How early in childhood can the first bipolar symptoms appear? And the impact of bipolar disorder on girls and women.

It is being increasingly recognized that bipolar disorder often has its onset in adolescence or early adulthood. First affective symptoms appear in early teenage, and even in preadolescence. There is a growing interest, with little consensus, in the affective and behavioral symptomatology in childhood and adolescence preceding the first onset of a clearly diagnosable bipolar disorder. There is a significant time-lag between the onset of the illness and first treatment. This may put patients at risk of increased morbidity, including   effects on personality, school, work and social functioning. There is growing evidence in the schizophrenia literature that this time-lag may predict a poorer response to treatment. Although there is no clear evidence of this in bipolar disorder, this issue should be borne in mind.

Early onset is often defined as occurring before the age of 25. The younger the age of onset of bipolar disorder, the more likely it is to find a significant family history of the condition. Early onset bipolar disorder most commonly begins with depression and there may be many episodes of depression before the first hypomania. Depression with psychotic features may be a predictor of future full-blown bipolar disorder in the early onset group. Akiskal (1995) has argued that syndromal dysthymia with its onset in childhood, particularly in the presence of a family history of bipolar disorder, may herald a bipolar disorder. Rapid cycling, mixed states, and psychotic features are more common in early onset conditions. The presence of early onset substance abuse should raise one's suspicions about bipolar disorder. Early onset bipolar disorder is more commonly associated with response to Divalproex and a relative failure of response to Lithium not only because rapid cycling, mixed states and substance use are common in this group but also because adolescents and young adults are less tolerant to the side effects of Lithium.

Gender Issues Associated with Bipolar Disorder

Female gender is more commonly associated with rapid cycling bipolar disorder (Calabrese et al, 1995), with or without thyroid dysfunction, perimenopausal exacerbation of the condition, the risk of exacerbation post-partum and being diagnosed as borderline personality disorder (especially in adolescents or young adults) when, in fact, some of these presentations could be explained by rapid cycling bipolar disorder. Biphasic mood dysregulation is being increasingly recognized as being more common in subjects with borderline personality functioning and there is merit in treating clearly established biphasic mood dysregulation even in the presence of personality dysfunction. Postpartum psychotic and serious mood disorders may well be part of a bipolar spectrum. There is also growing evidence that the pharmocokinetics of many psychotropic medications, including mood stabilizers, is altered in pregnancy, post-partum and even around menstruation. Bipolar disorder secondary to underlying medical or neurological conditions are associated with the condition in the elderly (Evans et al, 1995).

About the author: Vivek Kusumakar, MD, FRCPC is an Associate Professor, Head of the Division of Child & Adolescent Psychiatry, and Director, Mood Disorders Group, Dept of Psychiatry, Dalhousie University, Halifax, Nova Scotia.

next: Bipolar Disorder in Children and Adolescents: Medications, ECT
~ bipolar disorder library
~ all bipolar disorder articles

Sources

Akiskal HS. Developmental Pathways to Bipolarity: Are Juvenile-Onset Depressions PreBipolar? J Am Acad Child Adolesc Psychiatry. 1995. 34:6. 754-763

Calabrese JR, Woyshville MJ. A Medication Algorithm for Treatment of Bipolar Rapid Cycling? J Clin Psychiatry. 1995. 56 (Suppl 3) 11-18

Egeland JA, Hostetter AM. Amish Study 1: Affective Disorders among the Amish, 1976-1980. Am J Psychiatry. 1983. 140(1): 56-61.

Evans DL, Byerly MJ, Greer RA. Secondary Mania: Diagnosis and Treatment. J Clin Psychiatry. 1995. 56 (Suppl 3): 31-37.

Strober M, Carlson C. Bipolar Illness in Adolescents with Major Depression. Clinical, Genetic and Psychopharmacologic Predictors in a Three to Four Year Prospective Follow-Up Investigation. Arch Gen Psychiatry. 1982. 39: 549-555.

next: Bipolar Disorder in Children and Adolescents: Medications, ECT
~ bipolar disorder library
~ all bipolar disorder articles

