Bipolar

(Mood)

Disorder
 What is Bipolar Disorder?
“Manic-Depression”
 A brain disorder affecting moods and energy that effects over 2
million in the U.S.A.*
 Emotions, thoughts and moods are distorted resulting in mood
swings that are overly “high” to extremely sad and hopeless
 Defined as having one or more manic or mixed episodes and
depression episodes lasting most of the day, every day for 2
weeks or more
 A long-term illness that typically develops in adolescence or
early adulthood but symptoms often seen in childhood
 Often misdiagnosed as ADHD, OCD, OD, CD and depression
and sometimes schizophrenia
 Often leads to suicidal thoughts
 Can be treated and lead full productive lives
Mood disorders are very common, their life
prevalence is up to 20 %, and they have a high
level of morbidity and mortality as well as an
immense impact on disabilities worldwide.
The fundamental disturbance is a change in
mood or affect, usually to depression (with or
without associated anxiety) or to elation. The
mood change is usually accompanied by a
change in the overall level of activity.
Most of these disorders tend to be recurrent,
and the onset of individual episodes is often
related to stressful events or situations.
 Classification of Mood Disorders
A/c to International Classification of Diseases
(ICD-10)-
F30 Manic episode
F31 Bipolar affective disorder
F32 Depressive episode
F33 Recurrent depressive disorder
F34 Persistent mood (affective) disorders
F38 Other mood (affective) disorders
F39 Unspecified mood (affective) disorder
 Classification of Mood Disorders cont.
A/c to DSM-IV TR- Life time Prevalence
 Depressive Disorders-
#Major depressive Disorder 10-25% in ♀,5-12% in ♂
#Dysthymic Disorder Approx 6%
Bipolar Disorders-
-Bipolar I Disorder 0.4 – 1.6%
-Bipolar II Disorder Approx 0.5%
-Rapid Cycling 5 -15% in Bipolar Dis.
Cyclothymic Disorder 0.4 – 1%
Epidemiology
A.- Sex
In MDD
-Women : Men = 2:1
Why? Child birth, hormonal differences,
psychosocial stressors
In Bipolar
- Women = men
B.- Mean age of onset
Bipolar I = 30 years MDD = 40 years
C.- Marital Status
More in single, divorced, separated, poor
interpersonal relations

D-Socioeconomic Status
No correlation for MDD, bipolar more in
high SES
Depression more in rural areas
 Etiology -
A- Biological Factors
1- Biogenic amines ( levels in blood, urine, CSF)
Heterogeneous deregulation of the biogenic amines
Low nor epinephrine, Serotonin in depression,
Low dopamine in depression and high in mania
Others, GABA, Glutamate
2- Neuroendocrinal dysregulation
- Adrenal Axis- about 50% of depressive pts have
elevated cortisol levels
- Thyroid Axis
Antithyroid antibodies, low thyroid hormones,
development of rapid cycler, thyroid disorders
3- Sleep EEG abnormalities
- Delayed sleep onset , short rapid eye
movement( REM ) Latency, Increased
duration of 1st REM period, abnormal Delta
sleep
4- Neuroimmune dysregulation
5- Brain imaging studies
Enlarged ventricles and small frontal lobes,
Diminished cerebral blood flow
 B. Genetic Factors-
#Bipolar depression average risk 8% in 1st degree
relatives (base rate 1%)
#Major depression average risk 9% (base rate3%)
#Relatives of MDE patients do not have higher risk
for BAD, but relatives of BAD patients are at
higher (11%) risk for MDE hence…
Familial risk for BAD is higher
BAD patients have excess of MDE relatives
MDE patients do not have many BAD relatives
#Higher risk for offspring of patients who had
depression earlier than 20 years of age but not in
childhood
Twin studies-
Bipolar MZ concordance = 43% to 72%
Bipolar DZ concordance = 6% to 25%
Unipolar MZ concordance = 46%
Unipolar DZ concordance = 20%
Linkage analysis: Mixed results
Multiple genes?
Chromosomes 13 and 22
 Psychoanalytic theory

Oral fixation: Depends on others for self-esteem

(damaged early attachment and traumatic
separation in childhood)
Bereavement, introjection, and mourning work
Symbolic loss
But dream themes of depressed patients are of loss
and failure, not anger and hostility (Beck and Ward,
1961)
Depressed people do express anger
Mania is a defense against underlying depression.
 Cognitive theories
Beck’s theory:

Character of pessimism (NegativeTriad)

