The past few months have gone by in a whirlwind as we've sought to bring the subject of early-onset bipolar disorder to the public's attention through all the publicity for The Bipolar Child. In May,The Bipolar Child received a NAMI Ken Award which are given annually to "outstanding books which have substantially contributed to the public's awareness and better understanding of mental illness as a neurobiological brain disease." It was an honor to be recipients of this prestigious award and we both made rather political acceptance speeches in front of the Surgeon General (who was also an awardee for his landmark study, Mental Health: A Report of the Surgeon General). We told the audience what it is like for families who can't get a doctor to diagnose an illness that they and their children are struggling to withstand, how medications such as antidepressants and even stimulants can hurt these children when the illness is misdiagnosed, and how the DSM-IV does not reflect the true condition as it presents in childhood. Dr. David Satcher, the Surgeon General, took notes throughout Demitri's speech.
Also in May, Dr. Steven Hyman, the director of the National Institute of Mental Health issued an alert to family practitioners warning them about the use of antidepressants for children with depression who may have a bipolar disorder. "While it can be hard to determine which young patients will become manic," he wrote, " there is a greater likelihood among children who have a family history of bipolar disorder. Family practitoners should be aware of the signs and symptoms of mania so that they can educate families on how to recognize them immediately."
We consider this great progress and we hope this alert will deter the misdiagnosis and mistreatment of many children.
Certainly a groundswell is developing. The Child and Adolescent Bipolar Foundation continues to welcome over 2,000 visitors a day and now has 15 online support groups. Give yourself a great gift and go over to www.bpkids.org and become a part of this caring and dynamic community. With your help, changes can come for our children and grandchildren and there's not a moment to spare.
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This month, we'd like to focus on a symptom that is little understood or discussed but with which many children with bipolar disorder suffer: night terrors.
A significant number of parents in our study reported their children wakening in the night with blood curdling screams. One mother wrote to us recently and described her toddler's sleeping hours thus: "My son gets up many times throughout the night, crying, screaming, and thrashing his body. Sometimes his eyes are closed and you can't wake him due to a hypnotic-like state he seems to be in."
We have heard this story time and again in our discussions with parents because bipolar children appear to have these frequent and recurrent parasomnias.
What are parasomnias? They are a fairly well characterized group of night-time arousal disorders such as night terrors, sleep walking, confusional arousals, restless leg syndrome, bed wetting (enuresis), and teeth grinding (bruxism). For the purposes of this newsletter we will focus only on night terrors (pavor nocturnis).
When a child is experiencing a night terror and actually remembers it, he or she later reports dreams that are extremely threatening. The content has to do with some predatory person or animal chasing them, or terrible fears of abandonment such as their parents being killed. Some adults who suffer them and seem to have greater recall speak of ceilings and walls pushing down on them, and others report snakes and spiders slithering and crawling all over the bed or room.
Since other features of bipolar disorder indicate that these children have very low thresholds for arousal (they are easily provoked to anger, easily excited, they have low thresholds for anxiety and are easily overstimulated by external and internal stimuli), it is not surprising that they experience these physiological states of over arousal during sleep.
In fact, in a study of the relationship between parasomnias and psychiatric illness in a very large sample of adults, Dr. Maurice Ohayon and his colleagues at the Phillipe Pinel Research Center in Montreal reported a strong association between the adults who experienced night terrors and those diagnosed with bipolar disorders and depression co-morbid with anxiety.
In order to discuss night terrors, we need to explain the architecture of sleep and the way night terrors differ from nightmares, for night terrors are not happening during the dreaming sector of sleep--the rapid-eye movement (REM) sector--but apparently in the deepest stage of non-REM sleep, or in some transitory state in between.
The Typical Architecture of Sleep
Normally throughout the night a person experiences two kinds of sleep that alternate rhythmically. One is called rapid eye movement (REM) sleep, during which most dreaming takes place; the other (not surprisingly) is called non-REM.