• About Change
• An Inspiration from War
• Angels, Infants, and Hope
• Are You Considering Therapy?
• Bigotry
• Boundaries
• Clients and Success in Therapy
• Couples: Passive & Controlling Partners
• Depression: The Problem
• Depression: What To Do About It
• Discipline
• Do You Think You Can't?
• False Memories and Responsibility
• Fantasy And Reality: #1
• Fantasy And Reality: #2
• Feeling Safe
• Finding Purpose
• Getting Enough Attention
• Handling Criticism
• Healing From Sexual Abuse: A Strategy
• How To Talk About Feelings
• How Are You Spending Your Life?
• Living With Alcoholics
• Loneliness
• Motivation
• Personal Freedom
• Powerful Ideas: #1
• Problems With Anger
• Problems With Sadness
• Problems With Scare
• Quitting Addictions
• Self Love
• Sexual Abuse In Childhood
• Shame: What You Can Do About It
• Stop Making Comparisons!
• Subconscious Life Scripts
• Were You Loved As A Child?
• What Terror Does To Us
• What To Tell A Therapist
• Who Is The Real You?
• Why Are You Treated The Way You Are?

next: I Want Help Socially,

WHEN WINSTON CHURCHILL was a young man, his father concluded that Winston was "unfit for a career in law or politics" because he did so badly in school.

Barbra Streisand's mother told her she wasn't pretty enough to be an actress and she could never become a singer because her voice wasn't good enough.

Conrad Hilton, who created a business empire with his Hilton Hotels, once overheard his father say to his mother: "Mary, I do not know what will become of Connie. I'm afraid he'll never amount to anything."

When Charles Darwin was getting ready to set sail on his five-year expedition on the Beagle, his father was extremely disappointed. He thought his son was drifting into a life of sin and idleness.

George Washington's mother was a harping, complaining, self-centered woman by all accounts. She belittled Washington's accomplishments and didn't show up at either of his presidential inaugurations. She was always whining that her children neglected her, and she was especially enraged when her son George ran off to command the army for the American Revolution. She honestly believed it was his duty to stay home and take care of her.

In his youth, the late Leonard Bernstein, one of the most talented and successful composers in American history, was continually pressured by his father to give up his music and do something worthwhile, like help out in his family's beauty-supply business. After Leonard became famous, his father was asked about that, and he answered, "Well how was I supposed to know he was the Leonard Bernstein?!"

People may criticize you or make fun of your ideas or actively try to stop you. Often their efforts are only attempts to protect you from failure. But failure is only a possibility if you stop. If you keep going, a "failure" is just another learning experience. And besides, giving up on a heartfelt aspiration is worse than failing. "Many people die," said Oliver Wendell Holmes, "with their music still in them." That's true tragedy.

So listen politely to the worries and criticisms of your friends and family, and do your best to put their minds at ease, but then carry on. Listen last to your own heart. You know yourself better than anyone on earth. Make sure your song is sung.

Listen to your own heart. Don't let your music die with you.

Self-Help Stuff That Works makes an excellent gift. Order it now.

Why do people in general (and you in particular) not feel happier than our grandparents felt when they had far fewer possessions and conveniences than we now have?
We've Been Duped

What is the most powerful self-help technique on the planet? What single thing can you do that will improve your attitude, improve the way you deal with others, and also improve your health? Find out here.
Where to Tap

Would you like to be emotionally strong? Would you like to have that special pride in yourself because you didn't whimper or whine or collapse when things got rough? There is a way, and it's not as difficult as you'd think.
Think Strong

In some cases, a feeling of certainty can help. But there are many more circumstances where it is better to feel uncertain. Strange but true.
Blind Spots

When some people get smacked around by life, they give in and let life run them over. But some people have a fighting spirit. What's the difference between these two and why does it make a difference? Find out here.
Fighting Spirit

next: Just Keep Planting

WILLIAM MILLER, A RESEARCHER in the alcohol-treatment field, wanted to find out what kind of treatment would work best for controlling problem drinking. He divided his experimental subjects into two groups and tested the treatment group with a variety of methods, including Antabuse (a drug that makes you sick if you drink) and counseling.

That was the treatment group. But researchers always need a control group when they test the effectiveness of a therapy. They need a baseline of results to compare to the results of the experimental group. The control group was merely given a short self-help manual and told to read it and do their best.

Many of the treatments worked very well. But, Miller says, "To our amazement, people in the control group did just as well as the treatment group." They thought maybe they had flubbed the study somehow, so they repeated it and got the same results. Still skeptical, they repeated the experiment again and, once again, they got the same results.

People who simply took a short self-help book home were just as capable of moderating their drinking as those who received the expensive and more extensive treatment. Why?

Much of the most effective part of therapy is simply convincing clients to change and telling them how, which is of course something the therapist could put in a book. The changes you make in your life have to be made by you. Even good therapy is largely dependent on the client's self-help.

