• Thyroid malfunction
• Hormone imbalances
• Diabetes
• Mononucleosis
• Chronic Fatigue Syndrome (CFS)
• Lupus
• Cancer
• Cushing’s Syndrome
• Hepatitis
• HIV/AIDS
• Rheumatoid arthritis
• Medication or other substances that could have triggered symptoms

Sometimes we wonder whether doctors, including psychiatrists, follow the proper protocol in diagnosing bipolar disorder. Before diagnosing you and prescribing any medication, did your doctor perform a physical exam or refer you to an internist/specialist and/or order various tests to rule out medical issues that may have been causing symptoms of mania or depression?

What was the diagnostic process like for you?

Doctor image available from Shutterstock.

Chris asks…

Can long term (decade+) acute pain from an artery joining a vein directly in the spine that causes legs to not work very well lead to bipolar? Person has master degree in Mech Engineering and a MBA. Started to make poorer decisions which led to job loss, went on disability, divorce, severe ruminating, depression, possible suicidal thoughts, inability to think things through, sense of being lost and blaming one’s self for all that has gone wrong, fear or what is going to happen and impulsive behavior that cost his life savings.

He knew what to do but didn’t do it to prevent such a large loss of savings. He is seeing a therapist for mental health reasons and a regular doctor for his physical impairments. A lot of his symptoms I’ve seen in several bipolar individuals who I am familiar with. He asked me if he could be bipolar. Therapist thinks pain.

Dr. Fink Answers…

I can’t offer an accurate diagnosis without seeing the patient, but bipolar disorder is typically caused by a genetic susceptibility coupled with certain stressors, and pain certainly qualifies as a stressor. Divorce, job loss, and financial problems are also significant stressors. Your friend really should make an appointment to see a psychiatrist and obtain a differential diagnosis to help identify the root cause, whether it’s bipolar disorder or something else entirely.

We’ve posted a sample chapter of our book Bipolar Disorder For Dummies on our other blog, which you and your friend may find helpful: Chapter 5, “Getting a Psychiatric Evaluation and Treatment Plan.” It provides details on how to choose a psychiatrist and get the most accurate diagnosis. Hope this helps.

Photo by jancissmells, available under a Creative Commons attribution license.

The researchers postulated that because many of the structural, neurochemical, and functional abnormalities identified in the brains of those with bipolar disorder are also implicated in postural control, people with bipolar disorder would have less postural control and hence a greater magnitude of sway than those without a brain disorder. In other words, there’s a connection between motor and mood disorders. The results supported their hypothesis:

• The bipolar disorder group had increased sway area (diminished postural control), especially with the loss of visual information (eyes closed).
• The bipolar disorder group exhibited a loss of complexity – in this case, a diminished ability to make faster, small-scale postural adjustments.

A major complication inherent in the study, as the researchers themselves point out, is that other factors may have influenced the diminished postural control of the participants with bipolar disorder – primarily medication:

“The approach we have chosen for this study, i.e., studying euthymic, medicated patients, clearly presents difficulties in the interpretation of the present results because it is difficult to determine what proportion of the effect size arises from underlying mechanisms associated with bipolar disorder and what effects were due to medications.”

While neuroleptics tend to have a negative effect on sway dynamics, SSRIs and lithium tend to have a positive effect. Another complication consists of variations in the course of illness among the bipolar group and a history of alcohol abuse for some participants. However, even when the researchers accounted for such variations, the results indicated a connection between mood and motor disorders consistent with that of other studies. This suggests that motor disorders may be a core component of bipolar disorder.

The findings here add another layer to the complex neurologic story of bipolar disorder. We have known for a long time that some movement disorders (i.e. Parkinson’s and Huntington’s) have high rates of mood symptoms. This research is working in the other direction – looking at motor symptoms in mood disorder.

While this research does not have immediate or obvious clinical use, it is valuable in evolving our understanding of bipolar disorder as a brain based condition with a variety of associated brain changes. If people with bipolar disorder feel like they are clumsy or uncoordinated, it may be helpful for them to hear that this is likely part of their mood disorder, rather than something they are doing wrong. Perhaps motor based interventions, including exercise or physical therapy, may become more important in the treatment of bipolar disorder or at least in improving quality of life with bipolar.

An additional clinical use that I can think of is that we may eventually use movement symptoms as one piece of data in looking at high risk children, such as those born to people with bipolar disorder, and helping to tease out who among them has higher risk of actually developing the disorder.

Photo by TeeF86, available under a Creative Commons attribution license.

About a month ago, I was taken off my Lamictal, lithium, Seroquel, and Zoloft. I have a new Dr. who has prescribed me 150mg of Wellbutrin SR and 600mg of Neurontin. I became very depressed, had sleeping problems, and then as the third week hit, I became suicidal.

