Abstract
We describe one family, typical of several we have treated, where parenting failure was the presenting feature of maternal bipolar affective disorder (BPAD). The mother, father and three children were admitted to the Cassel Hospital Family Unit, a UK specialist service admitting highly troubled families [1]. The children were on child protection registers for neglect and physical abuse and subject to legal care orders. The mother was sometimes violent, had stabbed the father, had a history of self-harm, and recurrent depression. She had difficulty providing consistent parenting. The father would take over, causing marital disputes. Due to the mother's violence against the father the children were temporarily fostered. Eventually she hit one of the children severely. Numerous assessments followed and she received various diagnoses, including personality disorder, depression, OCD. No intervention worked.
At the Cassel the children responded to therapy. The mother disclosed a history of childhood physical abuse. The couple struggled to provide consistent parenting. She often went off, appearing unconcerned about the children's welfare. As she became increasingly quarrelsome, the couple could not agree on parenting and the children became increasingly anxious. When she was sent on short leave, the children remained with their father. Her mental health problem could then be distinguished from the general family disorder. Treating her low mood with fluoxetine caused increased agitation, suggesting BPAD.
Taking sodium valproate she reported feeling calmer, more organised in her mind, able to think before speaking, less frantic and driven, and enjoyed being a mother more. In groups she was thoughtful and responsive to criticism. Cooperation with her husband improved. The children became calmer.
Differentiating maternal BPAD from borderline personality disorder (BPD) in traumatised families is complicated. These families show considerable disturbance; marital discord, parental trauma, disturbance in the children. These mothers have longstanding parenting difficulties, aggressive outbursts, depression, volatile relationships. They receive diagnoses of BPD and/or depression. Long-term child protection interventions increase anxiety. Treatment with antidepressants leads to increased agitation or irritability. Detailed observations of these mothers over weeks, reveals sustained irritability, impulsivity and impulsive aggression, rather than reactive personality disturbance typical of BPD alone.
The relationship between BPD and BPAD is complex [2]. Affective instability, irritability and impulsivity feature in both, as do unstable relationships and substance misuse. Reduced sleep in BPAD resembles insomnia in BPD. Impulsivity characterizes both and is additive [3]. Co-morbidity is common and under-diagnosed. Most manic or hypomanic episodes are mixed, containing both symptoms of mania or hypomania, and depression, especially in women [4]. Patients seldom complain of hypomania, leading to delay in diagnosis. Antidepressant monotherapy for depressed mood may precipitate mania or hypomania in BPAD. Treatment with mood-stabilising medication is effective in reducing anger, irritability, impulsivity and aggression in women with comorbid BPD and BPAD. The differential diagnosis of mood elevation can be a major challenge and requires extended assessment with close attention to personal, family and treatment history, with collateral history from family members. Time-limited and cross-sectional assessments may mislead [5].