Habits of negativity (Negative schemas)

Erroneous thinking (Characteristic biases)

DEPRESSION
 Characteristic biases
Arbitrary inference
Selective abstraction
Overgeneralization
Magnification and minimization
 Assessment of Beck’s theory

Depressed people do show cognitive

biases in their thinking
Their apparent pessimism, however, is
accurate
The theory is correlational, not causal
The model is multidimensional
Treatment based on the theory is helpful
 Helplessness/hopelessness theories

Learned helplessness (Seligman & Maier,

1967)
Attributional reformulation (Abramson,
Seligman & Teasdale, 1978)
Personal/Environmental (a.k.a.
Internal/External)
Stable/Unstable
Global/Specific
Hopelessness: Add diatheses of low self-
esteem and hopelessness
 Interpersonal theory

Reduced interpersonal support

Experiences of rejection
Due to social structure
Inadequate social networks
Others may dislike them
Elicited by patient
Consequences of behavioral choices
Critical comments by spouse
Poor social skills and seeking reassurance
 Behavioral theories

Learned helplessness/hopelessness is a
behavioral theory with a cognitive twist.
Reduction in reinforcement leads to a
reduction in activity.
Depressive behaviors are reinforced.
Depressed people have taken part in
fewer pleasant events.
 Availability of reinforcers

The amount of reinforcement available

is a function of
Personal characteristics
Environment or milieu
Repertoire of reinforcement-producing
behaviors.
 Signs and Symptoms
MANIC DEPRESSION
 Feelings of grandiosity or very  Ongoing sad, anxious or empty
high self-esteem, euphoric mood
 Extreme talkativeness, racing  Lack of energy and ability to
thoughts concentrate
 Decreased need for sleep
 Sleeping too much or too little
 Highly distractible
 Lacks interest in others and
activities, irritable, feeling hopeless
 Engaged excessively with and worthless
pleasurable activities, often
recklessly
 Thoughts of death or suicide

SIGNS IN YOUNGER CHILDREN

Poor sleep and night terrors
High activity level
Easily startled
Bedwetting
Oppositional behavior
Range of Mood and Emotion
severe mania

mild to moderate mania (hypomania)

normal-balanced mood

mild to moderate depression

severe depression
 Patterns of mood disorders
4
Manic3
Hypo-2 Major
manic1 Depression
Bipolar I
0
-1 Bipolar II
De- -2
pressed
-3
-4 Identify episodes:
1 2 3 4 5 6 7 8 9 10 11 12 Manic
Weeks Mixed
Hypomanic
Major Depressive
 More patterns...
Manic3
Hypo-2
manic
1
0 Cyclothymia
-1 Dysthymia

De- -2
pressed
-3
-4
1 2 3 4 5 6 7 8 9 10 11 12
Major depression ( clinical picture)
1- Psychological symptoms
A- Depressed mood and sadness ( usually there is
diurnal variation)
B- Loss of interest and lack of enjoyment (anhedonia)
C- Sense of emptiness, helplessness, hopelessness,
worthlessness, pessimism, death wishes, suicidal
thoughts, loss of self esteem, self blame and guilt
D- Psychotic symptoms in severe cases and are going
with low mood
Delusions of guilt, nihilism, poverty, hypochondrias is
and somatic delusions.
Hallucinations: auditory, visual.
2- Physiological symptoms ( somatic
symptoms)
a- Diminished appetite
B- Weight loss
C- loss of sexual desire
D- Sleep disturbance: insomnia, early morning
awakening, interrupted sleep
E- Pains ( Headache, back pain)
F- Digestive upsets and loss of appetite
Sometimes atypical symptoms ( increased
appetite and hypersomnia
3- Behavioral symptoms
A- Negligence of self care
B- Social withdrawal, suicidal attempts
4- Motor and cognitive functions
A- Difficulty in attention and concentration
B- Slow thinking
C- Psychomotor retardation or agitation
D- Negative view of self, world and future
5- impaired social and occupational functioning
DSM IV criteria of Major Depressive
episode
- Five or more symptoms present in the past 2 weeks
with at least one either 1 or 2
1- Depressed mood and sadness
2- Loss of interest or pleasure
3- change in appetite
4- Insomnia or hypersomnia
5- Psychomotor retardation or agitation
6- Fatigue, loss of energy, or sexual problems
7-Feeling of worthlessness or excessive guilt
8- Decreased ability to think
9- Recurrent thoughts of death, suicidal ideas, or
attempts
- Specify:
A- Mild, moderate, severe
B-With or without psychotic features (mood
congruent/ incongruent)
C- With ;
1-Atypical features
- Mood reactivity, weight gain, hypersomnia,
interpersonal rejection
2-Melancholic features
Severe anhedonia, weight loss, early morning
awakening, guilt over trivial events, suicide
3- Seasonal pattern
Regularly occurring every winter or fall