She increased my Wellbutrin SR to 150 mg twice a day and Neurontin up to 900mg (300mg morning and 600mg in the evening). I feel she is not treating me for my rapid-cycling Bipolar. I am either up or real real down, more down moments than my manic high, which often occurs.

Is she helping me or going to hurt me? I do not want to visit any more hospitals as a result of a doctor not giving me the right doses or too little or, as it is now, I have no antipsychotic meds, which is worrying me. Is this why I feel so depressed and suicidal thinking?

Please help. I am 43. I am not a child with Bipolar. Is this weak for my case? I have been hospitalized twice with Bipolar and I really wish to stay out of them. HELP PLEASE!!!!

Dr. Fink Answers…

Hi, Kelly. I am so sorry to hear that you are struggling like this right now. Most importantly, you should continue to express to your new doctor how badly you are feeling and insist that she explain to you what she is doing and why.

In the meantime, I think it is urgent that you seek a second opinion as soon as possible. You do not say why the other meds were stopped – and how quickly you came off of them. Your story seems to have a lot of pieces to it, and you deserve a second look from another doc.

I would also encourage you to speak to your internist or family doctor immediately to tell them what is going on and also to get a referral for a second opinion.

Finally, I would suggest that you be sure to include any supportive people in your life to help you get through this and to find help – family, friends, or other professionals, EAP services at work, teachers, etc. Some insurance companies also have case workers who may serve as effective advocates.

We hope you’re feeling better soon.

We invite you to check out the post, especially if you’re interested in keeping up on the latest breakthroughs in identifying the genetic component of bipolar disorder. Although it may be years before these genetic studies translate into any sort of gene therapy, if that’s even possible, they deliver an immediate benefit in three important ways:

• The genetic link adds to the growing body of scientific evidence that proves bipolar disorder to be a genuine illness and not a personality flaw or behavioral disorder.
• As we get closer to identifying the gene or genes responsible for bipolar disorder, we get closer to developing a test for it.
• What we learn from the research helps in developing prescription medications that are more effective in targeting symptoms while causing fewer undesirable side effects.

Photo by Micah Baldwin, available under a Creative Commons attribution license.

Unfortunately, they don’t share treatment protocols; if the diagnosis is wrong, treatment may be counterproductive. Stimulants, like Ritalin, which are effective in treating ADHD can make a child with bipolar disorder more manic. Giving a mood stabilizer, like Tegretol, to a child with ADHD may result in little or no improvement or severe side effects. Getting the diagnosis right is the key to effective treatment.

As reported on Science Daily in an article entitled “Brain Imaging Identifies Differences in Childhood Bipolar, ADHD,” researchers at the University of Illinois in Chicago may have found one key component in differentiating between childhood bipolar disorder and ADHD. Using brain imaging technology, they examined the brain activity of children who had been diagnosed with bipolar disorder or ADHD as the children performed a series of memory tasks that had an emotional component.

In both disorders, brain imaging data showed dysfunction in the prefrontal cortex, but in those with ADHD, the dysfunction was more severe. Those in the bipolar disorder group had more deficits in brain regions involved in processing and regulating emotions.

I look forward to the time when these studies translate into tools and procedures that can be used in a clinical setting. Being able to more readily and accurately distinguish between ADHD and bipolar disorder certainly will result in more accurate diagnoses and more effective and timely treatment.

Photo by Horia Varlan, available under a Creative Commons attribution license.

Psychosis

Psychosis is defined as an abnormality of thoughts (content) or thinking (process). Psychosis is not a diagnosis in itself but a type of psychiatric symptom that occurs in a variety of diagnoses, including schizophrenia and bipolar disorder.

Schizophrenia is primarily a disorder of thinking – psychotic symptoms are the main presenting symptoms. Depressive or manic episodes sometimes include psychotic symptoms, but not always. Certain drugs such as LSD, mushrooms, and other psychedelics can also cause psychotic symptoms.

Abnormalities in Thought Content

Psychotic thought content consists of thoughts not based in reality. The most common forms of are hallucinations and delusions.

Hallucinations

Hallucinations are disorders of perception distinguished by the different senses:

• Auditory hallucinations: Hearing voices or other sounds not heard by anyone else.
• Visual hallucinations: Seeing things that are not there.
• Olfactory hallucinations: Smelling things that no one else smells.
• Tactile hallucinations: Such as feeling bugs crawling on you that are not there.

People with auditory hallucinations do not usually have awareness that the thoughts are in their head, at least until after they have recovered and can begin to work on identifying the voices. Even then, if they enter another acute episode, they often don’t have insight into where the voices are coming from or that they are saying things that are false. If someone tells you that they hear voices – and they know the voices are not real – it is less clear cut whether or not to identify this as a true hallucination.

