Dr. Henry Paul, MD

Psychiatrist, Author and Educator

OPPOSITIONAL DEFIANT DISORDER AND CONDUCT DISORDER

April 30th, 2014

In the group of disorders called behavior disorders, in addition to Attention Deficit (Hyperactivity) Disorder there are two other conditions: Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD).

Oppositional Defiant Disorder (ODD) is a characterized by:

Negativism
Rebellion
Arguing
Defiance
Anger episodes
Revenge
Resentment
Spite
Annoying others
Blaming others
Irritability
An overall passive aggressive stance (I will show my anger by not doing….”)

Conduct Disorder (CD), an even more serious behavior disorder, often related to the development of Antisocial Personality Disorder in adulthood, is characterized by:

Persistent breaking of rules
Aggression toward other people/animals
Fighting, bullying, cruelty, intimidation
Destruction of property
Fire setting
Lying
Stealing
Other law/rule breaking
Running away
Truancy
Breaking curfew

Both of these serious behavior disorders are difficult to treat, necessitating a multimodal approach and sometimes the use of medication: stimulants in ODD and sometimes antipsychotics in CD.

DISCLAIMER

Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

WHAT ARE THE DRUGS USED TO TREAT TDD & BDD?

April 25th, 2014

Below is a list of the major mood stabilizers. Of all of these, Lithium, Depakote, and Tegretol are the three most commonly used.

Lithium – Approved for children 12 years and older.
Depakote -Approved for children 2 years and older for seizures.
Tegretol – Approved for all ages for seizures.
Gabapentin – Approved for young people 18 and older. Approved only for epilepsy.
Lamictal – Approved for young people 18 and older. Approved for seizures in children.
Topamax – Approved for young people 18 and older and approved for seizures.
Trilpetal – Approved for children 4 and older and approved for seizures.

LITHIUM

The most well-known, well-studied, and longest used drug for BD is Lithium. Despite favorable publicity, the misconception still exists that Lithium is dangerous. The fear springs from the well-publicized stories of the rare Lithium toxicity reaction. I have prescribed Lithium to many hundreds of patients, young and old, and have only witnessed this reaction once. People can and do take Lithium for years with only positive results.

Lithium can be harmful to the thyroid and to the kidneys over the long term. It is essential that kidney and thyroid function tests be done regularly when taking this drug. Before starting Lithium, your child should have a complete blood count, an ECG, and thyroid and kidney tests.

TEGRETOL

Tegretol (Carbamazine) is an antiepileptic drug used commonly for BD in adults and young people. It is not approved for use in BD and is given off-label. It is approved for use in epilepsy for children as well as adults. Despite this off label use, it has been reported as quite successful in some of the few trials reported. The dosage recommended for young people is up to 300 mgs a day.

Before prescribing Tegretol a complete history and physical examination is necessary. There should be a complete examination of the skin as well as a complete blood count and other blood tests to be sure of the level of liver function.

DEPAKOTE

Depakote, as it is most well-known, is another anti-epileptic medication used as a mood stabilizer. Like with other antiepileptic medication this is used off-label in young people. But it is widely used and considered almost as good as Lithium for BD. It is specifically used quite a bit in teenagers with BD with good results. It is sometimes used as a first line monotherapy like Lithium or in combination with other drugs.

Before starting this drug a complete medical history and physical exam is necessary. There should also be a complete blood count, clotting tests, tests of kidney function, urine analysis, and a pregnancy test for girls. Caution should be taken and full disclosure about PCOS (polycystic ovaries) and pregnancy issues should be made.

DISCLAIMER

HOW DO WE TREAT BD AND TDD?

April 24th, 2014

The treatment of BD in children is similar to that of adult BD. First, we treat whatever the episode that is being experienced – acute phase treatment – and when things get better we focus on preventing future episodes – maintenance phase treatment. Most of the medications for both phases are the same. One must also keep in mind that BD children often have comorbid (additional) diagnoses which might need treatment, as well.

Acute Phase Treatment

The acute phase of treatment of BD means medicating a child who is either manic or depressed (but depressed with a history of mania or hypomania) or one who has TDD.