4- Catatonic Features
Motoric immobility, excessive motor activity,
negativism, mutism, posturing, stereotyped
movement, echolalia, echopraxia

5- Postpartum
Within 4 weeks postpartum
Differential diagnosis
1-Medical disorders
-Substance induced mood ( abuse as sedatives , hypnotics,
opoiods, phencyclidine,
or prescribed as contraceptive pills, corticosteroids, reserpine,
cimetidine, alpha methyldopa, propranolol, amphetamines )
-Thyroid, diabetes, adrenal diseases, Rhematoid arthritis,SLE
cancer lung,
-AIDS
2-Neurological ( Parkinsonism, CVS, epilepsy, brain tumors)
3- Other mood disorders
4- Bereavement
5- Other mental disorders
- Personality disorders
- Schizophrenia
- Dementia
 Treatment
Just like long-term illnesses such as diabetes and
heart disease, bipolar disorder is an illness that
requires medication to improve quality of life
 Not all medications work for every person
 Severity of moods and side effects must be weighed
Medical management by a psychiatrist is best
A combination of medication and talk therapy is
most effective, specifically cognitive behavior and
family therapy
Long-term management of symptoms reduces risk of
suicide
** suicide rate 10-15%, NIMH
Management of MDD
A) Acute phase treatment = induction of remission( 4-6
weeks)
1- MDD (mild, moderate)
Pharmacotherapy +Psychotherapy
2- Severe without psychotic features
Pharmacotherapy+ Psychotherapy+ ECT
3- Severe with psychotic features
Pharmacotherapy +ECT + Antipsychotic
5- MDD and catatonic
Pharmacotherapy +ECT + Antipsychotic + BDZ
6- MDD in bipolar
Mood stabilizer + antidepressant
Most depressive illnesses can be managed in
primary care setting, especially those with
mild and moderate symptoms
Refer to psychiatrist if: suicidal risk is high,
Severe depression or psychotic depression, non
response to treatment
I- Hospitalization
1- Suicide or homicide
2- To be sure of the diagnosis
3- Progressive symptoms and severe retardation
4- No social support
5- Catatonic
6- Psychotic depression
7- Refusal of treatment and food
8- Impaired insight
II- Electroconvulsive therapy (ECT )
1- Resistant pharmacotherapy
2- Condition need rapid improvement
3- Patient can't tolerate drugs
4- Catatonic
5- severe cases
6- suicidal symptoms
III- Pharmacotherapy
A- Choice of drug
- Patient preference
- Family history
- Adverse effect
- Cost of the drug
- Clinician experience
- Pattern of symptoms
B- Strategies and dose
- Monotherapy ( TCA or SSRI )
Others ( MAOI, SNRI, Trazodone, Mirtazapine )
- Duration of each trial = 4-6 weeks
- If failed , check compliance, dose, drug level, and
diagnosis
- Substitute, combine, augment with lithium,
carbamazepine, L- thyroxine , or consider ECT
1- Tricyclic antidepressants (TCA )
- Amitryptyline( Tryptizole) = 75-150 mg
- Imipramine( Tofranil) = 75-150 mg
Side effects
- Cardio toxic
- Sedation, postural hypotension
- Weight gain
- Anti cholinergic
- Neurological
2- Selective Serotonin Reuptake Inhibitor
(SSRI )
Escitalopram( Cipralex) = 20-60 mg
Fluoxetine( Prozac) 20-60 mg
Sertraline ( Lustral) = 50-200 mg
Fluvoxamine( Faverine) = 50-300 mg
Paroxetine( Seroxate) 20 mg
Side effects
- GIT upset , Insomnia, agitation, headache, sexual
- Serotonin syndrome especially in combination
( Abdominal pain, fever, sweating, and flushing )
3- Others
- Tetracyclic antidepressant as Maprotiline (ludiomil) =
