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ATYPICAL BIPOLAR SYMPTOMS
LETTERS TO THE
EDITOR
ATYPICAL BIPOLAR SYMPTOMS To the Editor:
As a psychiatrist who works with severely disturbed teenagers. I have read with interest this Journal's articles on bipolar disorder in young people (AACAP, 1997; Fristad et al., 1992). I am part of a journal club of psychiatrists who work with similar patients, and we collectively have a question regarding these studies. In these children, who present with severe irritability. hypersexuality, mood swings. affective storms. dysthymia. suicidalicyor thoughts of death, but no euphoria. what is the history of early trauma and of severe neglect, especiallyin the first 3 years of life? Our patients with these prominent affective symptoms uniformly have such histories. leading us to wonder whether their psychiatric symptoms are due to early failures in mothering and a variant of severe posttraumatic stress disorder, rather than the multiple genetic disorders suggested, for instance, by Drs. Wozniak and Biederman (1996). In particular. many leading researchers have demonstrated that nurturing in the first 2 or 3 years of life is crucial in the development of self-regulation. affective and physiological (Emde, 1996; Stern. 1985). The sequelae of severe trauma in children and adults are now fairly familiar to all psychiatrists, but the long-term effects of trauma to babies are still being elucidated. This is not to deny the existence of true bipolar disorder. especially in older teenagers. The pharmacological treatment of these neglected, traumatized children is often only moderately successful, as the authors above admit. Is it not possible that lithium, antiepileptics, clonidine, and 13-blockers are simply nonspecific sedatives in this labile population? Here is an example: Lauren was found by the police inside a car, at the age of 4 years. She was chained to the door and was attempting to care for her 2-year-old brother. Neither child had eaten or been changed for several days. Their mother was a cocaine abuser. The children remembered no other home. Lauren had also been physically abused. She was placed with various family members, none of whom could tolerate her unmanageable and aggressive behavior. By the age of 15 she had been placed in a residential treatment center. after living in multiple group homes, on the streets. and in juvenile hall. She became pregnant and postpartum she exhibited pressured speech. insomnia. a disheveled appearance, irritability, tears, and disorganized behavior.
However, she also had periods of calm. and her interactions were usually pleasant and friendly when she was not in the middle of an "affective storm." She refused lithium. but her insomnia responded well to diphenhydramine. Are Drs. Weller. Weller. Frisrad, Wozniak. and Biederman working with children with similar histories. or children from caring. "good enough" families? Perhaps we need a new diagnostic entity to describe children who have experienced nearcatastrophic abuse and neglect. who somehow survive into adolescence. who do not have typical borderline features, and who present with prominent affective symptoms that may resemble "atypical" bipolar symptoms . Our journal club would greatly appreciate responses from clinicians and researchers with experience with this population .
Mary G. Burke. M.D. Mr. St. Joseph-St. Elizabeth San Francisco American Academy of Child and Adolescent Psychiatry (1997) , Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder. JAm Acad Child Adolnc PJychiatry 36:138-157 Emde R (1996), Thinking about intervention and improving early socioemotional development : recent trends in policy and knowledge. Zero to
J. AM. ACAD . CHILD ADOLESC. PSYCHIATRY, 36:10, OCTOBER 1997
Three 17:11-17 Fristad M, Weller E. Weller R (1992), The mania rating scale: can it be used in children?J Am AcadChildAdolescPJychiatry 31:252- 257 Stern 0 (1985). TheInurpmona/Worldofth«Infant. New York: Basic Books. chapters 4 and 5 Wozniak]. Biederman] (19%). A pharmacologic approach to the quagmire of comorbidiry in juvenile mania. J Am Acad Child Adoksc PJychiatry 35:826-828
Drs, WOzniak and Biederman r(ply: Thank you for the opportunity to respond to the letter regarding our recent publication in the Journal (Wozniak et al., 1995a). Dr. Burke describes a case of particularly severe early abuse and neglect confounded by substance abuse in the mother. Although whether such disruptions in caregiving routinely result in bipolar disorder as a sequela is totally unknown, this sort of trauma was not a contributing factor in our sample of manic children . In fact. rates of trauma were low in our sample of manic children and were indistinguishable from those in controls. Actually. our clinical and research experience with these children is just the opposite: the majority of our manic children came from concerned and responsible families . Furthermore, our data on family history,