Practical written advice can be as effective as the most expensive help you can find because the two ways to improve your life are:

1. do something different
2. think something different

AND WRITTEN MATERIAL can help you accomplish both of those. All you need is a little motivation, and a book can furnish you with that too.

This book you now have in your hands may look inert. It may seem commonplace and ordinary. But it can really help you change your life! Use the ideas. Improve your actions and the way you think. Use it as a spur to your own motivation. You can make your life better - no kidding. Are you interested? Help yourself.

Make your life better by reading helpful books.

Self-Help Stuff That Works makes an excellent gift. You can now order it from any of twelve online bookstores. These are the most popular:

Would you like to turn your job into a spiritual discipline? Check out:
Getting Paid to Meditate

Do you feel overwhelmed with things to do? Do you constantly feel that you don't have enough time? Check out:
Having the Time

next: Speedy Reading One Chunk at a Time

There are many effective treatments for anxiety disorders including CBT, breathing control techniques, relaxation therapy, herbal treatments and exercise.

Contents:

• Cognitive behavior therapy (CBT)
• Breathing control techniques
• Relaxation therapy
• Exercise
• Caffeine reduction
• Complementary therapies
• Medication

Education and information about anxiety disorders are very important first steps in the treatment process. If people understand anxiety is an exaggeration of a normal response as well as why they experience particular symptoms (ie. tingling fingers occur because the body has moved blood to major muscle groups) this assists in breaking down some of the fear associated with having an anxiety disorder.

There are a number of treatment options available for anxiety disorders, including cognitive behavior therapy, breathing control techniques, relaxation therapy, exercise, caffeine reduction, complementary therapies and medications.

Cognitive behavior therapy (CBT)

CBT is based on the notion that people develop negative, self defeating patterns of thought which results in emotional distress (such as anxiety or depression) and maladaptive or unhealthy learned behavior. These thought and behavior patterns can be unlearned. CBT is conducted by a therapist (counselor, psychologist, psychiatrist) and usually consists of a series of sessions taking place over a number of weeks. Studies have found that CBT is at least as effective as medication in treating anxiety disorders and has the advantage of costing less over time and producing longer lasting benefits. There is, however, no clear evidence that combining medications with CBT enhances the treatment for anxiety disorders (13). The therapy typically produces benefits after a few weeks, depending on the frequency of visits to the therapist and the frequency of home practice. A disadvantage of CBT is that it requires a certain level of commitment, in both time and energy/motivation from a person. Also, it is not available in all areas of Australia.

CBT for anxiety disorders involves teaching people to examine the thought patterns that produce their anxiety (14). Underlying most types of anxiety is the tendency to overestimate both the likelihood of a feared consequence and how bad it would really be if the feared consequence actually eventuated. People are encouraged to practice realistic thinking in order to evaluate the real level of threat or risk which is anxiety-causing. They learn to use evidence to challenge unhelpful or unrealistic thoughts and fears. For instance, if a person with panic disorder feels they are going to die when having a panic attack they are asked to explore the chances of this actually occurring. Did they die last time they had a panic attack? The results of any medical investigations of their anxiety symptoms can be used here as evidence (ie. have any tests shown you have heart disease or other physical conditions?).

Other techniques used in CBT include controlled breathing techniques and graded exposure. Graded exposure involves getting people to gradually confront situations which produce anxiety symptoms. For it to be successful, people have to remain in the situation until their anxiety has subsided and they must confront the feared situation repeatedly and frequently. People with OCD are provided with techniques to help them resist performing compulsive behaviors.

Breathing control techniques

Many people hyperventilate when anxious, and this can add to feelings of anxiety and symptoms of dizziness and tingling. A controlled rate of breathing, aiming for a rate of 8-12 breaths per minute breathing in a smooth, light way is very effective at reducing symptoms of panic and acute anxiety. Smooth, light breathing is preferred to deep breathing which can accentuate feelings of anxiety and light-headedness. Breathing control techniques should be practiced several times a day when not particularly anxious in order to make it habitual. This makes it more likely that an individual will be able to implement the technique even when highly anxious and perhaps not thinking clearly.

Relaxation therapy

Relaxation therapy involves several techniques designed to help people achieve a relaxed state such as breathing techniques, progressive muscle relaxation and meditation. Progressive muscle relaxation involves tensing and then relaxing the muscles in the body, one major muscle group at a time. Over time, relaxation results in a measurable reduction in the basic level of anxiety or tension which an individual experiences.

