Introduction:
In adolescence, manic-depressive disorders are of major interest. It is indeed a psychiatric disorder:
• the genetic basis of which is well documented;
• manifesting from puberty, in often “atypical” forms, then more and more “classical”;
• particularly difficult to recognize in adolescence, on the one hand from a polymorphous and protean clinic, and on the other hand from symptomatic “overlaps” mainly with conduct disorders, addictions, and psychotic disorders;
• fundamentally in the long term: the diagnosis is therefore diachronic, based on the observation of an evolution;
• supposed, for some, to be independent of the “caring” personality of the affection, and to express itself in a stereotyped and almost similar way in adolescents and adults, thus appearing as a kind of “extradevelopmental” entity, and supposed to occur autonomously, that is to say to be little influenced by life events or existential circumstances.What we will nuance.
Among psychiatric disorders, it appears to be the most suitable for a medical-type approach, resulting in multiple classifications and redistricting up to the designation of “bipolar disorder” (which effectively eliminates any reference to the notion of Psychosis “, considered too imprecise, but undoubtedly also too disturbing). The occurrence of manic depressive disorders at this age brings with it the problem of the conjunction of a biological vulnerability with the vagaries of the development and the history of the subject, hazards which always modify singularly the phenotypic expression of a pre-existing disorder , and which must therefore be taken into account for better treatment and prevention.
In adolescence, mood swings are constant.
The integration of the regulation of mood with a personality in the midst of maturative revision is never without difficulty, as if to complete his adolescence and to find a thymic stability were synonymous. And it is often seen, in the healthy adolescent, alternations of mood – isolation, withdrawal, sulkiness … extraversion, excitement, elation – which are not without evoking the swing maniacodepressive.
It is impossible, therefore, to remove the crucial question of the relationship between mood disorders and the organization-structuring of the personality, which is illustrated by the return to vogue of the notion of “temperament” “cyclodys- or hyperthymic” … , or “irritable”, constitutionally determined but supposed to emerge more clearly from adolescence. On the basis of this report, we consider that in certain moments of disorganization, the play of investments and psychic counterinvestments turns the functioning of the subject in a direction similar to a psychotic functioning, or rather a struggle against a psychotic threat , because of certain consequences of this. However, there is no loss of contact with reality in the sense of dissociation. The manic-depressive entity remains very singular and contains, in its very symptom of alternation, the elements which make its individuality in the economic and dynamic sense of the term.
Epidemiological data:
Although E. kraepelin referred to a peak frequency of onset of “manic-depressive psychosis” in adolescence in the early 20th century, manic-depressive disorders have long been neglected in young patients until the last 15 years .The qualifier of these disorders now excludes the structural term of psychosis to focus on that of mood disorder. There are very few epidemiological studies centered on adolescence and they are controversial by diagnostic inclusions meeting different criteria. However, in a review of the American literature on “manic-depressive illness”, the authors report that 20 to 30% of bipolar adults experience an onset of disorders before 20 years of age. A more recent study, retrospectively examining adult patients as to the age of first occurrence of “bipolar disorder,” returned to onset in adolescence or earlier in 10% of cases. However, it is likely that a certain number of cases begin in a paucisymptomatic manner and are confirmed only at the time of the later emergence of severe disorders.
An epidemiological study of 1,709 adolescents aged 14-18 years and assessing the prevalence of type I and type II bipolar disorders according to the DSM IV criteria (Bipolar I disorder), with only 0.1% of patients with a lifetime diagnosis of a manic episode. According to the same study, the mean age of the first thymic episode in these adolescents was 11.75 years, and the episode was most often depressive in nature. The diagnosis of “pediatric bipolar disorder” (as it is now termed “juvenile mania”) is rarely described and highly controversial, especially in Europe.
The sex ratio, as in adults, is equal to 1. Some comorbidities are particularly frequent here (anxiety disorders, conduct disorders, substance abuse, hyperactivity with attention deficit etc.).
However, the associated or differential diagnosis of hyperactivity-attention deficit disorder (ADHD) remains questionable because the diagnostic criteria intersect. According to some authors, the presence of feelings of elation and ideas of magnitude is necessary to distinguish bipolar disorder.
For others, it is not the same disorder since bipolar disorders are characterized first by acute episodes well defined in time and free intervals while ADHD presents a continuous evolution. This “pediatric bipolar disorder” is described as “chronic, continuous”. Some authors point out the pitfalls associated with the use of adult DSM IV diagnostic criteria in children, without taking into account age-specific aspects of development and not having the same pathological character as in the l ‘adult. These latter authors are cautious about a diagnosis too fast.
Current Classifications:
In the DSM IV, the unipolar – bipolar dichotomy is still relevant. Bipolar disorders are described in the context of “mood disorders” in adults. There is no specific classification for bipolar disorder in adolescents or children, but there are additions to some symptoms that are more specific to these age groups.
The “mood disorders” section is itself divided into: thymic episodes, depressive disorders, bipolar disorders, other depressive disorders and specifications concerning either the most recent episode or the evolution of the recurrent episodes.
The description of the thymic episodes includes the major depressive episode, the manic episode, the mixed episode and the hypomanic episode. Bipolar disorders include: Type I bipolar disorder, Type II bipolar disorder, cyclothymic disorder and unspecified bipolar disorder.
Bipolar I disorder is characterized by one or more manic or mixed episodes, usually accompanied by major depressive episodes. Six subgroups are differentiated according to the type of the most recent episode.
Bipolar II disorder is characterized by one or more major depressive episodes accompanied by at least one hypomanic episode without a frank or mixed manic episode.
Cyclothymic disorder is characterized by numerous periods of hypomania and numerous depressive periods that do not meet the criteria for a major depressive episode for at least two years. There is no period of more than 2 consecutive months without these symptoms. In children and adolescents, this duration is reported arbitrarily at least 1 year.
The symptoms are not due to the direct physiological effect of a general medical substance or condition.
For all these bipolar disorders, thymic symptoms are not explained by a schizoaffective disorder, are not added to schizophrenia, schizophreniform disorder, delusional disorder or unspecified psychotic disorder. These symptoms result in clinically significant suffering or impaired social or occupational functioning.
As noted by Goodwin and Jamison, manic-depressive disorders can be assessed in adolescence using standardized diagnostic criteria used in adults (RDC or “Research Diagnostic Criteria”, SADS or Schedule for Affective Disorders and Schizophrenia, DSM).
The tenth revision of the International Classification of Diseases (ICD 10) subdivides different mood disorders in adults by:
• manic episode (including hypomania);
• bipolar affective disorder;
• depressive episodes;
• recurrent depressive disorder;
• Persistent affective disorders (including cyclothymia, dysthymia) and other affective disorders.
The French Classification of Child and Adolescent Mental Disorders (CFTMEA) considers the classification of child and adolescent thymic disorders from a different perspective, with an essential place for the functioning and organization psychic of the subject. Thus, dysthymic psychoses are part of axis 1 (or basic clinical categories), and moreover the authors distinguish:
• neurotic depression in the context of neurotic disorders;
• depression linked to a personality pathology (in particular narcissistic and / or anaclitic pathology, abandonment);
• reactional depression in the context of reaction disorders;
• Depressive moments belonging to variations in normal.
