Child Mental Health for Pediatric Clinicians

50. Am I Bipolar? with Dr. John Walkup

• Elise Fallucco • Episode 50

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Have you ever wondered if one of your patients has bipolar? On this episode, we talk about the red flags for bipolar - and questions you can ask to determine whether they may have bipolar. We discuss key signs such as the inability to regulate upside mood, decreased need for sleep, hypersexuality, and grandiosity, providing concrete examples and questions to help guide your clinical assessment. Join Dr. Elise Fallucco and Dr. John Walkup as they offer valuable insights into distinguishing bipolar disorder from other conditions like ADHD and anxiety.

00:00 50 - RED FLAGS for Bipolar w/ Dr. John Walkup

01:30 ***Not all MOOD SWINGS are bipolar***

02:10 RED FLAGS for BIPOLAR - Inability to regulate UPSIDE mood

02:28 Appetites for FUN and Mood

04:22 Energy Drive - Wake up ready to go

04:52 What Questions to Ask about SLEEP to see if they could have bipolar

06:03 Hypersexuality in KIDS presents as interest in romance

07:06 Grandiosity

Check out our website PsychEd4Peds.com for more resources.
Follow us on Instagram @psyched4peds

Dr. Elise Fallucco:

Welcome back to Child Mental Health for Pediatric Clinicians. I'm your host, Dr. Elise Falucco, child psychiatrist and mom. In honor of our 50th episode, we are tackling a really important topic. This is the question that many of us have encountered, and one of our listeners, Dr. Carolyn from Minnesota, had written in and said, So many of her patients go to Dr. Google and look up symptoms and then come to her saying, I think I have bipolar. How can we help families determine what is and what is not bipolar? Here to help us with this topic is one of my favorite podcast guests and colleagues, the internationally known child and adolescent psychiatrist, Dr. John Walkup.

Dr. John Walkup:

Hi, Elise. It's so good to be with you.

Dr. Elise Fallucco:

I can't go through your whole bio because that's a whole podcast. But suffice it to say, you are a frequent flyer. You should be in the rewards program, I think.

Dr. John Walkup:

Yes, exactly. It's so much fun that, we get to talk about things here that we never talk about anyplace else. And I think that's probably why your listeners like it, because it's it's on the ground. It's real. And it's it's about how doctors really think about stuff.

Dr. Elise Fallucco:

Yes. So let's go ahead and dive in. The most common thing I've heard from patients is sometimes I feel really angry or upset and then other times I'm fine or super happy. And so I think I have bipolar.

Dr. John Walkup:

yeah. There's also the, just the kind of confusion about bipolar because we use things like mood swings. And as soon as somebody has a mood that swings, all of a sudden they think they may have bipolar disorder where ADHD has mood swings, anxiety has mood swings, depression has mood swings, life has mood swings. Mood, moods are supposed to swing a little bit. It's where they swing to that kind of defines people who are in that bipolar world.

Dr. Elise Fallucco:

So to help us tease out which kids are in this bipolar world, can you share some red flags or clinical symptoms that would make you worry about possible bipolar in a child?

Dr. John Walkup:

so what I'm really looking for is inability to regulate upside mood, which is a different way of talking about expansive elevated mood.

Dr. Elise Fallucco:

Could you share like a clinical example of somebody who's unable to regulate upside mood?

Dr. John Walkup:

When I think about upside mood, I think a lot about appetites. Appetites for fun, appetites for pleasure, appetites for food. In teenagers, it's appetite for street drugs. It's appetite for risk. So when you're seeing kids who have lots of appetites I think about bipolar disorder. And and that's that upside mood thing, because we all feel, we all get engaged when we're happy, we want to do more, we want to live life, we can, feeling freed up, these folks feel that way all the time and they go gobble it up. That, that kind of intensity is what I'm looking for when I'm thinking about classic bipolar, particularly bipolar that isn't obviously diagnosable.