Exercise

Exercise is an important part of a treatment program for anxiety disorders. When we exercise our body releases endorphins, chemicals that make us feel happier and calmer, resulting in a general sense of well being. For people who are limiting their activities due to an anxiety disorder, exercise can provide an opportunity to get out and confront their fears.

Caffeine reduction

People with anxiety disorders will benefit from cutting down their intake of caffeine. Caffeine is a stimulant and increases the amount of the hormone adrenaline in the body. Too much caffeine, therefore, can cause symptoms associated with anxiety. Caffeine is found in coffee, tea, chocolate and some soft drinks (especially many of the so-called 'energy' drinks).

Complementary therapies

People with an anxiety disorder may find some complementary therapies to be beneficial. Massage therapy, aromatherapy, meditation and yoga have all been used in the treatment of anxiety. Herbal treatments include St. John's wort, passionflower, valerian and kava. However, more studies into the efficacy and safety of complementary treatments for anxiety disorders are still required. Kava, for example, has been the subject of a warning by the Therapeutic Goods Administration following international reports linking products containing the substance with liver damage.

It is important that people using complementary therapies together with conventional treatments inform their doctor about the type of therapy they are receiving. This is particularly important when taking a herbal remedy as they can have their own side effects (eg. St. John's wort causes photosensitivity) or interact with conventional treatments such as anti-depressants. Complementary therapies do not treat the underlying cause of anxiety.

Anti-anxiety Medication

Like complementary therapies, prescription medications only relieve symptoms associated with an anxiety disorder and do not address the underlying issues which cause the anxiety. Therefore, medication does not provide a long term solution to anxiety disorders. The medications most commonly prescribed for anxiety disorders are selective serotonin re-uptake inhibitors (SSRIs), a form of anti-depressant. These medications typically take several weeks to start working and symptoms often return after medication is discontinued. These medications should never be discontinued abruptly. It is common for the medications to cause some degree of nausea, headache and even a slight increase in symptoms of nervousness initially. These symptoms usually subside after a week or so. Other side effects include insomnia, dry mouth and delayed ejaculation. Drowsiness is less common. People sometimes have to try several SSRIs before they find one that is suitable for them. If SSRIs do not prove effective there are many other types of antidepressants that may be of benefit.

Benzodiazepines, (tranquilisers) were previously used to treat anxiety disorders. While these medications work quickly they have a sedative effect and there is a high risk that people will become dependent on them. The effect also tends to wear off quite quickly as the person becomes tolerant to the effects. Therefore, antidepressant drugs are now the preferred option as they do not result in dependence or tolerance. However, benzodiazepines may be suitable for some people with severe symptoms, for short periods.

Betablockers are sometimes prescribed for performance anxiety (eg. public speaking) as they reduce heart rate and tremor. They are more often used for control of high blood pressure and hence side effects include low blood pressure. They should not be used by individuals with asthma. Betablockers have not been shown to be more effective than a placebo when used for more generalised types of anxiety.

back to: Alternative Medicine Home ~ Alternative Medicine Treatments

Antidepressants aren't the only way to treat depression. Many are finding exercise, nutrition therapy, acupuncture and other natural treatments work even better than depression medications.

• Exercise PLUS 5 Other Natural Ways to Treat Depression
• Treating Depression and Bipolar Disorder Without Drugs
• Nutritional Therapy for Depression
• Important Information About Herbal Treatments
• Harmful Substances in Herbal Products

next: Exercise PLUS 5 Other Natural Ways to Treat Depression

Which alternative treatments work for depression? A succinct summary of the scientific evidence.

Most people with depression try to manage the illness themselves. Some of these self-management approaches have undergone some reasonable scientific testing and can therefore be tried, especially when the depression is not severe or life-threatening.

• Some common strategies like drinking more alcohol or smoking cannabis are clearly unhelpful.

• Other people try alternative therapies or adjusting their life-cycle. Some activities like increased physical activity or attention to sleep patterns are clearly beneficial.

• Herbal remedies for depression and other alternative health practices may be either helpful or harmful.

• Some of these approaches have undergone some reasonable scientific testing and can therefore be tried, especially when the depression is not severe or life-threatening. Treatments in the 'poor evidence' box below need more studies to see whether they are helpful or not.