150-300 mg
- MAOI if atypical features ( used cautiously )
- SNRI as Venlafaxine ( Effexor)= 75-150 mg
- Serotonin modulator as Trazodone( Trettico) = 150-
600 mg
- Bupropion ( wellabutrin) = 150 mg /day
- Nor epinephrine Serotonin modulator as Mirtazapine
(Remeron) = 30 mg
IV- Psychotherapy
A- Cognitive therapy
Goal; Alleviate episode and prevent recurrence
Technique: help patient to develop
alternative ,flexible, and positive ways of
thinking
B- Interpersonal therapy
Based on the fact that problems in interpersonal
relations precipitate depressive illness
C- Behavioral therapy
D- Family therapy
E- patient education
B) Continuation Phase treatment
- Aim : Prevent relapse
- Duration: 6-8 months
- Strategy: same treatment and same
dose
C) Maintenance Phase
- Aim: Prevent recurrence of symptoms
- Indications: Severe, psychotic depression,
positive family history, serious, or
recurrent
- Duration: If 2 episodes: interepisode
duration
- If more than 2 episodes: 5 years or for
life
- Strategy: Least effective dose
II- Dysthymia
Dysthymic disorder
Definition
Is a chronic disorder characterized by the presence of
depressed mood that lasts most of the day and is
present almost continuously
i.e Low grade depression, accentuation of depressive
temperament
Epidemiology
- 5-6 % of all persons
- Onset: childhood and adolescence
- Sex = equal
- More in unmarried people, low income
- Coexist with MDD, medical illness, anxiety disorders
especially panic, substance abuse and borderline
personality disorder
Etiology
As in depression
Clinical features
- 2 Years duration ( continuous )
Subjective > objective
- Depressed mood
- Habitual gloom, brooding, lack of joy, preoccupation with
inadequacy
- No severe disturbance in appetite, libido, psychomotor
retardation
DD
- MDD
- Minor depressive disorder
Episodic, periods of euthymic
- Double depression
MDD on top of dysthymia, Poorer prognosis
Treatment
I- Hospitalization
Mostly not indicated except if marked affecting
social life
II- Consider thyroid disease
III- Combine psychotherapy and
pharmacotherapy
A- Cognitive therapy
i- Technique
Teach patient new way of thinking
ii- Replace faulty negative attitude about
themselves, world and future
B- Behavioral therapy
Goals:
Increase activity, provide pleasant experience,
and teach patient how to relax
C- Interpersonal therapy
Improve interpersonal relations to improve self
esteem
D- Family and group therapy
IV- Pharmacotherapy
- Maximum dose
- Duration: 8 weeks
- Drug: bupropion, MAOI, TCA
- If failed
Augment with lithium
III) Other depressive disorders
1- Depressive disorder not otherwise specified
A- Premenstrual dysphoric disorder
B- Minor depressive disorder
C- Recurrent brief depressive disorder
D-Post psychotic depressive disorder of
schizophrenia
2- Mixed anxiety depressive disorder
3- Atypical depression
4- Secondary depressive disorder
- Mood disorder due to GMC
- Substance induced mood disorder
1-Premenstrual dysphoric disorder (Luteal
phase dysphoric disorder )
Definition
Syndrome characterized by mood, behavioral, and
physical symptoms occurring at specific time
during the menstrual cycles and resolves in-
between cycles
Epidemiology
40 % have symptoms
2-10 % have syndrome
Etiology
1- Hormonal changes
Abnormal high estrogen: progesterone ratio

