Bipolar Disorders in Youth (BD) and Forgiveness Therapy
Youth with symptoms of mood swings and excessive anger need to be carefully evaluated in regard to the diagnosis given to them. In the past irritability has been consider the prevalent mood in early mania. However, numerous childhood conflicts result in consistent periods of anger, including severe narcissistic personality conflicts, the rage associated with bullying victimization, severe conduct disorder, depression with anger attacks and, now, the new diagnosis disruptive mood dysregulation disorder.
Controversy exists in regard to the dramatic increase in the diagnosis of BD in youth and the proper treatment of these youth. Again, one reason is the criteria for lack of clarity in regard to the irritability and anger that are present. Another issue are the serious side effects associated with the recommended treatment for bipolar disorder in youth with severe anger, second generation antipsychotic. This chapter will also present the benefits of another treatment modality for excessive anger in youth, forgiveness therapy.
Between the mid 1990s and early 2000s in the United States, there was a dramatic increase in the rate of diagnosis of BD in children and adolescents, paralleling a discussion in the professional literature about the presentation of BD in youth. The proportion of bipolar diagnosis of all psychiatric inpatient discharges in the United States rose from 10 to 34% in children and from 10 to 49% in adolescents in 8 years. In 1996, there were 1.3 discharges with a bipolar diagnosis per 10,000 children and adolescents in the general population, whereas in 2004 the ratio was 7.3 per 10,000, a five-fold increase. (Balder & Carlson, 2007). In outpatient settings, the increase was approximately 40-fold during that period (Moreno, et al., 2007).
Retrospective studies showed that in 50% of cases BD begins during adolescence. Therefore, the developmental trajectory of BD is of great interest for researchers and clinicians. (Kessler, et al., 2005).
Symptoms and Comorbidity
In a study of preadolescent children who met the diagnostic criteria for mania, the clinical picture was characterized by severe irritability and their presentation was predominantly mixed with symptoms of major depression and mania co-occurring (Wozniak, et al. 1995). In the review of ten years of research into child and adolescent BD, Geller and Luby (1997) suggest that prepubertal-onset BD may be comorbid with ADHD and CD (conduct disorder) or have features of ADHD and/or CD as initial manifestations.
In another study of mania in children, 91% had lifetime comorbid Oppositional Defiant Disorder and 86% lifetime comorbid ADHD (Biederman, , et al., 1998). Manic episodes in adolescents may be associated with excessive anger as manifested in school truancy, antisocial behavior, school failure, substance use, and sexual acting-out.
A 2013 study revealed that most bipolar youth eventually experienced both irritability and elation irrespective of history. Irritable-only youth were at similar risk for mania but at greater risk for depression compared with elated-only youth and youth who had both irritability and elation symptoms (Hunt, et al., 2013).
Controversy over diagnosis of BD
Stringaris (2011) has stated that the dramatic increase in the diagnosis of BP in youth may have been the result of the assertion that irritability, which is continually present from a very young age, should be considered the typical mood of early mania (Leibenluft, et al., 2003 & 2006). Yet, he stated that chronic irritability does not seem to conform to what is usually thought of as a mood that occurs within a relatively sharply demarcated episode. In the words of the DSM : “a distinct period of abnormally and persistently elevated, expansive, or irritable mood,” (p.124).He recommended that studying the distinction between episodic and non-episodic mood changes—and more generally the time scales and variability of irritable mood—is crucial for diagnosis and treatment.
Carlson and Glovinsky (2009) stated that the question of whether preadolescent mania should be broadly or narrowly defined--the so-called bipolar controversy--has been an issue for at least 50 years. The question of whether and how a disorder characterized by discrete episodes of mania and depression with periods of relative normality between episodes relates to one characterized by more fluctuating and intense mood lability/dysregulation remains unanswered. The work of researchers in the twenty-first century will be to understand not only symptoms of bipolar disorder but also how it develops and how emotion regulation relates to both the development of bipolar disorder and to other conditions that are characterized by dysregulated emotion.
Krieger, et al. (2013) claim in their research that chronic irritability has been misdiagnosed as a pediatric bipolar disorder and, instead, support the new DSM-5 diagnosis of disruptive mood dysregulation disorder (DMDD) which is described in the child chapter on this site.
The Challenge of Medicating Youth with BD
Atypical antipsychotic drugs are regularly prescribed for the treatment of BD in children and adolescents in addition to mood stabilizing drugs. In the United States, the estimated number of office-based visits by youth that included antipsychotic treatment increased from approximately 201,000 in 1993 to 1,224,000 in 2002.
From 2000 to 2002, the number of visits that included antipsychotic treatment was significantly higher for male youth (1913 visits per 100 000 population) than for female youth (739 visits per 100,000 population), and for white non-Hispanic youth (1,515 visits per 100,000 population) than for youth of other racial or ethnic groups (426 visits per 100,000 population).
Overall, 9.2% of mental health visits and 18.3% of visits to psychiatrists included antipsychotic treatment. From 2000 to 2002, 92.3% of visits with prescription of an antipsychotic included a second-generation medication.
The trends in prescriptions of anti psychotics within the Texas Medicaid Program demonstrated that the prevalence of atypical antipsychotic use increased by almost 500% over 5 years, with an increase of 609% in children 5 to 9 years old (Patel, Sanchez, Johnsrud & Crismon, 2002).
Nearly 25% of youth on antipsychotic medication in one study were aged nine years or younger and nearly 80% of these were boys (Curtis, Masselink, Ostbye, Hutchinson, Dans, Wright, et al., 2005). Further, prominent differences in psychotropic medication treatment patterns exist between youth in the US and Western Europe with 1.5-2.2 greater use in the U.S.( Zito, Safer, de John-van den Berg, Janhsen, Fegertet al., 2008).
Serious Side Effects
Other treatment options for disruptive mood and excessive anger in youth, such as forgiveness therapy, need to be considered in view of the recent reports of serious side effects from the use of atypical anti psychotics. Specifically, a 2013 retrospective cohort study of youth in the Tennessee Medicaid program with 28,858 recent initiators of antipsychotic drugs and 14,429 matched controls showed that the users of anti psychotics had a 3-fold increased risk for type 2 diabetes that increased with cumulative dose (Bobo, Cooper, Stein, Olfson, Graham, et al., 2013).
Family-focused treatment for youth at high risk for bipolar disorder (FFT-HR) is a promising intervention. The youth in this study showed significant improvements in Young Mania Rating Scale and Children's Depression Rating Scale scores (Miklowitz, et al., 2011). An earlier study of FFT-HR showed that combining family psycho-education with pharmacotherapy enhanced the post episode symptomatic adjustment and drug adherence of bipolar patients (Miklowitz, et al., 2003).
Family and school psycho-education centered on forgiveness and anger-reduction in youth also has been shown to be effective (Enright, et al., 2007; Gambaro, et al., 2008 Holter et al., 2008; Magnuson, Enright, Fulmer, & Magnuson, 2009) and thus possibly could be employed to help youth diagnosed with bipolar disorder.
The use of forgiveness therapy is effective in treating excessive anger in youth and has been described in another chapter on this website. Forgiveness therapy diminishes excessive anger and helps to stabilize the mood in youth and in adults with bipolar disorder and should be considered in the treatment protocol for youth who meet the criteria for bipolar disorder and for all disorders in youth that are associated with intense expressions of anger.