TABLE 1. EVIDENCE-BASE OF DIFFERENT ALTERNATIVE TREATMENTS FOR DEPRESSION

*SAMe is an amino acid that occurs naturally in cells. # Vervain is a traditional herbal remedy for depression consisting of the aerial parts of a flowering plant.
Source: Jorm AF, Christensen H, Griffiths KM, Rodgers B. Effectiveness of complementary and self-help treatments for depression. MJA 2002; 176 Suppl
May 20: p. S84-96.

next: Full Description of all Alternative Treatments for Depression

• About Change
• About Shame
• Clear Communication: #1
• Clear Communication: #2
• Depression In The Culture
• Depression: The Problem
• Depression: What To Do About It
• Discipline
• How Much Change Is Possible?
• How Are You Spending Your Life?
• Living With Alcoholics
• Motivation
• Quitting Addictions
• Self Love
• Shame: What You Can Do About It
• Were You Loved As A Child?
• What To Tell A Therapist
• Who Can You Trust?
• Why Are You Treated The Way You Are?

next: I Want to Learn About Child Abuse.

• About Shame
• Are You Considering Therapy?
• Boundaries
• Depression: The Problem
• Depression: What To Do About It
• Discipline
• False Memories and Responsibility
• Feeling Like You Belong
  
• Feeling Safe
• Getting Enough Attention
• Growing Up Emotionally
• Healing From Sexual Abuse: A Strategy
• How Does Abuse Happen?
• Living With Alcoholics
• Loneliness
• Mistakes Every Good Parent Makes
• Natural Sadness
• Problems With Anger
• Problems With Scare
• Quitting Addictions
• Self Love
• Sexual Abuse In Childhood
• Shame: What You Can Do About It
• Should We Blame Our Parents?
• Taking Care Of Yourself
• Were You Loved As A Child?
• What Terror Does To Us

next: I Am a Therapist or Other Helping Professional

Chapter 13 of the book Self-Help Stuff That Works

by Adam Khan

GETTING CRITICIZED BY your supervisor; finding out that someone you love has lied to you; receiving some bad news - these things cause stress. And stress has negative consequences, as you well know. But these are only stressful events. The source of stress that wreaks the greatest havoc on your health and sanity is ongoing stressful circumstances.

Like what? Like when a stepchild moves in with you, permanently disrupting the privacy you had with your spouse; or when your younger brother marries someone who verbally abuses your favorite niece. These are the kinds of stresses you have to live with. They don't just come up and rock your world for a little while and then go away. They stay. And, like living in a house with a fire alarm going all day long, it starts to wear you down.

But there is something you can do about it. When you have an ongoing stressful circumstance in your life, you can modify your level of responsibility. Either take more responsibility or less. Start by asking yourself, "Am I trying to control something I can't or shouldn't control?" or "Is there something I should take responsibility for that I have been leaving out of my control?"

It might help to write it out. Write the questions and then jot down some ideas - where are you taking too much or too little control of some aspect of your life?

Be specific. You are responsible for your child in general, for example, but specifically, do you control what he wears or what he eats or when he goes to bed? You must decide. What exactly do you control and what is either out of your control or none of your business? You must decide.

If something is out of your control (or is none of your business and you've been trying to make it your business), you will relieve yourself of a lot of stress by letting go of it. Drop that one. Recognize it's out of your control and busy yourself with things that are in your control. You may be in the habit of trying to control that thing, so you'll have to remind yourself again and again for a couple weeks: "Oh yeah, I'm not trying to control that anymore." Write it on a card and carry it with you. Post notes to yourself on your bathroom mirror. Do whatever you have to do to remember you no longer have to waste your energy trying to control that thing.

Now, if you find something you should and can control and haven't been, roll up your sleeves and get to work on solving the problem. Use the problem-solving method from Chapter 80. Deliberately take steps to repair the troubling circumstances. That'll relieve your stress better than anything else. It may be difficult at first; it may actually cause you extra stress to face the situation and try to deal with it, but in the long term, your stress level will go down.

Take responsibility for what you are responsible for, and stop taking responsibility for what is not your responsibility. It's that simple. Control what you can control, and let the rest go. It will relieve a great deal of your stress. Control stress by stressing control.

Control what is your responsibility.

When a close friend of yours or your spouse is disturbed by something, and you want to help them, what do you do? What actually helps? Find out here:
A Friend in Deed

When Steven Callahan was struggling to survive during his seventy-six days on a life raft, what did he do with his mind that gave him the strength to continue? Read about it here:
Adrift

next: The Old Switcheroo