Early onset Bipolar Disorder

Incidence / Prevalence 

About 1 % of young people under the age of 18 but typically post-pubescent would experience bipolar disorder. The risk of this mental ailment affecting someone is higher in those with a family history. The illness can be triggered by adverse life events which are stressful, illicit substance use, sleep deprivation and on rare occasions by anti-depressants. Medical conditions (e.g hyperthyroidism) may mimic and present similarly at times and specialist intervention is almost always advisable. 

Presentation

The presentation characterised by 
  • Elation of mood with the person unjustifiably cheerful or euphoric. The mood may also show signs of irritability and periods of agitation. The mood also shows 'lability' or rapid fluctuations in some switching from elation to crying out of context within seconds. 
  • The person will feel and be observed to have a new found energy, may not sleep and eat excessively or go without food for prolonged periods without getting tired. 
  • Speech often is rapid and at times may become incomprehensible. Others may find it difficult to get a word in. The speech may become disjointed with the person moving from topic to topic. 
  • There is an increased in goal directed activity, seeking pleasure through indiscriminate or excessive sexual behaviours or other pleasurable activities.  
  • The affected person may demonstrate grandiose ideas and at times delusions thinking 'they are the chosen ones to rid the world of it's ills, proclaim to have contacts with famous celebs, and lead to spending sprees.
  • Some people experience associated hallucinations as well.  

Explanation

The illness occurs because the stress induces a chemical imbalance which removes the normally available regulatory control of the higher order faculties leaving the person very dis-inhibited in their behaviours. 

Assessment

This includes a detailed clinical history, mental state examination, physical exam as well as blood tests and at times brain scans to rule out medical causes. 

Exclusions

ADHD, borderline and unstable personality disorders, some forms of psychosis may present with similar features and need to be considered at the time of assessment.

Treatment

  • Invariably this involves use of medication to manage acute symptoms. This involves use of anti-psychotic medication such as Risperidone or Olanzapine. Other options such as Quetiapine or Aripiprazole may be considered based on side effect profiles when indicated. 
  • Close monitoring for response, side effects is required until the symptoms resolve. 
  • Treatment is recommended to continue for up to 2 years in first episode. Longer if there are further episodes. 
  • Repeated relapsed may need to be managed by mood stabilisers such as Valproate or Lamotrigine - the former contraindicated in adolescent girls due to tendency to cause polycystic ovarian syndrome. Lithium may also be considered for its mood stabilising abilities in some cases. 
  • Baseline lipid profile, LFT, RFT, TFT, FBC, HBA1C with weight need recording and then repeated at recommended intervals until a person is on medication. 
  • CBT is often introduced at a later stage to help a person cope with stress better. Work includes education to create awareness about the illness for both patient and family / parents. 
  • Family therapy may be indicated if conflicts are likely to cause relational stress which may cause relapses.  

 Dr A Joglekar