Dr. Elise Fallucco:

something that I like to anchor my history taking on in trying to sort out bipolar has to do with decreased need for sleep. Cause that sometimes can be more concrete or easier to figure out. In theory, our kids with bipolar can stay up all night or just need two or three hours of sleep or, just a couple hours of sleep. And can still be fine the next day and can keep doing that kind of day in and day out for at least five days, sometimes even longer. How do you go about teasing decreased need for sleep?

Dr. John Walkup:

Yeah. some of these kids that come to care have been diagnosed with ADHD and impulsive aggression, like DMDD diagnoses. And so they're sleeping fine because they're on a dose of, Abilify seven and a half at bedtime, right? So you you always have to ask, what's their sleep? Oh, they sleep fine. Oh, yeah. How about before? If they're not on the Abilify putting them to sleep at night. The other thing that, I'm aware of is that people with bipolar disorder wake up instantly, which is a different deal. I don't know if you remember doing rounds in training and you walk into the room of a patient with bipolar disorder, they're like, They're ready to go. They don't do that kind of, Oh,

Dr. Elise Fallucco:

Stretch your arms.

Dr. John Walkup:

yeah, they don't do that. They are like bang and ready to go. They are full on within a minute of within a second of waking up. It's that energy drive that's different than hyperactivity that you see in ADHD. And again, it's a qualitative difference that the clinician needs to get a feel for.

Dr. Elise Fallucco:

Back to the sleep How do you approach asking kids and families about decreased need for sleep if they're not already on a sleep aid?

Dr. John Walkup:

Yeah it's how much sleep do they need to be rested and ready to go. And some of these kids will sleep five hours, but they're up earlier and they're raring to go almost instantaneously. It's a different kind of falling asleep ritual. Then what with kids with ADHD, where sometimes they're so hyperactive at bedtime, it's just difficult to even lay down these kids are more engaged in mental activity or in their appetites, the things they want to do they're gobbling up experiences till 11, 12, 1 o'clock, then they'll sleep, then they'll wake up early. They won't look tired during the day that's different than the anxious kid who has trouble falling asleep and then wakes up tired or exhausted. Yeah

Dr. Elise Fallucco:

That's really helpful. So to recap, we've talked about some red flags or cardinal symptoms of bipolar. One being their mood, trouble regulating upside mood with a big appetite for fun. Number two, having to do with sleep, decreased need for sleep and waking up instantly with tons of energy. A third red flag for bipolar is hypersexuality. Can you talk about what that looks like in kids?

Dr. John Walkup:

They're a little bit more preoccupied with sexual behavior than most kids are in the prepubertal group that's sometimes, scatologic humor. Hyper reactivity of those things they see on television. So people who are kissing or having some kind of romantic thing, they get overstimulated by that when they see that on television. They're not hypersexual per se, but sexual matters are exciting to them. It's that appetite thing. And you'll see that in kids and families will talk about, Boy, you just can't have a romantic kind of show on the television around this kid because all of a sudden he gets triggered by it.

Dr. Elise Fallucco:

and you said scatologic humor? Did you mean talking about poop?

Dr. John Walkup:

I did. I did. Pee and poop and people pooping and, making noises and, they just love that stuff because it's offensive. It's funny. All kids get, have fun with that. Yeah. Yeah. Yeah. But It's just, again, a qualitatively different feel for their investment in these kinds of jokes and humor, body functions and stuff. And then let's talk a little bit about the grandiosity, like maybe some examples from clinical cases of, what do we mean when we say grandiosity? It's very specific to who the kid is and what they're triggered by. But it's a, it's an expansiveness, not just happiness, right? It's a bigger than life kind of picture or look. the silliest one is I want to be Superman. Every eight year old, I've ever met wants to be Superman. And so what I tell families is, if they say that's fine, but what's the engine that's driving it? And then is it that, that, that energy surge that's really driving that? And is there some kind of loss of grounding when they talk about Superman almost as if they could be Superman. Some of these kids they love to argue. That's the other thing. And families will think about them as a future lawyer. But they'll argue with teachers. They're arguing with principals. They'll have ways of running the classroom.