The objective of this classification is to take into account the overall psychic functioning of the subject. Manic depressive disorders in adolescents correspond to these “dysthymic psychoses”.
Genetic data:
Early genetic studies of manic-depressive disease highlight the existence of an undeniable genetic vulnerability of this disease. In family aggregation studies, the prevalence of manic-depressive disorder, usually 0.5 to 1% in the general population, is 8% in first-degree relatives for bipolar disorder and 10% in disorders unipolar. Twin studies show two to five-fold higher concordance rates in monozygotic twins compared to dizygotic twins. These different data reveal both the existence of a genetic background and the important role of psychoenvironmental factors (the concordance in monozygotic twins is not complete in any of the diagnostic categories). The interaction of environmental factors in the transcription and expression of genes is therefore fundamental. Different genes are involved, such as the short arm of chromosome 11 in the Amish population (never replicated). Chromosomes 10, 18 and 21 may contain other vulnerability genes. A recent study exploring early bipolar disorder would show the role of three loci. Bipolar disorders are thus part of complex heredity disorders with incomplete penetrance and phenocopy, genetic heterogeneity and polygenicity.
Some recent studies investigate early-onset bipolar disorder to determine more homogeneous clinical groups. Thus, the early onset of bipolar disorder may be associated with increased familial risk and certain clinical characteristics (greater frequency of psychotic signs, thymic episodes of mixed or manic nature, comorbidity with the disorder panic, etc.). A phenomenon of anticipation is described, that is, transmission of the disease from one generation to the next with increasing severity in frequency, intensity and onset. Mr.
Strober et al., Exploring family risk according to the age of onset of bipolar disorder, assessed the lifetime prevalences of psychiatric disorders in the relatives of 50 adolescent subjects with bipolar I disorder compared to 30 adolescents with schizophrenic disorders. The authors thus demonstrated a familial aggregation of major thymic disorders in the relatives of bipolar adolescents of type I greater than what is known conventionally in the literature concerning the adult subjects. In addition, adolescents with early onset of childhood disorders have significantly more first-degree relatives with bipolar I disorder compared to those with disorders that did not start in childhood. The authors assume that early-onset forms of bipolar disorder would represent “the expression par excellence of a geneticoenvironmental continuum”. In a recent study of 210 patients with bipolar disorders, F. Schürhoff et al. compared with a group of subjects with an early onset of bipolar disorder (before 18 years) to a group of subjects with a later onset of these disorders (after 40 years). It appears that patients with early onset of their disorders would have a more severe clinical form. This is significantly associated with a greater number of psychotic signs, a higher incidence of mixed-type episodes, greater comorbidity with panic disorders, and a poorer response to prophylactic lithium. This study also highlights the fact that first-degree relatives of subjects with an early onset of bipolar disorder have a significantly higher risk of thymic disorders, including bipolar thymic disorders. The two groups of patients, determined according to the age of onset of their bipolar disorder, therefore differ in the clinical expression of the disease and the familial risk.
Special vulnerability to adolescence:
A deterministic or genetic component remains subject to the influence of biological and hormonal changes (such as those appearing in adolescence), which result in “expressing” at this age a latent disease. It is thus that tables comparable to those of the adult appear only from puberty. This can be explained, from a neurophysiological point of view, at two levels (at least): the need for maturity of the mood-regulating cerebral structures; the need for a cognitive maturity, which resonates on the one hand with the expressed ideative contents and, on the other hand, on the consciousness of one’s mood by the subject.
Concerning the psychoanalytic approach, the explanation by S.
Freud of the process culminating in melancholy has also run up against the clinical findings of the absence of melancholic states that can be objectified before the prepubertal age. B.
Penot, reproducing the criticism of the role of psychic bodies in children, and based on Bowlby’s work, finds justification for this clinical fact: the possibility of melancholic depression in children would imply that the childish psyche already has a ” instances sufficiently stable and differentiated (Superego and Ideal of the Self). Bergeret similarly emphasizes this lack of postoedipian structuring to insist on the role of “a megalomaniac ego ideal imposed by parents in the genesis of the feeling of guilt”; the child’s superego being hardly autonomous, remaining dependent to a large extent on the external presence of the parents. As for the ego ideal, a key reference for self-depreciation, it is stable only at the end of the period of latency and during adolescence. It is only then that the subject is able to acquire a stable representation of himself and that his ideal reference images are reinforced and introduced durably.
A. Esman has identified four “normal” developmental factors specific to adolescence that may cause depression:
• low self-esteem and sensitivity to narcissistic injuries in early adolescence, accompanying physical changes in puberty, focusing attention on the body, and careful attention to physical appearance often to exacerbate self-consciousness and aggravate a dysphoric state when self-identified defects or inadequacies are perceived or elevated by others;
• ideas of grandeur, idealized representations of the self can persist from earlier periods and are reinforced by parental expectations. If this type of expectation is disappointed, again self-denigration and feelings of worthless appear;
• guilt and self-reproach express conflict and conflict with “sexual fantasies”, especially perverse or homosexual, or with sexual activities, especially masturbation. Similarly, conflicts about hostile desires, especially when directed against parents, can create feelings of guilt and self-aggression;
• last but not least, depressive affects in adolescence are generated by the process of change of love object or by the disinvestment of representations of primary parental objects. This process is often associated with a sense of loss until stable substitute objects are found.
P. Jeammet, noting that it is generally necessary to wait until adolescence and often even postadolescence to observe symptomatic psychoses such as acute delusions, schizophrenia, various acute psychotic experiences and major disorders of mood, “What is specifically psychotic in the evolutionary movement of adolescence is the threat of breakdown of the internal equilibrium between objective and narcissistic investments and the widening of a narcissistic-objectal (discourse) gap peculiar to that age … “. “There is, on the one hand, an instinctual impulse which is both increased and physically feasible, the awakening of incestuous and parish-minded desires and the Oedipal conflict, without any new object choices being able to satisfy them and constituting sufficient displacements to the parental imagos, but with an updating of infantile attachments and partial drives, and an autoretic withdrawal upon them; and on the other hand a loss or a weakening of the narcissistic support which previously ensured the idealization of the parents and the maintenance of a status and a child image “.
Many Anglo-Saxon authors (including SC Feinstein) have developed a pragmatic etiopathogenic analysis that combines genetic and biological data with some psychopathological data. They believe that in manic-depressive patients there would be a basal vulnerability of the “affective system” which, at the time of great psychic stimulations, would be the cause of a disorder not possibly controlled by the system of regulator of the humor. This particular vulnerability to stress, a veritable system of pathological activation, is closely linked to neurobiological changes, themselves related to hereditary factors. These subjects in particular have an extreme sensitivity to loss or fear of loss, which seems to be the trigger for many episodes.