The initial acute phase treatment for mania without psychotic features (hallucinations and delusions), or TDD starts with monotherapy treatment with one drug. The one drug is either a mood stabilizer such as Lithium, Depakote, or Tegretol, or less commonly Gabapentin, Trileptal, or Topamax, or an antipsychotic drug such as Risperdal, Seroquel or Zyprexa, or less commonly Abilify or Geodon. If a child only partially responds than an augmenting agent is often tried in conjunction with the first medication. Usually this consists of adding an antipsychotic to a mood stabilizer or conversely a mood stabilizer to an antipsychotic. Alternatively, if the child does not respond to monotherapy the psychiatrist sometimes skips the augmentation phase and just switches to another of the original choices of monotherapy listed above. Again, there is still an opportunity to add an augmenter. If the child still fails to respond than differing combinations of mood stabilizers and antipsychotics are often tried. On the whole most children do respond to one or more of the more common first line drugs (Lithium, Tegretol, Depakote or Risperdal, Seroquel or Zyprexa).

For BD children with psychotic features, it is common to start with a combination of a mood stabilizer and an antipsychotic drug. If this fails the psychiatrist can switch the combination of these drugs, and then add another antipsychotic medication or add another mood stabilizer. Finally, if all combinations of the common mood stabilizers and antipsychotics are exhausted, less effective mood stabilizers in conjunction with different antipsychotic medications may be prescribed.

Maintenance Phase Treatment

The maintenance phase of drug therapy is aimed at preventing recurrence of episodes of BD. Interestingly the maintenance drugs are the same ones used in the acute phase of treatment. There is little evidence that these drugs work as well in preventing relapses in young people as they do in adults. The maintenance phase usually lasts from one to two years and depends, to a degree, on the level of impairment, the chronicity of the condition, the number of episodes of bipolarity, and the level of stability reached by the youth and the environment in which she lives. While most young patients are able to get off these medications, there will be times that this will prove impossible. Sometimes relapse follows quickly upon stopping the medications. As with some adults, a decision will be made that drug therapy will be maintained indefinitely to help the child or adolescent progress in life, socially, educationally, and vocationally without the risk of further decompensation.

DISCLAIMER

CHILDREN WITH TDD ARE OFTEN MISDIAGNOSED

April 24th, 2014

Children with Temper Dysregulation Disorder with Dysphoria (TDD) are often misdiagnosed with Bipolar Disorder (BD). Why? Because there is confusion regarding the symptoms. Symptoms that include chronically aggressive, irritable unhappy children with frequent temper tantrums have often been diagnosed as having BD, when actually they should have been diagnosed with TDD.

TDD is a fairly new syndrome that has been known to many of us in the mental health community for years. It is a classification that has been suggested to replace the diagnoses of bipolar children in cases where symptoms include:

Having frequent tantrums in response to stress
Acting with rage and aggression out of proportion to whatever the cause
Having behavior that makes them appear younger than they really are
Experiencing these episodes at least several times a week
Feeling a lot of irritability, anger, and sadness (dysphoria) in between tantrums
Having tantrums that appear in more than one setting (home and school) and that start before a child is ten years old and no earlier than six years old

These symptoms appear quite frequently and they generally have to last a year to officially be called TDD. These children also share other characteristics:

They do not have mania.
They share a similarity to children with Oppositional Defiant Disorder.
They rarely develop BD but are more likely to become depressed as they get older if not treated. I have often seen depressed adults who describe their behaviors as children that sound like TDD.

Medications for BD, TDD, and Accompanying Conditions

Children younger than mid-adolescence rarely present with classically described BD. Therefore, the available treatments are those used for adults, but given to children “off-label”. The medical establishment calls the group of medications “Mood Stabilizers”. Other than Lithium, the most well-known of the group, most of the mood stabilizers were used originally by neurologists to treat epilepsy and are called anti-epileptic medications. These medications are often used in conjunction with antipsychotic medications for children with BD and TDD. Although, formal studies are somewhat lacking, it does seem that these drugs help. For the sake of discussion we will address the BD child as one who either presents as having classic BD (rare) or TDD.

DISCLAIMER

RECOGNIZING BIPOLAR IN CHILDREN AND ADOLESCENTS

April 21st, 2014

The adult presentation of Bipolar Disorder (BD), as it is historically known, begins to appear in mid to late adolescence. In younger children, classical BD is extremely rare. In dealing with literally thousands of children, I have come across only a handful of cases of classic BD. The upsurge in diagnoses has occurred in younger children because these children present with behavior disorders associated with mood changes that are hard to classify using the present diagnostic parameters. However, including them in the BD category might not be the solution. For example:

In childhood one rarely encounters the above mood episodes (mania/hypomania and depression) as separate, distinct entities. In other words, it is difficult to identify discreet episodes of elevated or irritable mood episodes, intervening normal periods, and than discreet episodes of depression. Thus in children who have mood variability with characteristics of bipolar episodes there is usually no cycling as there is with adults and the course is much more variable. In fact, it is rare to see full blown mania in young children. Keep in mind that there are normal times when children seem to feel great or even overly exuberant as a regularly occurring reaction to an external event or personal achievement.
Since in adulthood irritability frequently presents as part of a manic episode, the psychiatric community decided to put children with excessive irritability alternating with other mood variations in the category of BD. But this seems more like convenience for the diagnostician than truth. If all these children were, in fact, presenting with some form of BD than they would eventually develop true BD, which they do not.
Many children classified as Childhood BD really suffer from ADHD, a disruptive behavior disorder other than ADHD, Post Traumatic Stress Disorder (PTSD) with a behavioral disorder, or plain severe anxiety. Even youngsters with hypersexuality (typical of mania) often are sexually abused children acting out.
It appears to me that behavior disordered children who don’t quite fit the ADHD, Oppositional Defiant Disorder or Conduct Disorder entities have been deposited in the BD category for lack of a better fit. And since some of the medications used for BD help with excessive behaviors, the diagnosis is made.

In summary, truly bipolar children are a rarity in clinical psychiatry, although, on occasion, one does see such a child. More likely, your child who has a severe behavioral disorder, great variation in mood, resistance to medications for ADHD, or anxiety is suffering from a mixed disorder which defies strict diagnosis at this time. The good news is that there is treatment for these children.

DISCLAIMER

WHAT DOES BIPOLAR DISORDER LOOK LIKE IN ADULTS?

April 18th, 2014

Originally BD was called Manic Depressive Illness since it was characterized by episodes of mania and depression, often presenting as discrete episodes of illness with mostly normal intervals in between. The present APA manual of diagnosis defines BD as a mental disorder in which an individual suffers from at least one episode of mania or what is called a mixed episode (mania and depression together) and also usually has had separate episodes of depression, as well. Depression has been defined in a previous blog, so here we will concentrate on the definition of mania and its less serious counterpart known as hypomania.

A manic episode lasts at least a week and is essentially a disturbance during which a person has an unusually elevated, expansive, and/or irritable mood which is not usual for that person. In addition, the person might have at least three or four of the following:

Too rapid speech
Less of a need for sleep
Inflated ideas about himself, called “grandiosity”
The tendency to be more talkative than usual in a pressured manner and with rapidity
A feeling of racing thoughts
Difficulty being followed by others
Excessive energy
Distractibility
Physical agitation
Involvement in potentially destructive activities like sexual promiscuity or spending too much
An apparent increase in goal-directed activities at work, socially, sexually, or at home (excessive cleaning that keeps s/he up all night)
Psychosis, with hallucinations and delusions which are an extension of the mood disturbance like expansively thinking s/he is a world renowned figure from history, a famous athlete, a genius, a great inventor, etc.

Manic episodes can cause marked trouble for the person and can often result in breakdown in work, family, and social functioning. Hospitalization is sometimes necessary.

A hypomanic episode is very similar to a manic episode except it never involves hallucinations and delusions. It must only last four days and not a week to be diagnosed, and it does not cause as great a disturbance in functioning, although others usually notice a difference in behavior.

BD is usually characterized as Bipolar 1, 2, and Cylcothymia. Bipolar 1 Disorder involves at least an episode of mania and often periods of depression, as well. The episodes tend to be distinct but sometimes include mixed episodes of mania and depression. Bipolar 2 disorder is a form of BD with periods of depression and at least one episode of hypomania. Cyclothymia is a mood disorder with periods of abnormal moods that are a bit less than hypomania and have less serious depression, as well. In addition to bipolar types 1 and 2, mixed episodes, and Cyclothymia, many clinicians see varied forms of disordered moods that do not fall into neat categories. These are called “Atypical” bipolar disorders or soft bipolar disorder. In addition, we sometimes see hypomanic or manic episodes which might have been caused by an antidepressant, but this is quite rare. Some researchers say that it is simply a depressed person previously unknown to be bipolar that coincidentally develops the next stage (mania or hypomania) while s/he was being treated with an antidepressant drug.