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EDITOR
ATYPICAL BIPOLAR SYMPTOMS To the Editor:
As a psychiatrist who works with severely disturbed teenagers. I have read with interest this Journal's articles on bipolar disorder in young people (AACAP, 1997; Fristad et al., 1992). I am part of a journal club of psychiatrists who work with similar patients, and we collectively have a question regarding these studies. In these children, who present with severe irritability. hypersexuality, mood swings. affective storms. dysthymia. suicidalicyor thoughts of death, but no euphoria. what is the history of early trauma and of severe neglect, especiallyin the first 3 years of life? Our patients with these prominent affective symptoms uniformly have such histories. leading us to wonder whether their psychiatric symptoms are due to early failures in mothering and a variant of severe posttraumatic stress disorder, rather than the multiple genetic disorders suggested, for instance, by Drs. Wozniak and Biederman (1996). In particular. many leading researchers have demonstrated that nurturing in the first 2 or 3 years of life is crucial in the development of self-regulation. affective and physiological (Emde, 1996; Stern. 1985). The sequelae of severe trauma in children and adults are now fairly familiar to all psychiatrists, but the long-term effects of trauma to babies are still being elucidated. This is not to deny the existence of true bipolar disorder. especially in older teenagers. The pharmacological treatment of these neglected, traumatized children is often only moderately successful, as the authors above admit. Is it not possible that lithium, antiepileptics, clonidine, and 13-blockers are simply nonspecific sedatives in this labile population? Here is an example: Lauren was found by the police inside a car, at the age of 4 years. She was chained to the door and was attempting to care for her 2-year-old brother. Neither child had eaten or been changed for several days. Their mother was a cocaine abuser. The children remembered no other home. Lauren had also been physically abused. She was placed with various family members, none of whom could tolerate her unmanageable and aggressive behavior. By the age of 15 she had been placed in a residential treatment center. after living in multiple group homes, on the streets. and in juvenile hall. She became pregnant and postpartum she exhibited pressured speech. insomnia. a disheveled appearance, irritability, tears, and disorganized behavior.
However, she also had periods of calm. and her interactions were usually pleasant and friendly when she was not in the middle of an "affective storm." She refused lithium. but her insomnia responded well to diphenhydramine. Are Drs. Weller. Weller. Frisrad, Wozniak. and Biederman working with children with similar histories. or children from caring. "good enough" families? Perhaps we need a new diagnostic entity to describe children who have experienced nearcatastrophic abuse and neglect. who somehow survive into adolescence. who do not have typical borderline features, and who present with prominent affective symptoms that may resemble "atypical" bipolar symptoms . Our journal club would greatly appreciate responses from clinicians and researchers with experience with this population .
Mary G. Burke. M.D. Mr. St. Joseph-St. Elizabeth San Francisco American Academy of Child and Adolescent Psychiatry (1997) , Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder. JAm Acad Child Adolnc PJychiatry 36:138-157 Emde R (1996), Thinking about intervention and improving early socioemotional development : recent trends in policy and knowledge. Zero to
J. AM. ACAD . CHILD ADOLESC. PSYCHIATRY, 36:10, OCTOBER 1997
Three 17:11-17 Fristad M, Weller E. Weller R (1992), The mania rating scale: can it be used in children?J Am AcadChildAdolescPJychiatry 31:252- 257 Stern 0 (1985). TheInurpmona/Worldofth«Infant. New York: Basic Books. chapters 4 and 5 Wozniak]. Biederman] (19%). A pharmacologic approach to the quagmire of comorbidiry in juvenile mania. J Am Acad Child Adoksc PJychiatry 35:826-828
Drs, WOzniak and Biederman r(ply: Thank you for the opportunity to respond to the letter regarding our recent publication in the Journal (Wozniak et al., 1995a). Dr. Burke describes a case of particularly severe early abuse and neglect confounded by substance abuse in the mother. Although whether such disruptions in caregiving routinely result in bipolar disorder as a sequela is totally unknown, this sort of trauma was not a contributing factor in our sample of manic children . In fact. rates of trauma were low in our sample of manic children and were indistinguishable from those in controls. Actually. our clinical and research experience with these children is just the opposite: the majority of our manic children came from concerned and responsible families . Furthermore, our data on family history,
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