properly socialized (so they can reach adulthood without having had even one friend), and disrupt or completely destroy family dynamics, leaving everyone involved to struggle with deep, lifelong scars.

Further, the concern is that, by diagnosing and treating the disorder early, the child and the child's family can be spared the ravages of a full-blown manic episode -- something that would have probably changed the course of my entire life, for example.

"The hope is to know early on who is at risk so their condition can be diagnosed and treated as early as possible," Egan writes. "Mental illness wreaks brutal damage on a life, crippling decision-making, competence and self-esteem to the point where digging out from under years of it can be next to impossible."

Or absolutely impossible.

Egan's article does a good job of weaving together the personal stories of several families whose children suffer bipolar disorder with basic information about this mental illness along with modern treatment strategies.

Egan also reports the statistics, for example, she investigates the claim that there has been a "forty-fold increase" in diagnosis of bipolar disorder among children and adolescents visiting the doctor between 1994 and 2003, and suggests that this indicates one of two things; either bipolar disorder is the illness du jour or it has been terribly underdiagnosed in these age groups. But even though there is some diagnostic group-think occurring in the psychiatric community that leads to misdiagnosis with bipolar disorder, this "forty-fold increase" statistic is misleading because children with bipolar disorder are more likely to visit the doctor than those with other, milder, mental disorders, and further, the percentage of children diagnosed with bipolar disorder amounts to only seven percent of all children with mental health issues. This is hardly a huge number.

Additionally, many psychologists and psychiatrists report that bipolar disorder has been generally unrecognized in children, who are more likely to be treated for ADHD -- with the same medication regime used for bipolar disorder. This is partially because three of seven behavioral symptoms that are diagnostic for ADHD -- distractibility, hyperactivity and talkativeness -- are shared with bipolar disorder.

Despite the difficulty of diagnosing this mental health issue, it is possible that bipolar disorder might actually be on the rise among children and adolescents. This could be due to basic human behavior: the various genetic variations that contribute to bipolar disorder could be concentrated in subsequent generations due to the effects of assortative mating in humans -- people choosing partners who are similar to themselves. And the evidence suggests that a child with even one bipolar parent is 13 times more likely to develop the disorder. In fact, one couple with two bipolar children that were interviewed for Egan's story are bipolar themselves.

Of course, this leads to the question; will bipolar kids grow up to be bipolar adults? The answer to this question is unknown but It is possible that their condition might worsen, as Egan writes;

A long-term study in Pittsburgh overseen by Axelson and Birmaher suggests that as children grow, the severity of their disorders can change; bipolar II, the less severe form of the disease, can convert to bipolar I, the more severe form. Nearly a third of subthreshold bipolar cases (BP-N.O.S., or Not Otherwise Specified, in D.S.M.) convert to the more serious forms.

Despite the propensity for the disorder to worsen over time, there is some evidence that suggests that bipolar children can recover and lead normal lives -- if they receive the correct medication while they are young. But were these recovered young adults really bipolar, or did they have a different mental health issue? Until genetic markers correlated with bipolar disorder can be identified and used to definitively diagnose bipolar disorder, it is impossible to know the answer to this question. Currently, researchers are identifying some genes and genetic markers that correlate with bipolar disorder, and the hope is that these markers will help psychiatrists identify and better treat this disorder while it is still mild, thereby preventing it from becoming worse, as typically occurs when it remains untreated.

Interestingly, this progressive worsening of untreated bipolar disorder is similar to that seen for other medical conditions, such as epilepsy. Egan writes;

[T]here is .. a biological theory for why going untreated might worsen a bipolar person's long-term prognosis. Epilepsy researchers have found that by electrically triggering seizures in the brains of animals, they can prompt spontaneous seizures, a phenomenon known as "kindling." Simply having seizures -- even artificially generated ones -- seems to alter the brain in such a way that it develops an organic seizure disorder. Some scientists say that a kindling process may happen with mania, too -- that simply experiencing a manic episode could make it more likely that a particular brain will continue to do so. They say this explains why, once a person has had a manic episode, there is a 90 percent chance that he will have another.

Kiki Chang, director of the pediatric bipolar-disorders program at Stanford, has embraced the kindling theory. "We are interested in looking at medication not just to treat and prevent future episodes, but also to get in early and -- this is the controversial part -- to prevent the manic episode," he told me. "Once you've had a manic episode, you've already crossed the threshold, you've jumped off the bridge: it's done. The chances that you're going to have another episode are extremely high."