As we wrote in Overcoming Depression, 3rd edition:
Non-REM sleep has a four-stage development plan as revealed by electroencephalogram (EEG) sleep studies. Stage 1 is the light sleep that begins the night and from which a sleeper may be easily awakened. The brain waves are small and fast. After about a half an hour, the sleeper slips deeper into sleep as Stages 2, 3, and 4 of non-REM sleep progress. EEGS of Stage 3 reveal larger and slower brain waves. Stage 4 brain waves are large, slow, and regular. This is the deepest period of sleep.
After approximately 90 minutes have passed, a brief period of REM sleep appears (the eyeballs can be observed moving rapidly beneath the eyelids), only to be followed by one of the non-REM stages. A pattern develops in which the REM and non-REM sleep phases alternate with each other, cycling back and forth in a remarkably periodic ebb and flow. Later on in the night, REM sleep asserts itself for longer periods of time. Apparently the sleep cycle oscillates on a 90-minute time frame. The first 90-minute cycle might consist of 85 minutes of non-REM sleep and 5 minutes of REM; by the time the fourth cycle rolls around, it might consist of 60 minutes of non-REM and 30 minutes of REM."
But all is not always so regular. As Drs. Mark W. Mahowald and Carlos H. Schenck of the Minnesota Regional Sleep Disorders Center at the University of Minnesota Medical School have written:
"The rapid oscillation of states or the inappropriate intrusion of elements of one state into another may result in the appearance of parasomnias, which are particularly apt to occur during the transition periods from one state to another. Given the large number of neural networks, neurotransmitters, and other state-determining substances that must be recruited synchronously, and given the frequent transition among the three states of being, it is surprising that parasomnias do not occur more frequently."
Although people dream during the REM stage of sleep and can usually remember a nightmare or bad dream if it occurs at that time, a child or adult experiences a night terror commonly in stage 4 (and possibly 3) of the non-REM period. It has been supposed that the mind is void during the deeper stages of non-REM sleep, but this may not be true. A person having a night terror will moan, cry, scream and bolt upright in apparent terror. The heart beat can be as fast 160-170 beats per minute which is excessively fast. These rates are similar to those seen in severe panic attacks.
A night terror can last anywhere from 5-20 minutes and though the child's eyes may be open, he or she is still asleep and--typically--inconsolable. A parent should not yell at the child and startle him or her, but make reassuring and soothing sounds and make sure that no glass objects are anywhere near the bed area. Also, Halogen or hot lamps could be dangerous with a panicky child thrashing about, so keep the light low and away from the child's body and bedding. Take care to lock or blockade windows that are near the bed (but ensure that another window exit is available in the event of fire).
If you visit the Night Terrors Resource Center at www. night terrors.org, you can view a graph of the stages of sleep, and also read some first-person accounts of adults who have some recall of their night terrors. One sufferer reported "a blob pressing down on me;" another young woman tells of awakening to a horrible presence in the room, something that has to or wants to kill her. She also describes a meat hook swinging down at her from the ceiling.
Nightmares During REM Sleep
It may be the case that children with bipolar disorder are not only suffering night terrors, but also terribly disturbing nightmares during their REM stages of sleep. Over 10 years ago, Dr. Charles Popper of Harvard Medical School wrote one of the few discussions in the child psychiatric literature about these nightmares. In an article titled "On Diagnostic Gore in Child's Nightmares" he said:
As bipolar children talk about these dreams, they report the explicit appearance of blood (not just imagined or inferred, but actually visualized blood) and descriptions of mutilations of bodies, dismemberment, and the insides of body parts. Their dreams are considerably more affectively intense than regular nightmares.
Dreams of fighting are quite common. In the fighting dreams of children or adults with mere anxiety, a knife may be pulled out and brought into attack, but the dreamer wakes up just before the knife enters the skin or rips the clothing. For bipolar children, the knife goes in, the blood is seen, and the dream may continue at considerable length and with explicit visualization of gore...where the "newsreel" of a dream story normally stops, the "newsreel" in the bipolar children keeps going. ...In these individuals, it is as though their unconscious sensors of painful affect are not working, even in their dreams."