Family dynamics:
We know the frequency of a family history of bipolar disorder or more generally of mood disorders for a given patient and the daily clinic shows well the interrelations between the different pathologies presented by the different members of the family, “Communicating vases” where, when one is stabilized, the risk of decompensation for another is not negligible; or when the relapse of one of the parents often reactivates the identity problem of their child.
All this underlines the bad differentiation between the subject and the object.
Now, the degrees of indifferentiation between the subject and the object, and a minimum of unresolved ambivalence with respect to the object, are essential factors in the modulation of the subject’s family representation.
Thus, S. Nacht and P. Racamier (1959), wondering about the depressive image of the object, think that “… for the depressive, the object is perfectly good or perfectly bad. defends against its own ambivalence by splitting its object representation. It is impossible for him to apprehend the object as an autonomous and individual human being in its originality. The authors emphasize that in melancholia, exchanges of bad processes of the depressed with its object are carried out on a purely or almost purely intrapsychic plane … The object relation is mainly internalized. Moreover, concerning the nature of family exchanges, “everything depressed pushes its object to frustrate and make it suffer … Unconsciously, the entourage perceives what aggressive and accusatory have the demands, the sufferings and the” self-accusation of the patient. To this camouflaged aggressiveness and ambivalence, he reacts by counter-aggressiveness and ambivalence “.
S. Blatt et al. (1979) consider that there is a close connection between the representation by the subject (psychological developmental level and cognitive level) of his parents (negative images) and the nature and degree of the depression of the latter; the evolution of the parental representation is accompanied by a clinical evolution.
In our study of family dynamics, we observe that the only significantly disturbed familial psychopathological indices compared to the control group are maternal rejection and disharmony of the parental couple. Note that the comparison of unipolar or bipolar patients shows in unipolar patients the frequency of parental authoritarianism and of a problematic of conflicting filiation, which corresponds to the classical data of the literature.
We did not discriminate in this study, which for many authors constitutes a factor of poor prognosis, maternal disease, presence of the disease in both parents, high psychiatric comorbidity in parents suffering from major depression.
All these data allow us to evoke the vulnerability of the family balance and its important role in triggering access and relapse on patients themselves weakened and who anxiously and aggressively solicit their parents. The demonstration of a representation of maternal rejection in the patient suffering from manic-depressive illness joins the psychodynamic conception of the disorder, which is based on a relation to the primary maternal object with an essentially narcissistic function. Oral greed for the object is at the origin of the feeling that it does not meet its expectations; the least frustration is experienced as a rejection (whatever the reality of the intensity of frustration): “the depressive has not internalized the presence and the image of the loving object: therefore it can not happen of the real presence and the concrete gifts of an object which no longer exists when it is not there, and which does not love it when it does not prove it. “
The representation of a disharmony of the parental couple remains difficult to interpret (aggressiveness and ambivalence of the subject, lack of support on the part of the father in the close relationship between mother and adolescent, reality of the couple where one and / or the other are often ill, consequence of the adolescent’s illness on the parental couple, etc.).
Environmental factors and influence of life events:
Regarding environmental factors, there are few studies in adolescence. In a retrospective study of 46 bipolar patients, Glassner and Haldipur (1983), cited by Olié et al., Note that early-onset forms (before 20 years) report less often an event in the year before the onset of the disease than the late-onset forms (a non-significant difference), while the authors point out, it seems that young people tend to report more events than older ones.
Studies specifically focusing on manic depressive disorder in adolescence reveal a number of precipitating events during access: puberty, menstruation, pregnancy, physical illness with relational impact (visible malformations, stunted growth), syndromes loss (parental separation, death of a parent, severe and chronic parental rejection, chronic disease of a parent).
In adults, some studies have been published, the results of which are often contradictory and the methodological difficulties important. However, it emerges that the role of environmental factors is more evident on the first episodes of the disease. This is in line with RM Post’s theoretical neurobiological model that there is a progressive empowerment of the manic-depressive disease that would eventually become less sensitive to environmental factors. R. Levitan et al.(1998) examined the relationship between mood disorders and a history of sexual or physical abuse in childhood. In a sample of 621 individuals aged 15 to 64 with major depression or having experienced a major depression, they found that subjects with bipolar disorder had a significantly higher rate of history of physical abuse in compared to subjects with recurrent depressive disorders. A recent study explores the impact of life events in a group of 140 adolescents with one parent with bipolar disorder.
Independently of the weight of heredity, stressful life events are likely to favor the emergence of thymic disorders with a decreasing impact over time.
In adolescence, a major period of psychological vulnerability, one may wonder what impact life events can have and what the influence of family dynamics can be, even though another member of the family frequently suffers from the same disorders. In a daily clinic, a system of “communicating vessels” is constantly observed where, when one is better, the other is worse and vice versa. The relapse of a parent and, above all, a transition to the suicidal act may also reactivate the problematic identity or identification of the adolescent. As such, a study highlights the role of a psychosocial stressor (and in particular a sentimental rupture) preceding an acute episode and reactivating the problematic of identity (narcissico-objectal gap) in the context of manic-depressive disorders. ‘adolescence. In the systemic family study field, some authors particularly evaluate emotional attitudes and behaviors as “emotions expressed”, which would constitute an important risk factor in the evolution of psychiatric illnesses. These authors describe family functioning specific to the families of patients with bipolar disorders, whereby family members seek either to adapt to symptoms in multiple ways or alternate genuine and critical support based on their mechanisms of defense and their ambivalence.
Thus, vulnerability to adolescence is linked to genetic determinism, hormonal and psychological changes in puberty and the impact of psychosocial factors.
In a study of 38 adolescents with manic-depressive illness, we found a psychosocial stressor that was deemed to be determinant by the patient in the year before the episode of decompensation in nearly 76% of the cases. The severity of these stressors is generally significant (53% severe, 21% moderate).
Among the factors precipitating acute decompensation, we find: sentimental disappointment: 40.5%, physical or psychological chronic parental disease: 32.4%, death of a family member: 24.3%, separation, parental divorce: 18.9%, psychiatric disorders in the siblings: 16.2%, relocation: 8.1%, departure from a family member’s family environment: 13.5%, rivalry: 10.8%, difficulties schooling: 27%. Note that the same patient usually associates several stressors.
We do not establish a direct causality of life events / acute decompensation, but merely evaluate the impact of event factors and their nature as precipitating factors in vulnerable subjects and reflected on the “resonance” relationship between the life event and the particular psychological problems of manic-depressive patients.
One can only be struck in the analysis of the data collected by the intensity of the misfortunes reaching the close family circle and evoked by the patient as being major factors triggering their episode. Among the factors precipitating the episode of decompensation, we find in 40.5% of the cases a sentimental disappointment. Patients evoke a sudden rupture of a strongly invested love relationship, whether it was an opportunity for sexual intercourse or not. More than a disarray with sexuality, we found that the love object was invested in a particular way (narcissistic) each time. Thus, far from feeling abandoned by the beloved and far from blaming him, there was an intense worry about his becoming, and the reproaches concerned the patients themselves in their inability to remain in a relationship with two, feeling “fundamentally annihilated by sharing,” feeling the risk of losing themselves in the relationship to the other. This extreme, vital dependence on the object, revealed abruptly, is thus accompanied by an identification of the ego with the object, with a form of maternal concern for it. This seems to us to mirror the adolescent’s close relationship with his essential, maternal object. The sentimental relationship that is formed seems to refer the subject to the risk of “a rupture of a link with the maternal lifting object that was experienced as indispensable”. This is obviously all the more true if the mother does not help her child to manage the distance with her until independence. This is all the more difficult for her as she herself experiences this link as fragile.
