New research presented at the 17^th Annual British Association for Counseling and Psychotherapy Research Conference this past May reveals that there is a connection between diet and bipolar disorder, with sugar, caffeine and poor overall eating habits increasing the mood swings of bipolar individuals. The research also indicated that there are noteworthy differences in the eating patterns of these individuals at the onset of bipolar disorder – specifically, sudden increases or decreases in appetite or erratic eating patterns may occur.

My assessment of these findings is that erratic eating behavior together with the excessive consumption of sugar and caffeine isn’t good for any of us, and can certainly exacerbate the DIGFAST manic symptoms of a bipolar sufferer. Sugar and caffeine can’t be good for a manic or hypomanic individual right?

The study’s conclusion that those with bipolar disorder would benefit from nutritional intake awareness counseling is just too obvious. Diet modification can play a vital role in improving and/or alleviating a veritable host of physical and emotional/psychological/psychiatric conditions. In this regard, there’s nothing special about bipolar disorder in my estimation.

Considering the diets of those referred to me for the assessment or treatment of bipolar disorder is not high in the pecking order of things I need to do to help the client get better. I’m much more concerned about getting and keeping them motivated for treatment, stressing the importance of medication compliance to their overall quality of life and survival and building their support system.

The diagnosis of bipolar disorder in children and adolescents is currently the most hotly debated issue in pediatric mental illness. It is enormously controversial and depending on who you listen to, it has either reached epidemic proportions or it is virtually non-existent. Misdiagnosis is the major problem; whether the disorder is overdiagnosed or underdiagnosed only fuels controversy and is the wrong question anyway.

Mood Stabilizers:
Lithium continues to demonstrate high efficacy as a first line agent for the treatment of bipolar disorder. It seems to be more effective for mania than bipolar depression. Lithium is more effective than Depakote as monotherapy for bipolar disorder; symptom improvement is only marginal when both are used together.

Seroquel and Abilify are emerging stars in the treatment of bipolar depression. Some studies indicate robust results with Seroquel.
Traditional antidepressants have little if any benefit in the management of bipolar depression.

The nuances of study design do not yet support second generation antipsychotics as first line agents for bipolar disorder.

The writers of DSM 5 have identified what they believe to be a very troublesome problem – the seemingly out-of-control overdiagnosis of childhood bipolar disorder which had led to a veritable proliferation of antipsychotic and mood-stabilizer medication use in pediatric populations.

I honestly don’t know whether childhood bipolar disorder is overdiagnosed or underdiagnosed. Positions regarding the overdiagnosis vs. underdiagnosis conundrum depend on whom you ask, comparative studies, clinician biases and personal experiences with diagnosing this disorder.

My concern relates to the proposed DSM solution or “fix,” if you will, for the aforementioned wild overdiagnosis problem. The proposal calls for a new diagnosis called “Temper Dysregulation Disorder with Dysphoria” and is meant to provide a less risky diagnosis for kids misdiagnosed as bipolar. This would be no more than a diagnostic dumping ground that will eventually prove to be a makeshift solution at best, with considerable risks.

The biggest problem with the proposal is that it is not restrictive enough. It throws a life preserver to kids misdiagnosed as bipolar, while opening the flood gates to the misdiagnosis of normal kids who happen to have temperament issues associated with the aches and pains of growing up. Ever effort should be made to distinguish “mental disorder” temper problems from those that are within the boundaries of normal, but difficult, tantrums associated with childhood development, otherwise any kid who acts out, regardless of the circumstances, could conceivably fit into Temper Dysregulation Disorder criteria.

This will not be easy to pull off. Because in the real world, at the clinic level, many diagnoses are made by primary care clinicians with little expertise in psychiatry, less time with each patient, and who are overly intolerant of unruly behavior.

What’s the solution? Given the limited state of current knowledge, it is foolhardy to regard Temper Dysregulation as an independent syndrome that can stand on its own. Adopting measures on how to assess symptom severity and adding certain specifiers could help, but the best solution for now is to do nothing.

If it’s true that pediatric bipolar disorder is wildly overdiagnosed, the NIMH and the FDA may have to step up educational campaigns geared to professionals and the general public regarding the significant risks associated with the overuse of second-generation antipsychotics and to recommend employing restraint in the diagnosis and treatment of kids with temperamental outbursts.
The good news is that childhood onset bipolar disorder is getting much more attention than it did just a decade ago. Rising interest will hopefully lead to more research funding, scientific discovery and resources dedicated to pediatric mental illness.

Q.

A. My answer to this question is YES. Bipolar Disorder is very hard to diagnose in children because childhood onset presentations differ a bit from what would typically be seen in adults.
The salient features of childhood onset BPD are:

• Frequent, short periods of intense mood changes accompanied by demonstrable irritability and pronounced agitation
• Daily mood cycling is more common in children, less common in adults
• The high incidence of multiple co-existing disorders with symptom overlap seen in children

The prime example of a co-existing condition with symptom overlap is ADHD. Two of the symptoms presumed to be evidence of a mood disorder (Bipolar) – irritability and hyperactivity – are also key criteria for an ADHD diagnosis. The symptoms of Oppositional Defiant Disorder, Conduct Disorder and Anxiety Disorders in children also overlap with those in pediatric Bipolar Disorder.

