Statistically significant findings in both studies for patients with bipolar illness with early childhood traumas (compared with those without) included: a greater number of subsequent manic or depressive episodes, faster cycling pattern, more suicide attempts, and an increased number of additional psychiatric and medical disorders, including a higher incidence of alcohol or substance abuse.
Figure 1illustrates findings in those with and without a history of physical abuse, although a similar range of poorer outcomes was found for sexual abuse.
Figure 1Patients with bipolar disease and history of physical abuse in childhood Show full caption View Large Image Download Hi-res imageWe were also able to assess a subset of 373 patients prospectively rated by clinicians during naturalistic treatment. These data confirmed the findings based on retrospective self-reports and indicated that those with childhood adversity had a greater amount of time depressed, more days of mood cycling within a 24-h period, and less time well than those without early trauma. Interestingly, the abused group also reported a greater incidence of negative life stressors before the onset of both the first episode of illness and the most recent affective episode, suggesting that early traumatic experiences predispose to an increased exposure to and accumulation of other negative stressful life events into adulthood. 3 3 , The nature of the association between childhood abuse and a more adverse course of bipolar illness deserves further clinical and theoretical attention. 4 Whilst disruptive or provocative behaviours in children (signifying already present early symptoms) could be associated with the elicitation of physical or sexual abuse, 4 it is far more likely that the long-lasting behavioural and neurobiological consequences of early traumatic life-events (as seen in animal studies of early maternal deprivation 3 ) have a more direct effect on early illness onset and a more adverse course of bipolar illness.The patients with childhood adversities had a significantly longer delay (an average of 13 years) from bipolar illness onset until they were first treated with drugs for mania or depression than the patients without early abuse, in whom the delay averaged 8 years ( 5 figure 2). Thus the very individuals who most need early and effective therapeutic intervention, given the current evidence of their relatively poor prognosis, were precisely the patients who had the longest duration of untreated bipolar illness. This long lag before treatment with psychotropic drugs might also contribute to the increased incidence of alcohol and substance abuse in these youngsters, in part as an attempt at self-medication. These data converge with those of Wilens and colleagues, 3 namely that those with adolescent onset bipolar illness are at particularly high risk for developing alcohol and other substance abuse disorders. PTSD can also be a risk factor for developing alcohol and drug abuse. 6 Figure 2Age of onset and delay to treatment Show full caption View Large Image Download Hi-res imageAlong with the rising awareness of the substantial incidence of childhood physical and sexual abuse in the USA and other North American countries, there is increasing recognition that bipolar disorder often starts in childhood or adolescence. Results from adults (average age about 40 years) with bipolar disorder in two large networks 7c 8 , indicate that childhood onset (before the age of 13) was common and represented 15–28% of patients with bipolar disorder. Together, childhood and adolescent onsets (before age 19 years) accounted for 50–66% of patients with bipolar disorder. 9 8 , Furthermore, other data suggest the increasing incidence and a decreased age of onset in bipolar disorder occurs via both a cohort (year of birth) and an anticipation (generational) effect. 9 Most distressingly, we have found that the lag between onset of bipolar illness and first treatment is significantly longer in youngsters than adults, as also reported by Kessler and colleagues. 10 The paediatric and general medical community should have a heightened awareness of the possibility that bipolar disorder can occur before age 13 years and may not only be associated with a greater genetic vulnerability (ie, a family history of bipolar illness and substance abuse), but also with environmental stressors. Even in the youngest children, extreme irritability, affective lability (including brief periods of elation), decreased need for sleep, and the severity of impairment might begin to separate youngsters with bipolar disorder from those with attention-deficit hyperactivity disorder. 11 12 , Later distinguishing characteristics might also include suicidal or homicidal thoughts; delusions; hallucinations; and precocious sexual interests and acts. 13 14 , Careful differentiation of the two disorders is important, because the first line of therapy differs markedly. Stimulant medications are the treatment of choice for attention-deficit hyperactivity disorder, whilst mood stabilisers or atypical antipsychotics have the greatest effectiveness for childhood-onset bipolar disorder. In the bipolar group, treatment of comorbid attention-deficit hyperactivity disorder should be undertaken only after the primary manic-depressive symptoms have been controlled, as outlined by Kowatch and colleagues. 15 The outpatients in our study 15 and those studied by Kessler and colleagues 3 report that they were experiencing the most extreme delays in receiving an appropriate diagnosis and treatment when their bipolar symptoms started during childhood or adolescence. Further, those with PTSD 11 and childhood onsets of bipolar disorder were disproportionately represented by those with a history of physical or sexual abuse. Starting treatment in a more timely manner, and paying greater attention to the possible contributing role of early traumatic events, might help ameliorate the adverse course of bipolar disorder and may have an additional benefit of helping prevent the development of secondary psychopathology and substance abuse.We declare that we have no conflict of interest. 1
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