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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 irr itability. hypersexuality, mood swings. affective storms. dysthymia. suicidaliry or 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 ~-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 beh avior.
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. Fristad, 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 symproms that may resemble "atypical" bipolar symproms. Our journal club would greatly appreciate responses from clinicians and researchers with experience with this population . Mary G. Burke. M.D. Mt. St. Joseph-St. Elizabeth San Francisco American Academy of Ch ild and Adolescent Psychiatry (1997), Practice parameters for the assessment and treatmen t of children and adolescents with bipolar disorder. JAm Acad ChildAdolnc 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 AcadChildAdoksc PJychiatry 31:252- 257 Stern D (1985). TheInterpenonal World ofth~ Infant. New York: Basic Books. chapters 4 and 5 Wozniak]. Biederman] (1996). A pharmacologic approach to the quagmire of comorbidity in juvenile mania. J Am Acad Child Adoksc PJychiatry 35:826-828
Drs. WOzniak and Biederman T"(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 facror 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,
1319
LETTERS TO THE EDITOR
replicated in two entirely different samples, documented that the mania described in our children is strongly familial (Faraone et al., 1997; Wozniak et al., 1995b). Although concerns about abuse and neglect are frequently raised when mania symptoms are seen in a child, this critical issue has never been systematically investigated. Although we do not have an answer to this question, we can share our thoughts on the subject. First, the diagnosis of mania, as conceptualized in DSM, is descriptive and not etiological. It is akin to observing a sexually transmitted disease or a broken bone in a child irrespective of its association with sexual or physical abuse. Moreover, because bipolar disorder carries with it poor judgement, aggression, severe disinhibition, and hypersexuality, children suffering from bipolar disorder may be especiallyvulnerable to trauma and abuse. While clinicians must always take a careful trauma history, assuming that all casesof juvenile bipolar disorder must have a history of trauma can have serious consequences. As examples, we can cite two specific casesunder our care who, in the past several months, have been investigated by the Department of Social Services after evaluators in an inpatient unit and in a school, respectively, assumed that the severe symptoms of the bipolar disorder (disinhibition, violence, and angry statements directed at parents) must be posttraumatic. In both cases, the accusations against the parents were unsubstantiated and the casesdropped. However, the investigations led to family disruption, loss of privacy, and reluctance and fear about pursuing professional help. Thus, clinicians who treat severely disturbed children with both trauma and bipolar disorder many erroneously attribute the direction of causation to be trauma leading to bipolar disorder, when in many cases the opposite may be true. Janet Wozniak, M.D. Joseph Biederman, M.D. Massachusetts General and Mclean Hospitals Harvard Medical School, Boston Faraone SV. Biederman J. Mennin D. Wozniak J. Spencer T (1997), Attention-deficit hyperactivity disorder with bipolar disorder: a familial subtype? ] Am Ai:ad ChilJAJokscPsychiatry 36: 1378-1387 Wozniak J. Biederman J. Kiely K et al, (l995a). Mania-like symptoms suggestiveof childhood onset bipolar disorder in clinically referred children.
] Am Ai:ad ChilJAJokscPsychiatry 34:867-876
the young girl described by Dr. Burke manifested symptoms commonly associated with bipolar disorder, it is unclear from the report whether this child met the DSM-IV criteria for bipolar disorder or any other mood disorder. Thus it might be premature to suggest neglect and early trauma are specifically associated with bipolar disorder based on this single case report. To assess this issue further, we undertook to review the histories of the bipolar children in our article. Our report (Frisrad et al., 1992) focused on assessing severiry of mania in children in whom we had diagnosed bipolar disorder. Of the 11 children in our report, we were able to quickly review the charts of 10 (one chart was not immediately available) to determine whether they had experienced near-catastrophic abuse and neglect. On the basis of this preliminary review we can state the following: All appeared to have a preschool onset of affective symptoms. Age of first treatment ranged from 5 to 12 years. There was no history of neglect in any child. However, two children had witnessed the abuse of one adult by another adult. In addition, it was suspected that one of these two children had been sexually abused by a stepfather whom the mother later divorced. No child had a history of early multiple placements, although many had treatment placements during their school-age years. Finally, none had a history of any other significant early trauma or abuse. Thus, while we are familiar with the type of difficult patient Dr. Burke describes, the patients with bipolar disorder on whom we reported do not have this history of extreme early trauma. However, given the potential importance of the early history of bipolar children, we will be conducting a more extensive review of our subjects which will be reported in detail at a later date. This is clearly an area in which further research is needed. Mary A. Fristad, Ph.D. Ohio State University, Columbus Ronald A. Weller, M.D. Elizabeth B. Weller, M.D. University of Pennsylvania School of Medicine Philadelphia Fristad M. Weller E. Weller R (1992). The mania rating scale: can it be used in children? ] Am Ai:ad ChilJAdokscPsychiatry 31:252-257
WozniakJ. Biederman J. Mundy E. Mennin D, Faraone SV (l995b). A pilot family study of childhood-onset mania. ] Am Acad ChilJ Adalesc
Psychiatry 34:1577-1583
INFECTION-TRIGGERED OCD
Drs. Fristad, E. Weller, andR. Weller reply:
To theEditor:
Dr. Burke's letter raises many issues, most of which are beyond the scope of the data in published our work. However, her comments highlight the importance of accurate diagnosis of childhood psychiatric disorders. Although
We found the recent Grand Rounds by Tucker et al, (1996) most interesting. The possibiliry that antibodies directed against streptococcal epitopes may cross-reactwith epitopes in the CNS has been proposed by one of us (L.S.K.) and is of
1320
j. AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 36:10, OCTOBER 1997
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 irr itability. hypersexuality, mood swings. affective storms. dysthymia. suicidaliry or 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 ~-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 beh avior.