Acute decompensation allows the patient to “remain closely attached to his object and to attach it”, while satisfying more or less laboriously its aggressive and masochistic impulses.
It also appears that the accumulation of stressful life events (more or less predetermined by the disease), placing the subject in a “fatal destiny”, contributes to permanently fixing a vulnerable psychopathological organization.
Clinical aspects:
Problems specific to the issue of mood in adolescents:
Thymic symptomatology is often characterized by its lability and its variability (rapid, moreover), even the coexistence of symptoms of the manic series and the depressive series (mixed states).
There is in fact an interference with the “physiological” fluctuations, often not very discernable of a “pathological” mood.
There is also an overlap between the resonance of mood disorders and certain “experimental” attitudes, transgression or challenge (uninhibited sexual behavior, drug taking).
Depression is often expressed in the form of somatic complaints (asthenia, headache, rachialgia in particular, but more generally pain or various anxiety centered on the body).
Symmetrically, hypomania can result in instability, distractibility, irritability or even aggression (recognizable, if acute, to change from ordinary behaviors and attitudes of the subject, but sometimes chronic …).
The “outsourcing” of his suffering is a preferential mode of expression in the adolescent, hence the misunderstanding with the conduct disorders (fugues, fights, clastic crises, etc.) and the risk of progressive marginalization, with installation of a “negative identity”.
Mood disorders resonate privately on schooling (through difficulties of concentration, inhibition, or disinvestment of studies, to differentiate – but the two can coexist – from a behavior of opposition).
There are multiple ways of “self-treatment” of depression, through alcohol, drugs, but also drugs and all addictive behaviors, even “festive hypomania” …
There is thus the problem, generally speaking, of the expression (from the outset or secondarily) of the mood disorder through another manifest symptomatology …
The diagnostic difficulties that can be encountered in adolescence are related to the physical and psychological upheavals that make this period of life difficult to apprehend from a psychiatric and psychopathological point of view in the sense that these upheavals are not without influence, sometimes temporary, sometimes lasting, on an open and developing psychic structure and which is more eager for sources of identification. In fact, thymic oscillations are physiologically particularly pregnant (massive, intense, brutal) in adolescence and the psychic processes at work are close to those observed at the origin or during depressive states. Psychiatrists would also be more reluctant (at the risk of denial of the disorders) to make a diagnosis in adolescence, and especially this one, with a concern to avoid fixing a diagnosis even though the lability of the disorders and their sometimes very noisy are important elements of psychopathology in adolescence. The disorders presented by the adolescent are also very often trivialized, even denied, by the adolescents themselves, but also by their parents. However, it is necessary to recognize these disorders and treat them adequately on the psychotherapeutic and chemotherapeutic levels.
Psychotic Disorders:
The peculiarities of thymic expression also contribute to these diagnostic difficulties. In the first place, we must underline the presence of psychotic signs in 30% of the cases, which is clearly higher than in the adult. These psychotic signs consist mainly of delirious ideas with a theme congruent or not to the mood, hallucinations rather psychosensory and disorders of the course of thought (incoherence, relaxation of associations, perseverations, dams, …). All psychotic symptoms can be found, including so-called Schneider’s first symptoms and catatonic symptoms.These psychotic elements can be present whatever the nature of the episode, depressive, manic or mixed. The incidence of this psychotic symptomatology would decrease over time and with the repetition of thymic episodes;which goes against the theory of RM Post. This psychotic symptomatology leads to diagnostic errors in 50% of cases in the first episode in adolescence. This is closely related to the problem posed by the differential diagnosis of schizophrenia. Finally, many authors agree that often only the later evolution is able to decide from a diagnostic point of view; especially since later episodes become more “classical” during the course of the disease, with less psychotic symptomatology. The appearance in adolescence of psychotic symptoms therefore requires the search for associated thymic symptoms and a family history of thymic episodes. However, one study finds that experienced clinicians can make the error-free diagnosis between early schizophrenic disorder and bipolar disorder. Finally, the existence of psychotic signs congruent to the mood during a major depressive episode would have a predictive value of bipolarity and not of schizophrenia.
The existence of psychotic signs not congruent to the mood does not indicate the diagnosis of schizophrenia which proves on the other hand extremely probable in the presence of a mental automatism. Bipolar disorders have no degenerative evolution and do not organize themselves durably in a psychotic structure.
Mood:
As for mood, it is very often mixed, more frequent than in adults, with a coexistence of symptoms of the manic lineage (defensive against archaic and oedipal affects reactivating in adolescence) and of the lineage depressive. Some authors even advocate a mixed-state diagnosis in an adolescent with depressive symptomatology accompanied by irritability or anger. In the thymic episodes of the manic type, the classic euphoric tone often manifests itself more moderately or is replaced by a dysphoric mood, even instability, irritability, and extreme aggressiveness. In addition, this irritability may also be at the forefront of a depressive episode. The motor expression marked by agitation is also pronounced in adolescence. Depressed mood is often attenuated or masked, moving and manifesting in other symptoms such as somatic complaints (asthenia, headache, rachialgia …). These somatic disorders are frequently found in adolescents with bipolar disorders, whatever the nature of thymic access. Depressive attacks are therefore generally not very noisy, masked and marked by boredom, irritability, withdrawal, indifference … But they can also give rise to suicidal and addictive passages. Irrespective of the nature of the mood, irritability and aggression are frequently at the forefront of the thymic picture.
Conduct of transgression:
Transgression or challenge are sometimes an integral part of the clinical picture, with the presence in the forefront of conduct disorders which can also lead to diagnostic errors and mask the thymic origin. These conduct disorders include addictive behaviors, fugues, fights, clastic crises, inappropriate sexual behavior and risk etc. The risk of marginalization is high. The risk of addictive behavior or substance abuse is significantly increased in adolescents with bipolar disorders, compared to a group of adolescents with no such disorders (37% versus 7%).
Sexual disinhibition is a frequent semi-episode of the manic episode in adults and adolescents.
The feeling of omnipotence is found in all domains, with a feeling of sexual power and power of increased seduction, which can lead to repeated and displaced sexual solicitations. Adolescent studies estimate the prevalence of this sexual disinhibition or “hypersexuality” at about 40%. This “hypersexuality” described in adolescents manifests itself in different ways: elaboration of romantic scenarios, excessive use of the pink telephone, even emergence of delusions about teachers; older adolescents have multiple sexual partners with unprotected sex and feel an urgency associated with the sexual act. Such sexual disinhibition can therefore encourage risky behaviors and put the adolescent and his partners at risk. In some cases, rape may reveal a manic state in adolescence. On the other hand, the frequency of a psychotic dimension associated with this climate of sexual disinhibition can be the source of delusions with sexual theme and / or be a source of false allegations of sexual abuse. It is not unusual for a maniacal episode occurring in adolescence to be made allegations of sexual assault, whether the assault actually took place, the result of delirious construction, or inappropriate response of an adult to a morbid The medical consequences and the forensic implications of such allegations are major and important to know.
