Bipolar Disorder and Cerebellar Degeneration

[Barbara Steinberg]

About 9 months ago, my partner James who is low-functioning bipolar, had a change in the way he reacted to the medications he had been stabilized on for 5 years. They didn't work anymore.

At first I only saw the killer rage. Then, after he walked in and announced he had kidney disease and blood cancer, and no evidence would convince him otherwise, I realized that hypochondria had transmogrified into somatic delusions. 30 mg of Abilify daily was added to his regimen, and it worked. He was stabilized again.

He decided to start up his ebay button store again. In doing so, everything was foreign to him. The software had changed. His cognitive ability to figure out how to fill out an ebay form and do simple html was gone. What was once only dyslexia had become a more serious disability, which is called cerebellar degeneration in scientific studies. (As an aside, I went into the ebay store as him and fixed everything and spent days teaching him how to do things again. He learned very slowly, but he learned.)

A study in Neuropsychiatry Review found something significant. "Perhaps the most remarkable finding from these detailed evaluations was that 21 of the cerebellar degeneration patients (68%) met criteria for a mood disorder, including 11 (35%) with major depression and 10 (32%) with either dysthymia or a brief depressive episode."

In "Bipolar Disorders, An International Journal of Psychiatry and Neuroscience, images noted "abnormalities in the third ventricle, frontal lobe, cerebellum, and possibly the temporal lobe."

Cognitive development in bipolar disorder is understandably focused on children, so they could be spared this kind of suffering in later life. However, it seems there is a link between the worsening of all symptoms as the bipolar patient gets older. Cerebellar degeneration travels on the same bus with everyone else.

The ultimate question scientists don't know yet, is can the degeneration be drastically reduced in an older patient, if bipolar disorder is diagnosed and treated correctly in childhood?

References:
http://www.neuropsychiatryreviews.com/apr01/npr_apr01_cerebellar.html
http://www.blackwell-synergy.com/doi/abs/10.1034/j.1399-5618.2002.01157.x

[Jolyn]

Barbara, we still have a long way to go in understanding cerebellar degeneration and regeneration among people with mood disorders. We're just as much in the dark about the effects of early childhood intervention -- such as they are -- on later degeneration.

Evidence on the effects of early intervention is currently not attainable. Right now, we're limited to looking at children who show symptoms, are diagnosed correctly and medicated. Medication treatment of bipolar children is a fairly recent phenomena. See this article that sums up the state of early intervention with kids.

We aren't even sure for whom, among people with mood disorders, a course of degeneration occurs. There are several reasons for this lack of knowledge, some outlined in this article. On the other hand, a study found that responders to medication -- participants whose depression lifted -- improved cognitive functioning.

I've worked with many people, in a rehabilitative capacity, who have bipolar and other mood disorders for whom their doctors, including neurologists, insisted that there was little hope of improved functioning. In every case, they were mistaken. It always amazed me that in a supportive, active, optimistic, learning environment, just how much improvement occurred.

To sum up, we really know very little about cerebellar degeneration in people with mood disorders. We do know that:

Stabilization on medication, especially if it relieves depression, helps most people recover cognitively;

Avoidance of relapse prevents degeneration, including loss of significant cognitive functioning;

Psychiatric rehabilitation approaches can help many people regain cognitive functioning and practical skills, as well as learning new skills; and

Some psychotherapies are helpful to these ends as well.

[Barbara Steinberg]

Jolyn,

I have read your comment very carefully, and all the articles you sited.

My experience is only with one patient, so thank you so much for responding to my blog post. In the first article you sited, this quote stood out at me:
"The consequences of untreated bipolar disorder in children are very significant. ... Early identification and treatment of the syndrome with psychosocial and psychopharmacologic interventions is advisable to normalize the developmental processes."

James was neglected and didn't have that benefit, and I feel in my heart that what he's suffering now can be avoided in others. Maybe this event I'm describing 9 months ago was a relapse, but James has been getting worse since childhood. He has seen himself decline from someone who worked as a plumber 10 hours a day to someone who rarely goes out of his safe house.

As I sat there with him separating the parts of the html that were the logo or whatever else he wanted, dealing with paypal and ebay customer service, fixing listings with misspellings, and re-teaching him, he learned again. The care and love are so much a part of this solution. They are the other side of the coin of science.

[Jolyn]

Thank you so much for responding, Barbara! Yes, love and care are so critical. It's easy to fall into hopelessness without these. We're just beginning to understand the brain's plasticity. I'm intrigued with the idea that optimism, patience, realistic challenges, caring and more can actually change the brain.

Mood disorders are such individualized and complex disorders. When people show symptoms as children, then the developmental process that we all must go through to become healthy adults is interrupted. Early bipolar, like early drug and alcohol abuse, parental abuse and neglect, interrupt childhood and adolescent development.

If abuse, neglect, other trauma or substance abuse exists (or existed) along with the mood disorder, our prognosis and effectiveness of medication intervention are often further compromised.

You probably know that most people with bipolar have their first episodes later in life. That's what makes Dr. Sebat's and other researchers' studies so exciting -- early childhood intervention, even before any disease process occurs! Rather than treating with medication -- which we may find also interferes with some aspects health over the long term -- we may be able to predict much sooner and correct through genetic treatment.

As it is, we just won't know until we have enough children treated for long enough that we can see the effects of it. All we know now is that helps many children with bipolar in the here and now.

Keep the good work, Barbara! You're an inspiration and are really making me think through these issues!

[Bob Brooks]

From what I’ve read, there are a wide variety of causes of cerebellar degeneration from genetic causes to drug side effect to alcohol to cerebral congenital malformations.

One item worth noting: The National Institute of Neurological Disorders and Stroke (NINDS) is funding research to find the genes involved in diseases that cause cerebellar degeneration.

They say that “discovering these genes, identifying their mutations, and understanding how the abnormal proteins they produce cause cerebellar degeneration, will eventually help scientists find ways to prevent, treat, and even cure the diseases that involve cerebellar degeneration.”

Read more at:
http://clinicaltrials.gov/search/term=Cerebellar%20Degeneration