Medication primer for bipolar disorder

Larry Fisher, Ph.D., ABPN Director, Neuropsychology Services UHS Neurobehavioral Systems 12710 Research Blvd., Suite 255 Austin , TX 78759 512-257-3468; fax-512-257-3478 Email  Irritability may be a psychiatric disorder Chemical imbalance or personality disorder Depression, PTSD, ADHD Bipolar Disorder: Mania Borderline personality disorder Antisocial personality disorder  Irritability may be a neuropsychiatric disorder Birth disorders, traumatic brain injury, seizures Genetic disorder Alcohol or drugs during pregnancy Difficult delivery – anoxia at birth Irritability may be due to substance abuse Is Child-Onset (prepubertal) Bipolar Disorder just an early step in the evolution of classic adult Bipolar Disorder? Or, should we consider severe mood and irritability problems in children a completely different condition? Adolescent Bipolar- less controversial May meet DSM IV criteria for bipolar I or II Bipolar I – Manic (elated, irritable) for at least a week, with marked impairment in social or occupational activities or hospitalization, plus 3 symptoms (grandiose, euphoric, racing thoughts, pressured speech, no need for sleep, reckless) Bipolar II – Hypomanic (elated, irritable) for four days, no marked impairments or hospitalization, plus 3 symptoms from the above list. Severe mood and irritability issues need to Call it Child-Onset Bipolar Disorder Call it Intermittent Explosive Disorder Call it Explosive Mood Disorder Call it Organic Aggression Syndrome psychosocial interventions, and school accommodations. (Let us call it Bipolar) Bipolar Children show high prevalence of 42% (Wozniak, 1955) 46% (Pavuluri, 2006)) 30% (Wozniak, 1955) 29% ( Pavuluri, 2006) Not just a behavior or emotion problem Child Onset Bipolar Disorder kids show: Neuropsychological deficits (brain problems): • Memory problems are common • Lower verbal reasoning • Poor attention span • Slower processing speed • Decreased cognitive flexibility Neurocognitive deficits persist even after “recovery” from mania and depression. Kids with mania may show: ADHD Symptoms: hyperactivity, distractibility, impulsivity Intense energy; Talks too much Uncooperative, oppositional, aggressive Giggly, reckless, feels superior to teachers Slowness, lack of energy, no motivation I’m no good, never will be any good Loss of interest, apathetic, flat emotions Sad: feels worthless, hopeless, helpless Misinterpretation of jokes Extreme shyness, irritability, or bullying Peers may reject their bizarre behaviors Perceive hostility in peer’s neutral faces Fatigue, dry mouth, dizziness, poor bladder control, constipation, weight gain, tremor, diarrhea, drooling, itching, sweating, sedation, poor cognition, etc.  Absences (med changes, hospitalizations, etc.) Lithium (approved by FDA- ages 12 & up) Lithium carbonate – for mania and depression Valproate (Depacote) for mania Carbamazepine (Tegretol) for mania Oxcarbazepine (Trileptal) for mania Topiramate (Topamax) for mania Lamotrigine (Lamictal) for mania Risperidone (Risperdal) Aripiprazole (Abilify) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon) Clozapine (Clozaril) (selective serotonin reuptake inhibitors) Floxetine (Prozac) Paroxetine (Paxil) Escilalopram (Lexapro) Citaloprom (Celexa) Sertraline (Zoloft) Fluvoxamine (Luvox)  Methylphenidate (Ritalin Metadate,
Concerta, Daytrana)
Dextroamphetamine (Dexedrine,
Dexmethylphenidate (Focalin)
Methamphetamine (Desoxyn)
Lisdexamfetamin (Vyvanse)
Pemoline (Cylert) not recommended due to
liver failure
Atomoxetine HCL (Straterra)
Alpha Adrenergic Agonists
Clonidine (Catapres)
Guanfacine (Tenex)
Antianxiety Medication
Lorazepam (Ativan)
Alprazalam (Xanax)
Diazepam (Valium)
Clonazepam (Klonopin)
Thirst issues, gastrointestinal distress Fatigue, hand tremor, and drowsiness issues Seat near door for access to nurse if needed Dizziness, blurring, nausea, rash issues Positive Discipline, don’t try to punish it away Mood and Behavior Diary; sleep/light cycles Adding Structure: routines, rigid schedules Pick your battles; clear rules & Contracting Rebuilding family/school relationships Crisis Plan: suicidal/violent behaviors Stabilizing sleep, light, and activity patterns Building self-esteem and coping skills Peer assistant or buddy system Social skills training, match face to emotion Use social stories, or act out social situations Peer education regarding diversity Preferential seating – good peer role models Regular mental health counseling Speech help with “social” communications take turns, monitor peer’s interest in topic Schedule routine breaks Extra time between classes Preferential seating near natural light Delay start, reduce demands, on bad days Reduce homework, extend deadlines Extra tutoring after absences Email assignments to parents, if possible Emphasis on sight-words, not phonics More time for exams, and for class-work Visual aids for math, copies of assignments Highlight important material, reduce load Simplified instructions, condensed texts Use of tape recorder, calculator in class Get eye contact when giving directives Access to safe place when “ready to blow” Seating that allows a “buffer space” Resource room near end of day Teach anger management Teach self-calming techniques Less competitive activities (e.g.: yoga) Staff supervision in hallways, café, bus Don’t get in their face, gently redirect Suggest deep breathing, chill out time Keep your cool as kid gets hot tempered Look for glassy-eyed stare, grit teeth, fists up Rage lasts only 10 minutes if you back off Clear room, allow emotional “seizure” Don’t touch, avoid restraint if possible Bipolar kids may get strong medications Bipolar kids may have ADHD/LD Bipolar kids may have social deficits Multiple medications often used These may cause serious side effects On top of good days and bad days Classroom accommodations are needed Crisis management strategy is needed Clinical Manual for Management of Bipolar Disorder in Children and Adolescents. American Psychiatric Publishing Inc, Washington, DC. Helping Your Child Find Calm in the Mood Storm. Da Capo Press/Perseus Books Group, Cambridge, MA


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