Finally, we observe more often in adolescence an evolution marked by rapid cycles (more than four episodes per year). Confounding elements (temporal disorientation, anxious perplexity, confused speech in particular) are also frequently found during these acute thymic episodes in adolescence.
Evolution and prognosis:
Early or late start:
Concerning the medium- and long-term evolution of bipolar disorders occurring during adolescence, opinions are rather divided. Some authors consider that the development remains quite similar, whether the disorders started early, in adolescence, or later, in adulthood. For other authors, the prognosis would be more pejorative. G. Carlson et al.study the progression of subjects with bipolar disorder with early onset (less than 20 years) to those with later onset (over 35 years) (695 subjects). Subjects with early onset of their disorders had significantly more relapses during the first two years of follow-up (after a first manic episode), compared with those with early adulthood. They also spend significantly more time in hospital during these 2 years. In a prospective study, with a 5-year follow-up of 54 adolescents with bipolar disorders, Strober et al. found that 4% had ongoing disorders, 44% had a depressive or manic relapse, and 21% had at least two additional episodes during this follow-up.
A recent study examines the follow-up of 4 to 5 year-olds of 25 adolescents aged 9-16 years who had a first manic episode according to DSM IV criteria. The subjects were all euthymic after an average period of 44 days; 64% of the subjects had a relapse in an average period of 18 months, while for the majority, treatment was still ongoing.
Suicide and suicidal acts:
The issue of suicide is paramount. Suicide mortality is indeed high in bipolar subjects. A meta-analysis by F. Goodwin and K. Jamison of 30 studies from 1938 to 1988 (9,500 subjects) shows that 19% of adults with bipolar disorders die by suicide.
Suicide deaths occur particularly during the first 10 years of the disorder, making adolescents and young adults particularly vulnerable.
Studies investigating this risk show significantly higher rates of suicidal passing in adolescents with bipolar disorder compared to those with other psychiatric disorders or with no psychiatric disorders.
Brent et al. highlight the existence of risk factors in suicidal adolescents: diagnosis of bipolar disorders, thymic disorders with comorbidities, absence of psychiatric care and presence of a firearm in the home.
Suicidal passages would be more frequent in cases of mixed rather than manic episodes and would increase dramatically with the severity of depressive symptoms.
Predictive factors of bipolarity:
Psychosocial repercussions are generally of major importance, with regard to schooling with a risk of delay and failure.Due to conduct disorders, the risk of marginalization is high.
In the interest of prevention, recent studies seek to evaluate the so-called “predictive factors of bipolarity”. A prospective 3 to 4 year study by M. Strober et al. evaluates 60 adolescents hospitalized for major depressive episode.The authors show that 20% of these adolescents will develop bipolar disorder during this follow-up. The so-called “predictive” factors of bipolarity highlighted would be: certain clinical signs, a family history of thymic disorders and pharmacologically induced hypomania. The clinical symptoms identified are the rapid onset of depressive symptoms, the presence of psychotic signs (these being congruent to the mood) and a psychomotor slowdown.
Family history includes the presence of thymic disorders in family ancestry, a family history of bipolar disorder, and the presence of three thymic disorders over three generations. In another prospective study evaluating a group of adolescents, H. Akiskal et al. confirm the relevance of these so-called “predictive” signs of transition to a bipolar form of their thymic disorders, by their sensitivity and specificity, such as psychotic symptoms, family history of bipolarity, weight of heredity, continuous multigenerational family transmission and pharmacologically induced hypomania, with hypersomnia associated with slowing down, early onset (before 25 years) or postpartum.
Therapeutic aspects:
Drug management of bipolar disorders in adolescents:
Goal:
The aim of the medicinal protocols in bipolar disorders is twofold:
• obtain the sedation of the critical episode as soon as possible;
• introduce preventive treatment.
The available pharmacological means have multiplied in a few years with the introduction of new antipsychotic and / or normothymic molecules which have received an indication in these two therapeutic registers.
Setting-up of these treatments:
Hospitalization is initiated via emergency and reception facilities.
Hospitalization should be the rule, with close supervision given the risk of committing suicidal, aggressive or clastic acts; 27% of adolescents with bipolar disorder have suicidal tendencies. The aim of hospitalization is to protect the patient against himself, but also to protect his / her connection with the family and emotional environment on which the quality of social reintegration after the crisis depends.
The effectiveness of the treatment depends first on its compliance, which requires that the therapeutic protocol is presented, explained and commented on to the adolescent. “The drug must not be perceived as a stereotyped way of responding to individual difficulties, it may contribute to the desubjectiveness of the depressed state and make it a foreign body cut off from internal conflict, the adolescent and his history “.
Treatment of Melancholic Access:
French health agencies (French Agency for the Safety of Health Products [AFSSAPS]) and the European Medicine Agency Press Office (EMEA) recently renewed warnings regarding the prescription of antidepressants in adolescents given the increased risk of a suicidal act, indicating that preference should be given to psychotherapies. In the case of a melancholic episode, this recommendation can not justify delaying the initiation of an antidepressant protocol, but it insists on close hospital supervision of the patient.
An antidepressant treatment is necessary by targeting effective dosages. There is no controlled study demonstrating that one antidepressant is more effective than another antidepressant. Antidepressants are distinguished by anxiolytic sedative properties, or stimulating properties. They also have variable side effects, more or less well tolerated in this sensitive population of adolescents.
First-line serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (NAIRS) may be used. Preference is given to IRSNAs that have a wider spectrum of action. Venlafaxine does not have marketing authorization (MA) before 18 years; the milnacipran had until the end of 2004 a marketing authorization from the age of 15 years.
No IRS has a recommendation until 18 years, the EMEA formally discourages use of studies evaluating paroxetine.
Despite their age and side effects, only tricyclic antidepressants have an MA below the age of 15 years. The leader is clomipramine, which can be combined with lithium immediately (see below) as a synergistic antidepressant. In the adolescent, due to the greater individual variations at this age, a dosage of the antidepressant plasma level makes it possible to adapt the prescription to an effective dosage (from 50 ng / ml and up to 200 ng / ml).
The discerned interest of infusions would be an improvement in the delay of action, as well as in the introduction of a particularly recommended mothering and surveillance. In practice, treatment is initiated as 3-hour evening vows, with a gradual rise in dose levels of 25-50 mg / 24 h, until a dose is reached which varies according to the weight of the adolescent (1 to 5 mg / kg / day). Correlators of atropine effects may be associated (anetholtrithione) as well as cardiovascular analeptics (heptaminol), but not systematically.
A major anxiolytic treatment is associated: for example, a sedative neuroleptic such as cyamemazine may be associated with a non-benzodiazepinic hypnotic (alimemazine).