DISCLAIMER

BIPOLAR DISORDER IN ADULTS AND CHILDREN

April 14th, 2014

Bipolar Disorder (BD) is a disorder of mood. Called “bipolar” because the mood varies between the two poles of mania and depression, the condition affects about .5 to 4 percent of the adult population, depending on the diagnostic criteria used. That figure has been pretty steady over time. What has changed has been the number of children, pre-adolescents, and early adolescents diagnosed with BD recently. These numbers have skyrocketed, causing debate about whether, in fact, all these children suffer from true BD. While we know that mid and later-adolescents often suffer from forms of BD similar to those in adults, children younger than this can present with a wide variety of more vague, generalized, and diffuse symptoms. We are not sure of the exact number of correctly diagnosed children but do know for sure that the numbers have increased from 400 to 4000 percent depending on the criteria used. Thus, the number of children receiving medication for BD is still an evolving phenomenon.

BD is classified as a mood disorder and is characterized by periods of depression and mania (elevated mood, grandiosity, irritability, flight of ideas, rapid speech and motor hyperactivity) in adults, and only recently has become a more general diagnosis in young people. There is controversy about whether in fact true bipolar disorder exists in children.

DISCLAIMER

SIGNS OF DEPRESSION IN YOUNG PEOPLE

February 7th, 2014

Childhood depression is a great health challenge for our country. Depressed children and teenagers often appear as if their personalities have changed. Sadness is normal, but depression is more painful and deeper. The symptoms of depression in a youngster may vary from child to child somewhat, but overall they are fairly easy to recognize if you know what to look for.

A depressed child is often sad, angry, irritable, cranky, whiny, and prone to rage at times, even violence. Sleep and appetite patterns change, weight is lost, menstruation and normal bowel function are affected, personal appearance deteriorates, and serious fatigue could ensue as well. Self-esteem is lowered and often the youngster feels like she is bad, a loser, worthless, unlikable and inferior. Depressed young people often feel sick and have a host of pains – headaches, muscle stiffness, and stomach aches. School functioning will decrease as concentration, attention and attendance drop off. These kids will usually isolate from friends and family. Communication is lessened and often irritation in short spurts is all that a parent sees. Formerly fun activities give little pleasure and are sometimes replaced by risky pursuits and behavior. Energy is low, and fatigue is high. These depressed youngsters often look like they move in slow motion, heads down, slumped shoulders, with a sad and pained expression. They appear to be apathetic. Sometimes a depressed child will talk of running away or becomes angry at authority.

Suicide is a major concern with depression as the teen years approach. Depressed young people often feel hopeless, a particularly worrisome sign that is associated with suicide. Suicidal thoughts and even, tragically, successful attempts are not uncommon in teens. There are warning sides to watch for with suicide. I will address those in my next blog.

Fortunately, depression is a treatable condition if properly diagnosed. If you suspect depression with your child you must act immediately. Contact your pediatrician, the school counselor, your religious counselor, the local mental health association, or ask a friend who has been through this for a referral to a mental health professional. If you have further questions about the signs of depression, please email me.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

YOUNG PEOPLE DO GET DEPRESSED

February 4th, 2014

At first our eight-year-old Ivan’s teachers thought he had ADHD. He would stare off, seemed consumed with daydreams, and never paid attention to his work. But one day he told his gym teacher that he was just too sad to participate in basketball and that he was always sad and lonely. Now I feel that my wife and I misread his crying in his room as a reaction to poor grades but maybe he’s just been depressed all these years. After all, he never seems to really enjoy anything for more than a few minutes, drops new hobbies, and rarely gets excited.

Joanne seemed sad and withdrawn when she heard about her friend Sally’s leukemia. We figured, “Who wouldn’t be?” After ten days she seemed worse. She stayed in her room listening to Gregorian chants, started reading the Bible, and didn’t eat or even come out. Last night she said she felt guilty that she didn’t get sick herself. She said we would be better off without her around and wrote a poem about the joy of death.

For many years the psychiatric establishment didn’t believe that children could experience depression. We saw depressed children every day, but because many of the theories that informed our work implied that children had not reached a developmental stage capable of getting depressed, we could not call them depressed.

This backward thinking stopped much research and development of treatments for childhood depression. We now know this was shortsighted. As the stories above, and hundreds of thousands like them, attest, children and teenagers of all ages experience depression. According to the American Academy of Child & Adolescent Psychiatry about 5 percent of children and adolescents in the general population suffer from depression at any given point in time. Still, tragically, the great majority of these youngsters do not get proper evaluation or treatment due to limited availability of care and lack of compliance with treatment. This leads to high levels of family, educational, and social problems, as well as substance abuse and other psychiatric problems, and even suicide — one of the leading causes of death for adolescents in this country.

