Posttraumatic stress disorder and substance use disorder in adolescent bipolar disorder.

Post-traumatic stress disorder (PTSD) in children is an increasingly studied disorder associated with substantial distress and morbidity (Giaconia 1995). While Breslau et. al. reported that 40–76% of children had been exposed to a traumatic event by age 17 (Breslau 2006; Giaconia 1995), the estimated lifetime prevalence of the full syndromatic PTSD in the general population is between 1 and 14% (Khantzian 2003), and its prevalence in children is around 6% (Giaconia 1995). Both genders are equally likely to experience trauma, though females are more likely to experience sexual abuse, and females are six times as likely to develop PTSD (Giaconia 1995). Despite an increased awareness of PTSD in clinical child psychiatry, PTSD in children remains relatively underexamined. For example, children under the age of 15 years were not included in the DSM-IV field trials (Scheeringa 2006). Data also indicate that comorbid psychiatric disorders are common in PTSD (Giaconia 1995). Adolescents with alcohol dependence exhibited significantly higher rates of conduct disorder (CD), oppositional defiant disorder (ODD), attention deficit/hyperactivity disorder (ADHD), major depression, and PTSD than community controls without alcohol dependence (Clark 1997). Rates of alcohol and drug dependence, depression, and anxiety were substantially higher in youths who had a lifetime diagnosis of PTSD before age 18 compared to youths who had never experienced a trauma, and some what higher than youths who had experienced a trauma but did not develop PTSD (Giaconia 1995). Trauma and other adverse life events strongly correlate with alcohol use disorders (Clark 1997). Along the same line, pretrauma psychopathology remains a significant predictor of the development of PTSD in adults (Goldberg 2005). For instance, the existence of anxiety and mood disorders during childhood were associated with developing PTSD in relation to trauma. Among mood disorders in childhood, depression and bipolar disorder (BPD) are increasingly recognized as important clinical entities (Geller 2004). BPD is often comorbid with other psychiatric disorders, including ADHD, ODD, CD, anxiety disorders, and substance use disorders (SUD), and comorbidity varies with age (Geller 2004; Wozniak 1999). In addition, recent data suggest that juvenile BPD also significantly increases the risk of substance use disorder (SUD, including drug and alcohol abuse or dependence) (Wilens 1997). Recent work has begun to link PTSD and SUD in BPD adults. In relation to trauma history, Garno et al. (Garno 2005) reported higher risk for SUD, rapid cycling, and suicide attempts in individuals with BPD who had experienced severe childhood abuse. Those who had a history of severe childhood abuse had significantly younger age at onset of BPD, as well as more manic symptoms than those without trauma histories. However, little information is available regarding the interplay of BPD, SUD, and PTSD in adolescents. Given the increasing recognition of SUD in BPD youth(Wilens 1997) and indications that BPD youth may be at high risk for trauma and PTSD, the relationship of these disorders needs to be examined. To this end, as part of an ongoing controlled longitudinal family study of BPD youth, we examined the relationship of BPD, SUD, and PTSD. Based on the literature we hypothesized that there would be an increased rate of PTSD in children with BPD compared to controls, and, that SUD rates would be higher in the BPD sample with PTSD compared to those without PTSD. In an exploratory manner, we examined the temporal relationship between PTSD, BPD, and SUD. To our knowledge, this is the first prospective controlled study of BPD adolescents to examine this association.