Delusions that are congruent or not to the mood require the use of a polyvalent antiproductive neuroleptic; haloperidol or loxapine which has the advantage of being much better tolerated and which has a marketing authorization from the age of 15 years.
Treatment of manic access:
In the space of a few years, the protocols of management of the manic accesses in the adolescent have radically evolved. Only 10 years ago, the treatment was based on the use of classical neuroleptics of the phenothiazine family, with powerful sedative effects, but with strong acute dyskinetic side effects, leading to a high number of therapeutic failures. non-treatment observations.
New neuroleptic molecules have arrived on the market, forming the class of second generation neuroleptics also called – improperly stricto sensu – antipsychotics.
They differ from the first-generation neuroleptics by a combined action on the D 2 limbic receptors and the 5HT 2Aserotoninergic receptors. Thymoleptic action has been shown to be distinct from antipsychotic action, and their use has become widespread in the management of bipolar disorders. Given their maneuverability, effectiveness and tolerance, their use has developed considerably in adolescents.
The most studied is risperidone. Its effectiveness was noted in almost 80% of cases. Several cases reported on small series indicate good tolerance. Risperidone is a drinkable suspension, tablet and injectable solution. The availability of a prolonged form of action makes it possible to envisage from the start of the treatment a continuity pharmacotherapeutic between the short and the long term. The association with a normothymic increases efficiency and safety; the risperidone-lithium or risperidone-valproate combinations are of equivalent efficacy. Rare cases of neuroleptic malignant syndrome have been described.
Olanzapine is an antipsychotic also provided with an antimanic action. It has been evaluated in adolescents with resistance to normothymic treatments.
A study of a cohort of 23 children and adolescents reported a favorable response of 61%. Olanzapine is well tolerated in the short term. There is a galenical presentation, alternative to injectable treatment, particularly interesting in its use in emergency: the orodispersible form.
In terms of surveillance in its short-term use, there have also been described rare malignant neuroleptic syndromes. It is reported by the pharmaceutical company that produces it that there is no risk of prolonging the QTc space in adolescents without a history of cardiac rhythm disorders.
Other antipsychotics have been used in the management of manic episodes in adolescents. Quetiapine is not available in France. Clozapine is effective in treating acute episodes.
Anti-epileptic molecules have been used in North America for the indication of bipolar disorder with a recognized efficacy in 75 to 90% of cases in small series: oxcarbazepine, topiramate, but both not the AMM in France in this indication. Divalproate has a specific AMM in manic states, but not for this age group. Recent studies in adolescents indicate their efficacy and safety of use (for their use, see below).
Clonazepam is a substance with antimaniaic properties recognized beyond sedative and muscle relaxant effects. This product has not been specifically studied in adolescents.
In the expectation of a specific action of the antipsychotics, it is, by the use, a coprescription useful in case of strong agitation.
In general, it is recommended to continue antipsychotic treatment at least 4 weeks after reduction of manic symptoms.
Prophylactic treatment:
Manic-depressive disorders are defined in their natural course by the recurrence of manic or melancholic attacks.
The psychological, emotional, social and familial consequences of these accessions are all the more burdensome as they occur at an early age, integrating the process of maturing adolescence with adulthood. That is to say the need to be able to prevent these recurrences in order to reduce as much as possible the negative impacts.
The optimal prophylactic approach consists of two stages: an early diagnosis and a prescription of a mood stabilizer as soon as the indication is made, initially monotherapy, with the optimization of the efficacy thanks to plasma dosages.
There are now psychotropic so-called normothymic, or thymoregulatory. Their preventive action is at several levels:
• Prophylaxis of the change in mood following a crisis in bipolar disorders: either preventing a melancholic turn in a mania crisis, or preventing a manic change as a way out of a melancholic state;
• prophylaxis of a relapse at a distance from a critical episode, after a free interval, in unipolar disorders such as bipolar disorder; prevention can be required then from the first manic episode or from the second episode of melancholy.
Preventive treatments are introduced over very long periods, several decades if possible. The prevention of relapses of manic-depressive disorders therefore poses the problem of compliance first; 50% of relapses are attributed to poor compliance; and the rate of relapse of bipolar disorder in adolescents is three times higher in those who do not benefit from preventive chemotherapy (an 18-month study in 37 adolescents).
In order to avoid the inopportune stops of the thymoregulatory treatment, it must therefore be simple and explained to the patient, both in its preventive action and also in its undesirable or secondary effects. The importance of dual care, medication and psychotherapeutic treatment, in a preventive approach, should be stressed, while emphasizing this fact, which raises questions: the risk of manic relapse after interruption of a lithium treatment would be significantly higher than the natural risk.
Lithium salts:
Presentation of the treatment:
Lithium remains the first choice treatment in the prevention of manic depressive disorders. All the published studies on the lithium treatment of bipolar disorders in adolescents concern small cohorts. The results are very variable, with a rate of favorable responses oscillating between 50% and 100%. The indication of lithium has widened towards the characteristic disorders and the aggressiveness, the attentional deficit disorder and hyperactivity; clinical overlap between these different diagnostic categories was highlighted.
There is no metabolite: the ion is directly the active molecule. When administered orally, lithium is rapidly resorbed at the jejunum. The plasma peak is reached in 3 to 4 hours. Bioavailability is total. The ion does not bind to plasma proteins and diffuses throughout the body. Not metabolized, elimination is essentially 90% renal; 10% is eliminated by other fluids in the body such as sweat and saliva, as well as faeces. The half-life of lithium is about 24 hours; the plateau of equilibrium in repeated administration is reached in 5 to 8 days.
The plasma level should be between 0.5 and 0.7 mEq / l. Below this rate, prevention is inefficient, in excess of 0.9 mEq / l for the most sensitive, and 1.2 mEq / l in general, the toxic dose is exceeded.
Side effects of lithium:
Lithium has several types of side effects.
Digestive disorders:
These are the most frequent, estimated at 30% of subjects treated with lithium. These include nausea and vomiting that occur during lithium peaks. These disorders are enhanced by the evening meal of a sustained release derivative.
They tend to fade spontaneously over time.
Neurological Disorders:
They are frequent, especially at the beginning of treatment. It is a fine tremor of the extremities linked also to the lithiémic peak.
Again, the prescription of a sustained release form, which cuts off the plasma peak, eliminates this undesirable effect.At the beginning of treatment, muscular fatigue may also appear, with somnolence, dizziness and headache, which disappear gradually in a few weeks.
Thyroid disorders:
They involve endocrine monitoring by regular measurement of serum hormone levels (decreased serum levels of T 3and T 4 , increased serum levels of thyroid stimulating hormone [TSH] and an exaggerated response of TSH to thyreo-releasing hormone [ TRH] hypothalamic).
Thus, 5 to 30% of long-term patients can develop biological hypothyroidism without clinical consequences. Clinical hypothyroidism is much rarer. These thyroid disorders appear after several months of treatment; they generally regress gradually, either spontaneously in a few months or in a few weeks when the treatment is discontinued.