This may explain why children with bipolar disorder seem fixated on blood and knives and always seem under threat. Something is overaroused in the amygdala--the part of the brain that governs "fight or flight." While researchers such as Jonathan Winson, author of Brain and Psyche: The Biology of the Unconscious have suggested that REM sleep preparations were for the formulation of strategies for dealing with local predators--to rehearse and ready the system--this primitive survival mechanism is overstimulated in these children and, trapped in transitory states from one stage of sleep to another, they are suffering horribly.
This emotionally charged imagery of these night mares and parasomnias are spilling over to the conscious mind during the day. Is it any wonder that these children are so often in combative and irritable modes and that they are terrified of going to sleep at night?
We are concerned about the effects such parasomnias are having on the psychological development of these children. The rate and frequency of night terrors and nightmares and the nature of the highly disturbing content which seems referable to fight-or-flight mechanisms seems coupled with many of the behavioral problems these children have. Many of the behaviors are congruent with "fight": oppositional, defiant, argumentative, defensive, behaviors; while other behaviors are more consonant with "fright": anxious, fearful, withdrawn, and phobic. The disturbances in sleep may be contributing to the disturbances within the psyche, or reinforcing them on a nightly basis.
What would induce a more typical, less threatening sleep pattern? No one has studied this in youngsters, but practitioners suspect that a drug like clonazepam (Klonapin) may help because of its capacity to reduce Stage 4 sleep.
A Need for Research
Should any of you wish to email us at our web site (firstname.lastname@example.org), we'd be interested in any descriptive accounts of your child's night terrors, including age of onset, frequency, and how long after the onset of sleep they are occurring. Please notate whether your child suffers any other parasomnias such as restless leg syndrome, sleepwalking, bed wetting, etc. Because there may be some connection with the thermoregulatory system, please let us know if your child runs a low-normal body temperature, or is intolerant to heat or cold. Of course, if you noticed better sleep and less night-time arousals after the use of any medication, be sure to write us about that also.
It's important that sleep studies begin so that these disturbing night terrors and nightmares can be diminished or eliminated. The first step is connecting night terrors as a common symptom of early-onset bipolar disorder.
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We'll write again in the fall. Meantime, may your families' summer days and nights be balmy, and may the sleep of your children be restful and benign.
Janice Papolos and Demitri F. Papolos. M.D.
Anch, A.M., and Browman, C.P. et al. Sleep: A Scientific Perspective. New Jersey: Prentice-Hall, Inc., 1988.
Arkin, A.M. et al. The Mind in Sleep: Psychology and Parapsychology. New Jersey: Lawrence Earlbaum Associates, 1978.
Borbely, Alexander. Secrets of Sleep. New York, Basic Books, 1986.
Borzel, Nicolas L. "Nightmares and Night Terrors: The Horror Movies of the Mind." http://sawka.com/spiritwatch/borzel.htm.
Mahowald, Mark W., and Carlos H. Schenck. "Diagnosis and Management of Parasomnias." in Clinical Cornerstones (Sleep Disorders) vol.2 No. 5.
Ohayon M.M., P.L. Morselli et al. "Prevalence of Nightmares and Their Relationship to Psychopathology and Daytime Functioning in Insomnia Subjects." Sleep 20 (5):340-348.
Ohayon, M.M. et al. "Night Terrors, Sleep Walking, and Confusional Arousals in the General Population: Their Frequency and Relationship to Other Sleep and Mental Disorders." Journal of Clinical Psychiatry 60 (April 1999):268-276.
Papolos, Demitri F., and Janice Papolos. Overcoming Depression, 3rd. Edition, New York: HarperCollins, 1997.
Papolos, Demitri F. and Janice Papolos. The Bipolar Child. New York: Broadway Books, 1997.
Popper, Charles. "On Diagnostic Gore in Child's Nightmares." American Academy of Adolescent Psychiatry Newsletter (Spring 1990).
Winson, Jonathan. Brain and Psyche: The Biology of the Unconscious. Garden City, NY: Anchor Press, 1985.
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