WHAT YOU’LL NEED TO KNOW BEFORE STARTING YOUR CHILD ON MEDICATION

January 7th, 2014

If you have been told that your child would benefit from taking medication, the following guide will help.

Have your doctor explain your child’s diagnosis in as much detail as possible. Is there a known cause for the difficulty? What course might the disorder take if not treated? For example, if a child with ADHD doesn’t get treatment, the chance of substance abuse increases as the teenage years approach. Teenagers not treated for depression have an increased suicide risk. What positive effects of the medication will the psychiatrist be looking for? How long should it take? What will he do if it doesn’t work? While there is no medication which totally cures everything, your child’s prescription should target specific symptoms.
Make sure your child gets other forms of treatment along with medication. What does your doctor recommend? Individual talk therapy? Special school interventions? Behavioral therapy? Family counseling? Be wary of the practitioner who simply gives you a pill and wishes you good luck.
Make sure your child is physically healthy. If not, then the prescribing psychiatrist needs to be familiar with any medical condition. To this end, the doctor should take a detailed medical history of your child. In addition, I like to see a report of a recent physical examination from the child’s pediatrician. I also suggest a routine blood screening including a complete blood count, a routine metabolic screening, and also a routine twelve lead electrocardiogram in most cases. The blood tests and EKG will not only give signs of present conditions but will serve as baseline readings. Some medications affect blood tests and the EKG, and if we don’t have a baseline it will be difficult to know if future abnormal readings are caused by a medication or were always present.
Have a clear understanding of the medication’s side effects. Most side effects are fleeting and mild and don’t interfere much in your child’s life in any way, but they can be specific depending on the medication. You should know what they are so you don’t get worried. Serious or long lasting side effects for the child and teenage psychotropic drugs are rare, but again, you should be told of the signs. If you read information from the internet, be careful about the websites you choose. Don’t jump to the conclusion that the information you find online is more accurate than your psychiatrist’s years of clinical prescribing experience.
Make sure your child’s doctor, or a covering professional, is available twenty-four hours a day, 365 days a year, for any concerns you have about your child. Anything less is unacceptable.
Understand why the great majority of psychotropic medications given to young people are prescribed off-label, which means they haven’t been specifically approved for use by children. You will want to ask your prescribing psychiatrist what his particular experience is with the medication as well as what studies have shown about its use in children and teenagers.
Find out from your doctor what time of the day and how to give your child the medication. With meals, all pills at once, full or empty stomach? Although, many pharmacies now include a written summary of various aspects of the drug, follow the prescriber’s recommendations over those of the pharmacy. Call the doctor if there is a difference.
Determine what the medication will cost. Are there ways to cut the cost? Your pharmacist is the best source for that information. Cost alone should never force a decision as to choice of medication. Sometimes insurance companies make it difficult to get medication. Be persistent and get help from your psychiatrist to be sure your child gets exactly what the doctor ordered: generic or brand, the correct quantity, and refills, if possible.
Ask if there is a difference between generic and brand name drugs. I have not seen much of a difference between their effectiveness. Generic is usually okay. Some patients demand brand name medications and I go along with it, but with the caveat that these will cost more money with little research showing a beneficial effect.
Tell your child’s doctor about any other medications, supplements, or home remedies your child is receiving to be sure there are no adverse interactions with the prescribed medication. Remember even natural remedies can cause interaction problems.
Never compare dosages in milligrams between medications; they all differ and cannot be compared because of potency differences in the manufacturing process. Thus one milligram of one medication might equal in efficacy ten milligrams of another. For example, I recently had to explain to a patient that the new medication I was giving was measured in one half to two milligrams dosages and was replacing one that measured about thirty milligrams. It was simply another compound whose potency was measured differently.
Be prepared for your child’s doctor to recommend more than one medication. This use of multiple medications has become more common, as it sometimes gives better results. There are, however, risks to this practice which your doctor will need to explain. Risks include medication interaction, increased side effects, as well as decreased compliance because of the difficulty some patients have with multiple prescriptions. Always find out why your doctor is prescribing multiple medications and ask specific questions about the benefits and risks of such prescribing.
Always trust yourself and all the knowledge you have about your child. No one knows your child better than you and thus your observations of side effects, therapeutic effects, and overall well-being are the most valuable. Don’t be intimidated. Call your psychiatrist with any concerns.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.