Cardiovascular disorders:
They are represented by frequent and benign repolarization disorders, and rare but dramatic myocarditis.
Hematologic disorders:
Hematological disorders are sometimes observed: isolated increase in white blood cells. It is a benign and reversible granulocytosis mainly focused on the polymorphonuclear neutrophils, appearing in the first months and regressing totally in a few days when the treatment is stopped.
Kidney disorders:
They are of complex origins. We can distinguish a polyuropolydipsic syndrome, again frequent and benign, of spontaneously reversible but capricious evolution, which can either persist, disappear or reappear after long periods.To avoid dehydration, it is important to advise polyuric patients to drink low-calorie drinks with sodium intake. There have been very rare cases of irreversible renal damage with chronic renal failure, nephrotic syndrome or diabetes insipidus, although the precise mechanism of these disorders has not been identified.
Dermatological disorders:
Acneiform disorders may be aggravated when they exist after a certain period of treatment.
The incidence of these adverse effects should not be neglected in adolescents.
Toxic risks of lithium:
Chronic lithium poisoning has never been described in contrast to other heavier metals used in pharmacology.
Therefore only acute intoxication is to be prevented, especially since the toxic threshold of the product is very close to therapeutic threshold.
Poisoning, when not voluntary, is favored by certain iatrogenic factors, which are well known: hydrosodic depletion (water losses due to effort, fever, vomiting, diarrhea); a drug interaction (steroids, all non-steroidal anti-inflammatory drugs except salicylates, carbamazepine, diuretics, ACE inhibitors and especially in psychiatry neuroleptics: this association is to be monitored in the treatment of the condition acute maniac).
Start-up and monitoring of treatment:
The initiation of a lithium treatment requires a prior somatic assessment. In the kidney, a measure of proteinuria and renal clearance of creatinine should be used (contraindication if creatinine clearance <70 ml / min). This assessment must be supplemented by an ionogram, an ECG and a thyroid balance.
The teratogenic risk of lithium, which is very low but very real, risks malformation of the large vessels existing especially during the first trimester of pregnancy, imposes precautions for use in the pubescent girl (pregnancy test) and may require the addition of a ” a hormonal contraceptive coverage.
The dosage form exists either in the form of drinkable ampoules or in the form of tablets which have the advantage for some of them of allowing a sustained release form. This sustained-release form should be preferred in children and adolescents because it minimizes side effects in this population that is much more sensitive to lithium than adults.
The dosage should be gradual, distributed throughout the day to limit the plasma peaks, with lithium monitoring to be done in the morning on an empty stomach before any medicinal intake (ie 12 hours after the last evening dose). If a sustained-release tablet is taken, lithium monitoring should be done 24 hours after the last dose, or here a ves- sic control given the particular pharmacokinetics of the product. From weekly to early, lithium control should be weekly in the first month of treatment and gradually become monthly and quarterly as soon as the balance is reached.
Efficiency of lithium:
Although several studies have demonstrated the effectiveness of lithium in preventing relapses (70% of cases in adults), the most recent data are much more nuanced.
Two-thirds of the observed relapses were due to inadequate lithium dosages.
Antipsychotics:
General characteristics:
Already evoked in the management of melancholic episodes and manic episodes, the new antipsychotic molecules have a proven preventive efficacy in bipolar disorders.
The antipsychotic and normothymic association increases the effectiveness of prevention. The risk of weight gain with antipsychotics is greatly increased.
Anticonvulsants: valproic acid and its derivatives, valpromide, divalproate:
In France, only valpromide has AMM in the indication of the prevention of manic-depressive disorders, while the Anglo-Saxons preferentially prescribe valproate. The prescription of divalproate in the manic states naturally pushed to maintain it in normothymic terms although paradoxically, the molecule did not receive precise indication as a preventive measure. In fact, the valproid is transformed into valproate from the first hepatic passage, and these products are pharmacologically very close. Their mode of action seems especially GABAergique by reinforcement of the presynaptic turnover.
Again, comparative studies with respect to lithium are few. Valpromide has definite efficacy in the prevention of manic depressive states, especially in the prevention of manic attacks; its only advantage over lithium is its better tolerance.Valpromide has the best indications for bipolar disorder with rapid cycling. Valproate is interesting in the treatment of mania. The coexistence of depressive elements during the acute manic episode could be a predictor of good response of the manic state to valproate.
The usual dosage for prophylaxis varies between 600 and 1500 mg / d to be reached in 300 mg increments. The recommended starting dose is 15 mg / kg / d; during blood tests, valproate with a longer half-life is dosed; the effective plasma level is between 50 and 125 μg / ml.
Precautions for use are linked to the potentiating effect of valpromide on other products (alcohol, psychotropic drugs).
In this case too, pregnancies are discouraged and it is preferable to associate a contraceptive treatment because of the risks of malformation of the neural crest of the fetus; but the occurrence of a pregnancy does not require cessation of normothymic treatment if supplementation with folate is instituted.
There have also been reports of induced pancreatic disorders, as well as, in women, endocrine disorders of the hyperandrogenism type with polycystic ovarian disease.
In open studies in adolescents with refractory bipolar disorders, the combination of divalproate with lamotrigine was used with 72% favorable responses; dermatological side effects such as skin rash have been reported.
Carbamazepine:
Compared to lithium, the efficacy of carbamazepine does not appear to be superior, nor is it compared to valproic acid derivatives. No satisfactory study on the methodological level could establish that it was the same in its general indications. Carbamazepine has also been proposed in bipolar disorders resistant to lithium.
Open-label studies of carbamazepine in the prevention of relapse of bipolar disorder in adolescents highlight the interest of this product in adolescent tolerance and hence in its adherence. Others insist on the numerous digestive side effects and insist on the risks of liver and spinal toxicity.
In practice, the effective dosage is between 400 and 800 mg / d. Serum levels should be obtained in the range of 20 to 40 mmol / l, ie 5 to 10 mg / l; let us add that the maintenance of the plateau of the serum level is facilitated by the existence of a galenic form with sustained release and by a twice-daily drug intake. Surveillance is essentially biological, with a hemogram (platelets) and an assay of liver enzymes due to the risk of cytolysis.
In the adolescent, the contraceptive problem is complicated by the decrease in the contraceptive activity of estrogen-progestogen hormones by increased hepatic catabolism initiated by carbamazepine, which should make preferable mechanical methods, constraining and sometimes less reliable.
Start-up and monitoring of treatment in adolescents:
Moment of prescription:
When is preventive treatment required? Insofar as normothymics are involved in the curative treatment of manic or melancholic attacks, they may be prescribed from the start of access. This is the case for lithium, which is both an antimaniaque, associated or not with neuroleptics, and an adjuvant of the tricyclic antidepressant treatment of the melancholic episode.
Although mood stabilizing therapy has not been initiated during seizures, it is now recommended that it be introduced as early as the first manic episode, which is a sign of bipolar disorder, and as early as the second severe episode of depression, which reveals most likely but not a manic-depressive disorder.