According to Egan's article, this is the standard treatment for children who are diagnosed with bipolar disorder;

  1. establish the correct dose of an effective medication early in childhood
  2. family therapy to help strengthen family ties and their collective ability to deal effectively with this mental disorder
  3. teach stress reduction techniques to reduce the likelihood of triggering a manic episode


"The Bi | Polar Puzzle" by Jennifer Egan. 14 September 2008. NYTimes Magazine.


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This is a very informative article! Thank you!

Interesting. It was thought for a long time that one didn't acquire bipolar disorder until the early 20's and that children with ADD had a propensity for it to turn into bipolar later on. I wonder which one is true.

I am a hypomanic bipolar, and I didn't get diagnosed until age THIRTY-SEVEN, omg! My son is a touch Asperger, but I also worry that he might be bipolar as well. It's going to be difficult to tease that out from typical ASD moodswings, though, and it makes me wonder if the neural wiring is at all related on the genetic level. Clearly both conditions are genetic, and a lot of female Aspies are also bipolar, apparently (citation needed). I will now cease rambling and remember to take my medication.

The article was good. I remember seeing the articles on the study that reported an explosion in childhood BP diagnoses. Now the picture is clearer with better understanding of the data and how the medical community approaches possible BP cases.

I liked how the author said recognizing and treating BP in children particularly is complicated and challenging. Part of the problem is the lack of understanding by non-specialists.

"... bipolar disorder has been generally unrecognized in children, who are more likely to be treated for ADHD -- with the same medication regime used for bipolar disorder."

That's peculiar, was that in the article? Because it's not the same medication regime at all. ADHD is treated with stimulants, which are almost never given to bipolar patients because they can trigger mania, and ADHD is not treated with lithium (the bipolar gold standard) or any other mood stabilizers or antidepressants.

I'm surprised to see the kindling theory trotted out again, I thought it was passe. There wasn't evidence to support it. Is there now?

All this is not to say pediatric bipolar isn't a concern that needs to be taken seriously, it certainly is, but I just wanted to clarify those two things. What are your thoughts?

sandra -- yes, that was in the article. the article did not state that it was the ONLY medication regime used, but that it used for a minority of children diagnosed with ADHD. (the treatment regime for ADHD sometimes includes a combination of zoloft or prozac and a stimulant, from what i recall).

i am not sure if the thought that stimulants can trigger mania is actually true, since that was denied again and again by the neuropharmacologists in the hospital where i was, and at least one of those neuropharmacologists is the expert in the world for treating bipolar disorder.

the article doesn't discuss the evidence that supports the kindling hypothesis, but the author did interview several psychiatrists who were convinced that kindling plays a powerful role in mania, at least.

in my own subjective opinion, kindling makes sense, since my own manic episodes can become very intense if they are allowed to continue for very long. however, i have no idea (or opinion) as to whether having that first manic episode increases the likelihood of having more, though ..

I'm glad to hear that there is progress being made. Good article. Bravo.

By Timothy Wood (not verified) on 17 Sep 2008 #permalink

To Perky Skeptic: There seems to be a definite link between maternal mental health and autism. Research is still exploring the issue, but recently researchers in Sweden found children whose parents had schizophrenia were more likely to have autism ( The Interactive Autism Network, which is seeking to gather data and facillitate autism research, has found a strong link between maternal depression and autism ( I don't know of any research on bipolar disorder and autism specifically, but it seems the more we learn the more we see an apparent genetic link between mental health issues and autism.

But yes, I agree with everyone, great article on a topic that definitely warrants more discussion.

Although it's purely anecdotal, I suspect that part of that 40-fold increase may be mental health professionals' attempts to reconcile kids who obviously have ASDs with a strange but seemingly prevalent reluctance to diagnose ASDs except in the cases of severe and blatant autism. I was diagnosed with unipolar depression and then cyclothymia as a teenager by several psychiatrists who all started seeing me with the conspicuous assumption that I was just a brat, and it wasn't until this year that I was able to get a psychiatrist to seriously consider that my symptoms fit those of ASDs much more closely...or, um, at all. My current diagnosis is PDD-NOS since the psychiatrists I've seen seem to have a peculiar aversion to Asperger's as a diagnosis.