2- Biogenic amines affected by changes in

hormones

3- Societal and personal issues about

menstruation and womanhood
Clinical picture
Presentation for 1 year
A- Mood symptoms
Depressed mood, anxiety, lability of affect, angry or
irritable, increased interpersonal conflicts, sense of
being out of control
B- Behavioral changes
Diminished usual activities, easy fatigability, change
in sleep, appetite, and difficult in concentration
C- Physical symptoms
Breast tenderness, headache, joint pain , muscle pain,
and sense of bloating ( wt gain )
Symptoms are severe to affect work, school, and social
activities and relations
DD
- If no intercycle relief of symptoms, consider
other mood disorder
If severe symptoms, exclude medical and
surgical causes as endometriosis
Treatment
1- Supportive psychotherapy
2- Mild antidepressant esp. Fluoxetine (has long
half life) , and bezodiazepines esp.
alprazolam
3- Vitamins
2- Minor depressive disorder
2 weeks of mild symptoms than MDD
Treatment, mainly psychotherapy
3- Recurrent brief depressive disorder
Depressive disorder last from 2 days- 2 weeks
Recurrent / month for 12 months, not related to
menses
Mostly +ve family history of mood disorder
4- Post psychotic depressive disorder
MDD in residual phase of schizophrenia
5- Secondary mood disorder
A- Mood disorder due to general medical
condition (GMC)
- Persistence disturbance in mood
( depressed or elevated )
- Evidence ( history, examination, or lab of
general medical condition )
- Absence of delirium
- Significant impairment
B- Substance induced mood disorder
- Persistence disturbance in mood ( depressed or
elevated )
- Evidence ( history, examination, or lab of substance
intake )
- Absence of delirium
- Significant impairment
Pharmacological causes of depression
- Cardiac and antihypertensive drugs
- Sedatives and hypnotics
- Steroids and hormones
- Stimulants and appetite suppressants
- Analgesics
Pharmacological causes of mania
- Amphetamines
- Cocaine
- Corticosteroids
- Cyclosporine
- Hallucinogens
- Methylphenidate
- Opiates and opioids
- Phencyclidine
II- Bipolar disorders
Episodes of both depression and mania (bipolar I) or
hypomania (bipolar II) occur in separate episodes
with a period of full or partial remission in between
episodes
Clinical picture
1- psychological
Mood: elation, euphoria, and irritability
Thinking: racing thoughts, flights of ideas, mood
related psychotic symptoms e.g delusions of
grandiosity and power
Speech: hypertalkativness in a loud and rapid voice
Judgment: impaired
2- Behavioral
- Hyperactivity, restlessness
- Grandiose attitude and inflated self esteem
- Increased sociability, aggression and
excitement
- Enthusiasm, multiple projects
- Sexual and social disinhibition
- Wearing bright colors, excessive cosmetics
- Overspending of money
3- Physiological
Full energy and lack of sense of exhaustion,
decreased need for sleep, increased sexual
activity, excessive eating
4- Cognitive and psychomotor
- Hyperactive
- Psychomotor agitation
- Distractability
DSM IV criteria of Manic episode
1- Elated, expansive, or irritable mood for 1 week
- Three or more symptoms present in the past 1 week
2- Inflated self esteem or grandiosity
3- Decreases need for sleep
4- Hyper talkative
5- Flights of ideas
6- Distractability
7- Involvement in pleasurable activity
8- Disinhibition
9- Impulsivity
10- Preoccupied by religious, sexual ideas or
behaviors

- Specify:
A- mild, moderate, severe
B-With or without psychotic features (mood
congruent/ incongruent)
C- With catatonic features, postpartum onset
D- If recurrent; rapid cycler or not
Hypomania
4 days of mild manic symptoms not affecting
function, but observed by others

Mixed episode
The patient meet the criteria for depression and
mania every day for 1 week

Bipolar with rapid cycler

4 episodes in 1 year
Treatment of Bipolar disorder
A) Acute phase = 4-6 weeks
I- Hospitalization ( as in MDD )
II- ECT
- Catatonic excitement
- Acute mania
III- Pharmacotherapy
Mood stabilizer + sedative + antipsychotic if
with psychotic features
IV- Psychotherapy
Has no role, cognitive therapy may be used to
prevent further attacks.
Approved mood stabilizers
-Typical features: Lithium carbonate
( Comcolit) 400 mg tab, 2 tablet/ day
divalproex( depakene chrono) 500 mg tab, 1-3
tablet/day, olanzapine( Zyprexa)
-Atypical features (Dysphoric mania, mixed
episode, rapid cycler ): Carbamazepine
( Tegretol)200 mg tab. 3-6 tablet/day, or
Divalproex
- Sedatives used: Benzodiazepines e.g
Clonazepam( rivotril ), antipsychotics
discontinued after 2-3 weeks
- Antipsychotics( Chlorpromazine, haloperidol)
- Trial = 4-6 weeks
If fail check drug, dose, diagnosis, compliance
Substitute, or combine lithium + Divalproate
- Drugs
A- Lithium
Dose = 800-1200 mg/day
Serum level = 0.8-1.2 meq /l

B-Carbamazepine and Divalproex

C- New antiepileptic: Lamotrogine and Gabapentin
( add on )
 Side Effects and Toxicity of Lithium
Relate to plasma concentration levels, so constant monitoring
is key

Higher concentrations ( 1.0 mEq/L and up produce

bothersome effects, higher than 2 mEq/L can be serious or
fatal

Symptoms can be neurological, gastrointestinal, enlarged

thyroid, rash, weight gain, memory difficulty, kidney
dysfunction, cardiovascular& Renal dysfunction, poluria,
tremors, hypothyroidism, Hypokalemia & ECG changes,
Seizures