Dr. Elise Fallucco:

So some of the obvious red flags for bipolar, we would say would be An inability to regulate their upside mood. So being very expansive, euphoric for an extended period of time or with a high degree of intensity that we wouldn't expect, sometimes that's accompanied by elaborate thinking and kind of grandiosity. Intense focus on whatever their goal activity is, whether it's painting or writing

Dr. John Walkup:

In adults, it's gambling. It's pornography. It's buying things, selling things, it's that kind of stuff. And you just have to walk it back developmentally to see what those things would look like in, in in kids

Dr. Elise Fallucco:

It's yeah, increased focus with pleasurable activities And sometimes that's drugs. Sometimes that's risk taking behavior. Sometimes that's You know, hyper sexual behavior

Dr. John Walkup:

yeah, the other thing is I've never met one of these kids who's happy. Yeah. To be honest. And so I think sometimes people make the mistake to think about grandiosity and euphoria as happiness. These kids are miserable. And the reason they're miserable is that nobody likes them. They're not functioning well.

Dr. Elise Fallucco:

Nobody

Dr. John Walkup:

appreciates the kind of drive for their appetites and supports their drive for those appetites. So they always feel like the world is frustrating them. And that's not depression. That's really just the kind of demoralization that comes from Being afflicted with inability to regulate their appetites in a way and the world just is not going to support them. Most of us are pretty boring and these kids don't want to be boring for one minute of the day. And when we frustrate them and expect that they do boring things like get up and get dressed and go to school and function. In routine kind of family activities and stuff when we put those expectations on them, they get frustrated by them, and they become unhappy because they're misunderstood and their appetites are not facilitated.

Dr. Elise Fallucco:

So

Dr. John Walkup:

you sometimes see this. It's a mixed picture of pressure and intensity, but really great unhappiness because nobody gets them. Nobody understands them. And people are getting frustrated and unhappy with them. I don't call that a mixed episode, but you do see this kind of mixture between grandiosity and misery.

Dr. Elise Fallucco:

It's almost as if they need so much to hit their pleasure center. It's not just Oh, somebody told a great joke. That's funny. I'm in a great mood. Like they've got to go to the extreme and it's, more excessive drug use, excessive sexual activity, whatever the thing is that gives them pleasure. They need it at a much higher level. Then, and nobody's,

Dr. John Walkup:

nobody's going to support that.

Dr. Elise Fallucco:

No, and that's got to be so frustrating. It makes me think we should have so much empathy for people who are going through all of this because they're really not truly, as you're saying, they're not really happy on the inside and they're, experiencing a lot of failure and frustration.

Dr. John Walkup:

And one of the things with good treatment is as they get better regulated in terms of their mood management, their relationships come back

Dr. Elise Fallucco:

So we've covered a lot of content, and I'm gonna break it down with some final tips. Basically, when your patient or their family, or you are concerned that you have a patient with bipolar, here are the questions you should ask. First, let's ask about sleep. Are they having trouble falling asleep at night because they're so involved with doing exciting, enjoyable things? Do they only need a few hours of sleep and can wake up instantly ready to go with plenty of energy throughout the day? The next questions have to do with their mood. When their mood is up, do they get so excited that they chase more and more pleasure, whether it's drugs or food or whatever it is? Are they so consumed with gobbling up pleasurable experiences that it's hard for them to return to a regular mood state? And finally about grandiosity. Do they truly believe that they're better, smarter, stronger, wiser than everybody else, that they could get up and teach the class and then get frustrated?'cause nobody understands them. These would be the questions to think about when you're wondering if somebody could have bipolar, and if you're driving around or walking around or don't have time to write these questions down, don't worry. We've got you. Check out our website at psyched for peds. That's P-S-Y-C-H-E-D, the number four peds. dot

com

Dr. Elise Fallucco:

Where we'll have a list of these questions to ask when you're concerned about bipolar. And of course, regardless if you have a hunch that something's not right, that symptoms are not quite fitting into A DHD or anxiety or whatever, please consult your child's psychiatry friend or your state's hotline, and we hope you'll tune in next week. Where we will continue the conversation with Dr. Walkup about gray cases that could be bipolar. Thanks again for listening. See you next week.