In psychiatric illnesses, such as schizophrenia, the hallucinations are almost always primarily auditory. Visual, olfactory, and tactile hallucinations are much more likely related to other brain impairments, such as drugs or drug overdose or severe medical illness that compromises thinking, including organ failures, sepsis (blood infection), or seizures.

Delusions

Delusions are ideas or thoughts about the world that are not based in reality. Delusions may be present in any of the following forms:

• Paranoid delusion: Thinking that people or other beings are trying to hurt you or that organized systems out in the world are focused on harming you. Paranoid delusions are the most common type.
• Delusions of reference: Believing that messages are directed at you personally when they are not; for example, believing the television is addressing you personally or that the professor in your class is telling you coded messages during their lectures that no one else can hear.
• Delusions about thinking: Thinking that people are reading your thoughts, inserting thoughts in your head, or controlling your thinking and behavior.
• Grandiose and religious delusions: Thinking that one has super or supernatural powers and/or control over others; thinking one is a famous religious figure or closely connected to deities or other religious phenomenon.

Abnormalities in Thought Process

Disorders of thought process are also common in psychosis and are sometimes easier than disorders of perception to observe from the outside. They include the following:

• Loose associations: Someone’s thoughts are only loosely connected to each other in the person’s conversation.
• Tangential thinking: Someone gets off track onto other topics and never gets back to the original point.
• Circumstantial thinking: A less severe form of tangential thinking in which someone goes all around topics, but they still get back to the original point.
• Thought blocking: Someone’s thoughts appear to just stop randomly.
• Flight of ideas: A highly pressured and extreme form of tangential thinking or sometimes loose associations common in mania.

Photo by Vern Southern, available under a Creative Commons attribution license.

Other types of hallucinations and delusions are present in psychosis, but those described here are some of the most common.

Results of a study published in the January 2011 edition of the American Journal of Psychiatry entitled “Childhood trauma and children’s emerging psychotic symptoms: A genetically sensitive longitudinal cohort study,” claim to show that childhood trauma from maltreatment and bullying is associated with children’s reports of psychotic symptoms.

While the report serves an important role in calling attention to the serious psychological and psychiatric damage that intentional abuse and bullying can cause, it also raises the question of what is and is not psychosis, especially in children.

Reviewing the Report’s Findings

The findings in this report seem to suggest that trauma in childhood is associated with higher rates of psychotic symptoms at age 12 years – specifically higher rates than in those who have not experienced such trauma. Interestingly the data also suggest a higher risk of psychotic symptoms is related to trauma events that are associated with intent to harm – abuse by an adult or bullying by a peer – as opposed to trauma that was accidental.

The findings also suggest that the more trauma is experienced, the higher the likelihood of psychosis – a “dose dependent” relationship between dose of trauma and likelihood of psychotic symptoms. Furthermore these higher risks of psychosis were not due to genetics, IQ, socioeconomic deprivation (i.e. poverty), or early psychiatric symptoms.

This is powerful data regarding a group of children followed from birth until age 12, which is one of the best ways to look at how children’s psychiatric problems evolve over time. And it adds even more fuel to the public health argument that being vigilant for abuse and bullying is one of the best ways to prevent psychiatric problems in children – leading to better outcomes for the child and family and lower costs to the community in the future.

Questioning the Definition of Psychosis in Children

My problem with this study is the definition of psychosis. It has always been difficult to be clear about what is and is not psychosis in children. Children have vivid fantasy lives, making it quite challenging to distinguish between childhood psychosis and fantasy.

There is also a long standing debate about the self-report of psychotic symptoms; for instance, when a child reports hearing voices, is that true psychosis or are they sorting out their own internal monologue and defining it as a voice? That is a developmentally difficult question to answer.

Often in adults with psychosis, they do not have insight into their psychosis. When they “hear a voice,” they believe it to be real, so they will often tell you, at least early in their illness, that they do not hear voices. When a child talks about angels following them home from school to guard them, is that a childlike religious belief or a true delusion?

Actively engaging with an angel, seeing the angel as controlling other people and events, and changing one’s own behavior in response to the angel are more characteristic of a hallucination or a delusion. But is just believing an angel is present psychosis? This is a tough call, especially in a child.

Diagnosing Psychosis in Children

In reading the article I was not convinced that I would have diagnosed so many of these children with psychotic symptoms. I tend to rely on more active, observable findings such as:

• Disorganized and fractured thinking or speech.
• Observable responses to voices.
• Frank delusions about the world that are inconsistent with age and developmental level.

Childhood Psychosis Over-Diagnosed or Under-Diagnosed?