Not advised to take during pregnancy, affects fetal heart

development
 Combination Therapy

Combination therapy with Lithium and anti-

epileptics may demonstrate better protection
against relapse, greater therapeutic efficacy, and
studies support this as a rule vs. an exception
 If Lithium Doesn’t Work

40% of Bipolars are resistant to lithium or side

effects hinder its effectiveness

Therefore, we must consider alternative agents for

treatment
 Valproic Acid (Depakote)
An anti-epileptic, it is the most widely used anti-manic drug
Augments the post-synaptic action of GABA at its receptors
(increasing synthesis and release)
Best for rapid-cycling and acute-mania
Therapeutic blood levels: 50-100 Mg/L
Side effects include GI upset, sedation, lethargy,tremor,
metabolic liver changes and possible loss of hair

Can also be used for anxiety, mood, and personality

disorders
 Carbamazepine (Tegretol)
Superior to lithium for rapid-cycling, regarded
as a second-line treatment for mania

Correlation between therapeutic and plasma

levels (estimated between 5-10 Mg/L)

Side effects may include GI upset, sedation,

ataxia and cognitive effects
 Gabapentin
Primarily an anti-convulsant, yet also “off label,”
or without FDA approval for treatment of Bipolar
and many other anxiety, behavioral and substance
abuse problems, possibly pain disorders

GABA analogue
not bound to plasma proteins, not metabolized, few
drug interactions
Half-Life is 5-7 hours

Side Effects include sleepiness,dizziness,ataxia and

double vision
 Lamotrigine
Reported effective with Bipolar, Borderline
Personality, Schizoaffective, Post-Traumatic Stress
Disorders

98% of administered drug reaches plasma

Half-Life is 26 hrs.
Inhibits neuronal excitability and modifies synaptic
plasticity

Side Effects may include dizziness, tremor, headache,

nausea, and rash
 Atypical Anti-psychotics
3 types that may be used for BP- Clozapine,
Risperidone, and Olanzapine

Risperidone seems more anti-depressant than anti-

psychotic

Clozapine is effective, yet not readily used due to

potential serious side effects

Olanzapine is approved for short-term use in acute

mania
B) Continuation Phase = 6 months
Strategy: Same dose of mood
stabilizer, discontinue
antipsychotic
C) Maintenance phase
If more than one episode, for 2
years
Cyclothymic disorder
Definition
Chronic ( 2 years ) fluctuating disturbance include
periods of hypomania and depression in milder form
than bipolar I, shorter duration than bipolar II
Epidemiology
Life time prevalence = 1 %
Coexist with border line personality disorder, and
substance abuse
Clinical features
- Presentation : marital difficulties, instability of
interpersonal relations
- Changes in mood are irregular, abrupt
sometimes occur within hours
- Patient may be achiever if controlling his
symptoms or may have professional and
social difficulties

Differential diagnosis
- Substance abuse
- Mood disorder due to general medical
condition
- Personality disorder
- Bipolar II disorder
Treatment
I- Pharmacotherapy
- Mood stabilizer ( Lithium, carbamazepine,
depakeme, clonazepam, gabapentin )
- Antidepressant used with cautious to avoid
antidepressant induced hypomania
II- Psychotherapy
1- Individual therapy
Education to increase patient awareness to their
condition and to help him to develop coping
mechanism for their mood swings
2- Family and group therapy
 School Accommodations
 Inform teacher how disorder is manifested and alert to side
effects of medication
 Is there an IEP? If so, accommodations, modifications and
interventions are written along with goals
 Counseling with school psychologist or social worker
 Reduced work load due to level of concentration and fatigue
 Provide clear instructions to alleviate/prevent frustration
 Offer instruction, corrections and feedback in a calm, positive
manner
 Prearrange an area in and/or outside the classroom for the
student to retreat to when needed and a discrete cue
 Allow extra time to complete assignments
 Mutually choose a peer mentor to assist when needed
 Consult with the school psychologist for additional information
 Employ effective classroom management programs
 Family Issues and
Interventions
Attend to behavior such as rage with therapeutic
hold, quiet retreat area and pick your battles,
behavior modification does not work well
Siblings relationships and marriages often become
strained
Get family therapy
Don’t ignore signs of suicide ideation or extreme
hopelessness
Educate family on disorder and how to deal with
mood swings
Seek support groups and parent resources
Thank You

The End