Another issue complicating the diagnosis of BPD in children is that there is no consensus on how to measure symptom severity. If a child is perceived as disruptive, it could be evidence that his or her behavior deviates wildly from the mean, or it could be that the individual(s) describing, assessing or attempting to diagnosis the child is overly intolerant of unruly behavior. From a clinician standpoint, there are many that do not possess the temperament or objectivity to be diagnosing bipolar disorder in children, and therefore shouldn’t be doing so.

In spite of how far we have come, we are still at an early stage of defining, assessing, diagnosing and even treating this disorder in children. In our current age of managed care-imposed time constraints often accompanied by a quick-fix mindset, we too often operate in “diagnostic rush to judgment” mode. And a troubling, and potentially dangerous precedent is set because we don’t know yet to what extent symptoms of irritability and agitation will predict which children will develop the adult form of Bipolar disorder. So the saga will continue – too many children will be diagnosed when they shouldn’t be or will not be diagnosed even though they should be, as a result of how widely or narrowly we cast the net.

There is good news. Pediatric bipolar disorder is getting much more attention than it did just a decade ago. Rising interest will inevitably lead to more scientific discovery, hopefully better treatment, and possibly even additional resources targeted to pediatric mental illness.

Although this comes as no surprise to me, there is now clear evidence that lithium is the most efficacious single agent for managing bipolar mania and bipolar depression. If, for whatever reason, lithium is not effective as monotherapy, combining Depakote with it does increase efficacy – although not markedly. The lithium/Depakote combination therefore is optimal in the treatment of bipolar mania.

From clinical experience, what are your impressions?

The seven classic symptoms of mania and hypomania are probably best summed up through the use of the acronym

D I G F A S T

Distractibility: Inability to maintain focus on tasks

Insomnia: Reduced need for sleep accompanied by increased energy in spite of little sleep

Grandiosity: Inflated self-esteem

Flight of ideas: Racing thoughts

Activities: Increase in goal-directed activity – work, social, school

Speech: Excessive, circumstantial, tangential chatter, pressure to keep talking or more talkative than usual

Thoughtlessness: Risky behavior, such as excessive involvement in pleasurable activities that have a significant potential for adverse consequences – excessive spending, risky sexual behavior, reckless driving, gambling, impulsive traveling

DIFFERENCES BETWEEN MANIA AND HYPOMANIA

Mania:

• - Marked occupational/social dysfunction
• - Often a need for hospitalization
• - 67% of patients have a lifetime history of psychosis
• - Minimum of one week duration according to DSM IV

Hypomania:

• – No significant occupational or social dysfunction
• - No hospitalization
• - No psychotic features
• - Minimum four-day duration (average is 2-3 days)

The manic phase of bipolar disorder carries a peculiar treatment challenge that most other mental disorders do not: Because mania is a desirable and enjoyable state for many, if not most patients, medication noncompliance is a particular hazard during these manic episodes. Repeatedly starting and discontinuing mood stabilizers results in erratic blood levels of these medications and a subsequent decrease in their overall effectiveness. This, in turn, can lead to an increased susceptibility for the occurrence of future episodes, a progressive worsening of symptoms and a heightened mortality risk. Clinicians should continually emphasize the serious risks of noncompliance with these patients and focus on coaching them to take these medications as prescribed.

Enlisting the assistance and cooperation of the bipolar client’s family members can prove to be a significant asset toward gaining medication compliance. Family members are our de facto healthcare specialists and are too infrequently utilized by prescribers and therapists as sources of information regarding the client’s progress (or lack thereof). They are often first to recognize the warning signs of symptom reemergence and can serve as our first-line allies in getting their de-compensating, medication noncompliant bipolar loved one back on the road toward progress.

In truth, bipolar disorder is quite difficult to diagnose in children, and the presentation of childhood mania differs dramatically from adults. Children in the manic phase of the disorder tend toward extreme agitation and destructive outbursts, as opposed to the euphoria more common among adults.

The most widely used medications in the treatment of pediatric bipolar disorder are lithium and Depakote. Although studies confirm the effectiveness of these medications, their safety is questionable due to the life-long nature of bipolar disorder. Long term lithium use is linked to weight gain, acne, tremors and kidney dysfunction. Prolonged Depakote use is associated with pancreatitis and liver failure. Both medications require stringent blood-level monitoring. The bottom line: The benefit-vs.-risk of medicating childhood-onset bipolar disorder is a considerable concern.

Irritability, frustration intolerance, aggression and inattentiveness are present in both disorders.

Did I miss anything? What are your experiences when it comes to differentiating Bipolar disorder and ADHD?