The percentage of children that these authors report as having a definite psychotic experience is close to 6% of the study population, which is a huge number of children. Many other studies would suggest a much lower frequency of psychosis in 12 year olds.

There tends to be something of a split in the professions: those who feel psychosis in children is under-diagnosed and more common than we think, and those who find it very rare. I tend to fall in the latter category, so this article goes against my assessments of the frequency of psychosis in children.

While the issue of childhood trauma and psychiatric symptoms is important, and this data suggests connections, I am not sure that the connection with psychosis is well supported yet.

Note: The writing of today’s post generated an interesting discussion about the definitions of “psychosis,” “delusions,” and “hallucinations.”

Tune in Friday for definitions and explanations of these terms.

Photo by Jeremy Weate, available under a Creative Commons attribution license.

Carla asks…

My son was in nursing school, age 27, and working as a graduate assistant at the same time. He was going without sleep, but feeling sleep deprived, so he was drinking caffeine energy drinks. He passed a big test, went out with the guys, and overdid the drinking. The next day, he played in a flag football game and got a head injury that required stitches. After the injury, he was sleeping maybe 2 hours a night, and felt terrible. Two days later he has a psychotic break!!!!!

I swear he never exhibited bipolar symptoms growing up. He did have test anxiety and some attention issues in school, but overall was a good student, etc. He did not have extreme mood swings.

As a result of the psychotic break, he was hospitalized, and came out of it, on Seroquel. He has managed ok, but has terrible self-esteem issues because of it. The doctor at the mental health center has now switched him to Abilify.

How can we be sure he needs these meds?? Does he have bipolar or was it just a combination of crap that produced the perfect storm????

Dr. Fink answers…

We hear this a lot, and the answer is always the same: You can’t be sure it’s bipolar disorder unless the mania or psychotic break occurs spontaneously – not influenced by antidepressants, excessive stimulants, alcohol or substance abuse, sleep deprivation, and so on.

In this case, there seemed to be a number of triggers – sleep deprivation, excessive stimulants – caffeine, and a head injury. Given this package of potential causes of psychotic and/or manic symptoms, it’s hard to say for certain whether this eventually will be a story of true bipolar disorder or turn out to be a one- time episode brought on by severe circumstances.

It could be that your son does have an underlying vulnerability to bipolar disorder and that is why symptoms developed in response to the stresses on his system. We know that many people undergo similar life events without developing psychosis and mania, so the question is: Why did these events lead to this outcome in your son? At this point, it’s hard to say, until his story unfolds more over time.

The absence of mood symptoms in childhood does not rule out the development of bipolar disorder. Many people with bipolar recall having depressed and/or irritable symptoms as a child or teen, but certainly not all.

The more pressing question is what to do about it? Do you stop the medications and risk experiencing another episode or continue the medications even though they may not be necessary? This requires an ongoing discussion with the psychiatrist to determine if and when it might be reasonable to try decreasing or coming off of medications. Usually I wait until someone has been stable for an extended period of time (at least a year, sometimes more) before considering this step.

But this is complex. Many factors contribute to the decision to stay on or to taper or discontinue medications in a case like your son’s. It has to be part of the treatment process – careful monitoring by and communication with the doctor will be crucial.

Also, you mention your son’s self-esteem challenges, and I wonder whether he’s in psychotherapy with the psychiatrist or if he has established a relationship with a therapist. He has gone through a traumatic life experience, and regardless of how it plays out he would likely benefit from a psychotherapy that would help him work through this and avoid or reduce the impact of later repercussions.

Photo by “redmuse_poet,” available under a Creative Commons attribution, non-commercial license.

Based on results from the study, researchers concluded that “Relatively few children with rapidly shifting moods and high energy have bipolar disorder, though such symptoms are commonly associated with the disorder. Instead, most of these children have other types of mental disorders.”

I first wrote about my concerns surrounding this issue in 2007 in a post on my Bipolar Blog entitled “Bipolar Disorder Overdiagnosed in Children?” Back then, Benedict Carey of The New York Times wrote a piece calling attention to the 40-fold increase in the diagnoses of bipolar disorder in children between 1994 and 2003, climbing from 20,000 cases in 1994 to 800,000 cases in 2003.

Unfortunately, the situation still exists. The good news is that there seems to be a groundswell of evidence to support the fact that bipolar disorder is over-diagnosed in children. Hopefully these and other studies will call attention to this undesirable situation and stem the tide.

Yes, children can have bipolar disorder. Diagnosing it and treating it early is important. But if something else is going on or some other condition other than bipolar disorder is at work, which it is more often than not, we need to be more precise in our diagnosis in order to provide the best treatment possible – whether that be medication or some other intervention.

Photo by Mike Baird of Morro Bay, CA. Available under a Creative Commons attribution, non-commercial license.