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. Fristad, 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 symproms that may resemble "atypical" bipolar symproms. Our journal club would greatly appreciate responses from clinicians and researchers with experience with this population . Mary G. Burke. M.D. Mt. St. Joseph-St. Elizabeth San Francisco American Academy of Ch ild and Adolescent Psychiatry (1997), Practice parameters for the assessment and treatmen t of children and adolescents with bipolar disorder. JAm Acad ChildAdolnc 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 AcadChildAdoksc PJychiatry 31:252- 257 Stern D (1985). TheInterpenonal World ofth~ Infant. New York: Basic Books. chapters 4 and 5 Wozniak]. Biederman] (1996). A pharmacologic approach to the quagmire of comorbidity in juvenile mania. J Am Acad Child Adoksc PJychiatry 35:826-828
Drs. WOzniak and Biederman T"(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 facror 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,
1319
LETTERS TO THE EDITOR
replicated in two entirely different samples, documented that the mania described in our children is strongly familial (Faraone et al., 1997; Wozniak et al., 1995b). Although concerns about abuse and neglect are frequently raised when mania symptoms are seen in a child, this critical issue has never been systematically investigated. Although we do not have an answer to this question, we can share our thoughts on the subject. First, the diagnosis of mania, as conceptualized in DSM, is descriptive and not etiological. It is akin to observing a sexually transmitted disease or a broken bone in a child irrespective of its association with sexual or physical abuse. Moreover, because bipolar disorder carries with it poor judgement, aggression, severe disinhibition, and hypersexuality, children suffering from bipolar disorder may be especiallyvulnerable to trauma and abuse. While clinicians must always take a careful trauma history, assuming that all casesof juvenile bipolar disorder must have a history of trauma can have serious consequences. As examples, we can cite two specific casesunder our care who, in the past several months, have been investigated by the Department of Social Services after evaluators in an inpatient unit and in a school, respectively, assumed that the severe symptoms of the bipolar disorder (disinhibition, violence, and angry statements directed at parents) must be posttraumatic. In both cases, the accusations against the parents were unsubstantiated and the casesdropped. However, the investigations led to family disruption, loss of privacy, and reluctance and fear about pursuing professional help. Thus, clinicians who treat severely disturbed children with both trauma and bipolar disorder many erroneously attribute the direction of causation to be trauma leading to bipolar disorder, when in many cases the opposite may be true. Janet Wozniak, M.D. Joseph Biederman, M.D. Massachusetts General and Mclean Hospitals Harvard Medical School, Boston Faraone SV. Biederman J. Mennin D. Wozniak J. Spencer T (1997), Attention-deficit hyperactivity disorder with bipolar disorder: a familial subtype? ] Am Ai:ad ChilJAJokscPsychiatry 36: 1378-1387 Wozniak J. Biederman J. Kiely K et al, (l995a). Mania-like symptoms suggestiveof childhood onset bipolar disorder in clinically referred children.
] Am Ai:ad ChilJAJokscPsychiatry 34:867-876
the young girl described by Dr. Burke manifested symptoms commonly associated with bipolar disorder, it is unclear from the report whether this child met the DSM-IV criteria for bipolar disorder or any other mood disorder. Thus it might be premature to suggest neglect and early trauma are specifically associated with bipolar disorder based on this single case report. To assess this issue further, we undertook to review the histories of the bipolar children in our article. Our report (Frisrad et al., 1992) focused on assessing severiry of mania in children in whom we had diagnosed bipolar disorder. Of the 11 children in our report, we were able to quickly review the charts of 10 (one chart was not immediately available) to determine whether they had experienced near-catastrophic abuse and neglect. On the basis of this preliminary review we can state the following: All appeared to have a preschool onset of affective symptoms. Age of first treatment ranged from 5 to 12 years. There was no history of neglect in any child. However, two children had witnessed the abuse of one adult by another adult. In addition, it was suspected that one of these two children had been sexually abused by a stepfather whom the mother later divorced. No child had a history of early multiple placements, although many had treatment placements during their school-age years. Finally, none had a history of any other significant early trauma or abuse. Thus, while we are familiar with the type of difficult patient Dr. Burke describes, the patients with bipolar disorder on whom we reported do not have this history of extreme early trauma. However, given the potential importance of the early history of bipolar children, we will be conducting a more extensive review of our subjects which will be reported in detail at a later date. This is clearly an area in which further research is needed. Mary A. Fristad, Ph.D. Ohio State University, Columbus Ronald A. Weller, M.D. Elizabeth B. Weller, M.D. University of Pennsylvania School of Medicine Philadelphia Fristad M. Weller E. Weller R (1992). The mania rating scale: can it be used in children? ] Am Ai:ad ChilJAdokscPsychiatry 31:252-257
WozniakJ. Biederman J. Mundy E. Mennin D, Faraone SV (l995b). A pilot family study of childhood-onset mania. ] Am Acad ChilJ Adalesc
Psychiatry 34:1577-1583
INFECTION-TRIGGERED OCD
Drs. Fristad, E. Weller, andR. Weller reply:
To theEditor:
Dr. Burke's letter raises many issues, most of which are beyond the scope of the data in published our work. However, her comments highlight the importance of accurate diagnosis of childhood psychiatric disorders. Although
We found the recent Grand Rounds by Tucker et al, (1996) most interesting. The possibiliry that antibodies directed against streptococcal epitopes may cross-reactwith epitopes in the CNS has been proposed by one of us (L.S.K.) and is of
1320
j. AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 36:10, OCTOBER 1997