Product selection:
Unless otherwise indicated, it is permissible to have recourse to the most effective normothymic, namely lithium.Environmental factors (social stability, parental guidance) have a decisive influence on adherence to lithium therapy, which is particularly restrictive because of the monitoring of the serum level it imposes and the side or undesirable effects it causes .
Secondly, the choice relates to anticonvulsant products which have a good thymoregulatory quality, with considerably less employment than lithium.
In the absence of lithium and antiepileptics, or in case of resistance to one of these products (relapses or partial remissions), the prescriber can choose one of the two antipsychotic molecules available in France: risperidone or olanzapine.
Duration of treatment :
It is permissible to continue chemoprophylaxis as long as there is a vulnerability; so many authors agree on the need to pass the critical course of adolescence under the influence of a well-conducted treatment. The decision whether or not to continue mood stabilization in adulthood is based on the evolutionary profile of the disorder, family history, and emotional and social environment. The possibility of considering therapeutic windows in young adults under conditions of psychological stability appears to us fundamental in order to avoid the feeling of biological control.
In the case of lithium, discontinuation of lithiotherapy in patients responding to this treatment may induce secondary resistance in 20% of cases. Long-acting carbamazepine has been described for exhaust effects with loss of mood stabilizing activity. In either case, it remains difficult to assess the exact pharmacological significance of these findings, since in many cases, therapeutic adherence is difficult to maintain after several years.
Information for the patient and his / her family:
The information of the patient and his family must be an important time for the introduction of normothymic treatment.It is preferable to carry it out in several stages, and the best remains to be able to accomplish it during the time of hospitalization when this treatment is given on the immediate turn of the access.
Information on surveillance and specific side effects should be carefully addressed in order to limit their incidence. The typical example is cravings and weight gain: lithium is sometimes responsible for a weight gain which is the first cause of untimely cessation of treatment. Mechanisms evoked as functional hypothyroidism, insulin-like effect or polyuropolydipsic syndrome are not always sufficient to explain this weight gain which reaches 30% to 50% of patients. Hunger is a frequent complaint with a painful hunger, there is less satiety, a desire to eat more, a carbohydrate-oriented diet preference, an objective increase in the consumption of drinks. It is therefore important to inform the adolescent about these adverse effects, to advise him or her on the dietary plan and to invite him / her to give in to the cravings before the feeling of hunger causes a large and uncontrolled food intake.
Schooling and learning are not disturbed by well-accepted and well-conducted normothymic treatment.
Sexuality and contraception, on the other hand, require treatment-related constraints to be addressed. The adolescent must be informed that she can have a sexuality subject to contraception in order to prevent an undesirable pregnancy which would require the discontinuation of thymoregulatory therapy even if the teratogenic risk is limited (1% of pregnancies exposed in the first trimester ).
Psychotherapy:
Manic-depressive illness, perhaps more than any other condition, requires a double treatment of chemotherapy and psychotherapy; not only because of the closely related biological and psychological vulnerabilities (notion of lived heredity) that we have mentioned, but also because of the awareness of the disease mentioned by RM Post.
The biological and psychological balance changes at each episode (transduction phenomenon, unconscious resonance and reorganization of the personality around the repetitive mood disorder), favoring relapses, more “easy”, less linked to stressful life events or triggered by more mundane factors, and altering sensitivity to treatment.
The indication of individual psychotherapy will be asked at the end of acute access. It appears very quickly, in the acute phase of a melancholic or manic episode, that a psychotherapeutic approach has little control over a rigid system of thought at the origin of which one perceives a psychic suffering totally invasive. The symptomatic improvement obtained, then discusses the desirability of a psychotherapy.
The identification of conflicts of identification seems desirable, especially since they are the source of the depressive vulnerability which predisposes to relapses and which does not respond to antidepressant chemotherapy.
Here, then, is emphasized the prophylactic effect of psychotherapy.
The isolated prescription of a mood stabilizer will not prevent ruptures in narcissistic wounds, whereas isolated psychotherapy may have little control over the rigidity of the system of melancholic thought or a permanent background of hypomania.
Work on the environment:
When dealing with a depressed adolescent, to achieve a genuine parental mobilization to ensure intrafamilial support for the adolescent, the therapeutic objective must be at the outset. If structured family therapy is not feasible, the need for regular consultations with parents to create the conditions for therapeutic co-operation to provide assistance to parents is equally necessary.
The contribution of family care in the therapy of bipolar disorders, where the indifferentiation of the various characters constantly observed is a point of vulnerability as regards evolution, is important, but also source of major difficulties that make its practice delicate. The therapeutic system will quickly stick to the image of the family system: the processes of separation, that is, differentiation and individuation, as they can be expressed in disagreements and conflicts, are extremely difficult to implement because these processes represent a vital risk; any conflictualization can lead to death by the impossibility of reacting and turning aggressiveness against oneself or by destroying the other through overflowing of excitement and aggression. Disagreements are experienced as losses of the love of the other;the emotional impact is extreme, the sensitivity extreme, and the therapist, taken in this relational style, advances very cautiously, avoiding being intrusive and remaining, like the family, often glued to the symptoms, daily, concrete, shelter from dangerous affects.
The vulnerability of the family balance, underpinned by a problem of undifferentiation, has an important role in triggering access and relapse on fragile patients. One of the essential aspects of family therapy is to grasp this subject-object indifferentiation and to evaluate its role in the representation that the subject of the object can make.
To cure adolescent depression is necessarily accompanied by an evolution of the subject’s parental representation, which is not parallel to family development: “I preferred when he was depressed rather than excited and aggressive” a parental sentence, often heard when a depressed person leaves a depressive state, suffering from manic-depressive psychosis, especially as improvement is often accompanied by a transient moment of aggressive manic overexcitation of the parents .
The involvement of parents in therapy promotes differentiation and reinforces the primary processes of empowermentindividuation, as it allows us to address the weight of conformity to parental wishes (in their transgenerational dimension) and the fantasmatic experiences of everyone around the process of separation-individuation. Above all, it makes it possible to work to support for parents the symptomatic improvement of their adolescent, which awakens a buried family problem. The latter is likely, if not concomitantly developed, to favor the decompensation of another member of the family and to generate contradictions contributing to the relapse of the adolescent. However, family therapy does not always succeed in disentangling the family from a masochistic equilibrium, probably because it is vital for one of the members (risk of acute decompensation).
Attention must also be directed to other aspects of the external reality of the adolescent: habitation, comrades and above all educational and professional integration. One must be vigilant and ensure that its temporary decline is not endorsed by social consequences such as dismissal, redoubling, undesirable change of direction that would subsequently confirm it in the negative view of itself. Indeed, in these patients, particularly in the course of manic bouts resorbed by the treatment, the return to a state of inhibition which can accentuate the socioscular disintegration caused by the acute state. Hence a kind of urgency to restore a normal school curriculum, which can not wait for the psychotherapeutic effect and which, to be the object of great attention, requires close collaboration with social organizations. School and social reintegration has in itself a therapeutic effect, restoring the positive feeling that the adolescent can have on his own.
