Lecture 18: Bipolar Disorder In Youth

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2 Key Questions in pediatric bipolar

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1) Does bipolar disorder actually occur in children and adolescents?
2) If so, what does it look like?

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T or F pediatric bipolar shows similar manifestations of the same undelrying problem we see in adults

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F
*shows different manifestations

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mainc episode

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-distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary)
-three (or more) of the following (next flash) symptoms have persisted (four if the mood is only irritable) and present to a significant degree:

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symptoms of manic episode

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-inflated self-esteem or grandiosity
-decreased need for sleep
-more talkative than usual/pressure to keep talking
-flight of ideas or subjective experience that thoughts are racing
-distractibility
-increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
-excessive involvement in pleasureable activities that have a high potential for painful consequences (e.g., sexual behavior, shopping, gambling)

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Depressive Episode

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Meets criteria for a major depressive episode

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Hypomanic Episode

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Same as manic episode except:
-Lasting at least four days
-No marked deterioration in functioning

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diagnose bipolar 1 (4)

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-Manic episode lasting 7 days (unless hospitalization is required)
-May or may not show depression
-Specifier – with mixed features(have episodes not purely on one pole)
-experiencing episodes that include symptoms of both mania and depression

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diagnose bipolar 2

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-at least one major depressive episodes and at least one hypomanic episodes
-does not ever have a full manic episode (if they do then its 1)
-specifier – with mixed features

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diagnose cyclothymia

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-Period lasting at least 1 year when there numerous hypomanic and depressive symptoms that do not meet full criteria for either a manic episode, mixed episode, or major depressive episode

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Between 1990 and 2000 diagnoses of bipolar disorder in children _____

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quadrupled

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1999 saw the publication of a book entitled the Bipolar Child by a New York psychiatrist
argued what?

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that bipolar disorder in children was overlooked

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2001 field decided that bipolar disorder could be diagnosed in children. Noted that there can be differences in presentation of bipolar in children and adults.
Adults have ___ episodes of mania or depression
In children, may see changes in mood even within the same day

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discrete

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How narrow or broad should the criteria be?
if using a narrow phenotype we want to look at (2)

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Classic” adult symptoms
Mania, grandiosity
*Some children/adolescents meet the full diagnostic criteria meant for adults

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some people saying we use a broader phenotype to include (2)
problems with these (2)

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-irritability and mood lability
1) irritability: differential diagnoses ex) depression, odd, cd, adhd
2) children often show rapid mood changes (between depression and mania on the same day)

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Some authors have argued that to be diagnosed with bipolar disorder, children must show core features of mania (2)

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Grandiosity, elevated mood

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Practice Parameters of the American Academy of Child and Adolescent Psychiatry saying that
-_____ criteria for adults should be applied to children and adolescents
-___ which may include irritability, present as a marked change in the individual’s state.Illness represents a departure from baseline functioning

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-DSM-IV-TR
*saying broader approach may not be best
-Mania

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Note that many children do not meet the duration critera for a full manic episode, which is required for ______, so (2) are more common diagnoses

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bipolar
bipolar 2 and cyclothymia

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clinical reality is that you need to give diagnoses and a huge # of clinicians having kids present irritability/lability so they called it bipolar
because of this the push was for____to call this something else

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-DSM 5

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people wanted to capture :
frequent severe tantrums and chronic irritability, fact that irritability does NOT have to be present, that you can have severe irritability and mood regulation all these resulted in inclusion of what new disorder of

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Dysruptive Mood Dysregulation Disorder (DMDD)
*Very controversial,No published data using these criteria

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DMDD:
-Severe recurrent _______ manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation

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temper outbursts

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DMDD:
The temper outbursts are inconsistent with

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developmental level

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DMDD:
The temper outbursts occur, on average,____per week

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three or more times

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DMDD:
The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is

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observable by others (e.g., parents, teachers, peers)

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DMDD:
Symptoms are present for

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12 months or more

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DMDD:
Not diagnosed before age ___or after age ___

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6
18

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DMDD:
Age at onset of the outbursts and irritable mood is before age ___

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10

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DMDD:
Child has never met criteria (except duration) for a ____ (even lasting one day)

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manic episode

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DMDD Is not diagnosed concurrently with (2)

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ODD (DMDD is more severe)
bipolar

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_____is related construct to DMDD
also includes symptoms of

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severe mood dysregulation
hyperarousal

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Children diagnosed with bipolar (using criteria for adults) much more likely to have future manic episodes than children with _____

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SMD

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Children who meet criteria for SMD more likely to go on to develop ______

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major depression

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Research team worked retrospectively by applying new criteria to data already collected
-Found that DMDD was not well-differentiated from (2)
No difference between youth with and without DMDD diagnosis in symptom severity or functional impairment
-DMDD showed poor ___

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-CD or ODD
*58% of youth with ODD and 62% of youth with CD met criteria for DMDD
-stability

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-Second study using retrospectively applied criteria found that (2)criteria are very important
-Half of the sample was reported to have severe
-When frequency criteria (3 x week) applied, number drops to ____%
-Irritability present in ___% of children
When _____(1 year) applied drops to 1.5-2.8%
-All criteria yields a prevalence of about ___%

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the frequency and duration
temper outbursts
6% to 7%
8-13%
duration criteria
1

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DMDD:
-____of this diagnosis not firmly established
-Risk of _______
-____is an important construct

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Validity
over-diagnosis
Irritability

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Lifetime prevalence of bipolar disorder in children and adolescence is about _____
Very rare prior to
rates rise in

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0.4% to 1.2%
puberty
adolescence

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-About ___% of people with bipolar disorder experience their first episode in adolescence
-Peak age of onset between ____
-Most people report first episode was
-Mania in adolescence associated with (3)
Often mistaken for __________

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60
15 and 19
major depression
psychosis, mixed episodes (mania/depression), extreme mood lability
schizophrenia

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recovery of bipolar categorized as
-8 consecutive weeks in which an individual does not meet the DSM criteria for(4)
-_____of children and adolescents with bipolar disorder will recover within a year
-_____ of the children who recover will show recurrence within a year
-Children with pre-pubertal onset bipolar disorder are ____ times less likely to recover than those with adolescent onset

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manic episode
hypomanic episode
depressive episode or
mixed episode
40% to 100%
60% to 70%
two

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Rate of mania in adults who had Bipolar I as a child are ___ times higher than population prevalence
this suggests_____
taken together the evidence suggests a ___course

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13 to 44
continuity
chronic

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bipolar comorbid with (2)

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ADHD
disruptive behavior disorder
*similarity in symptoms, challenging diagnosis

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60% to 90% of children, 30% of adolescents with bipolar meet criteria for ______

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ADHD

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Possible that stimulant medications may ____ bipolar symptoms

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exacerbate

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20% of children with bipolar disorder meet criteria for

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conduct disorder

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Conduct symptoms may be a consequence of

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bipolar presentation
*Risk-taking activities associated with mania

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-Work with adults suggests that bipolar is highly
-If one or both parents have bipolar, chances are__ x greater that child will develop bipolar or another mood disorder (e.g., depression)
-However, twin studies suggest that
-If one identical twin has bipolar disorder, ___% chance that the other twin will have it
-Genetics appear to play a bigger role in
there is a multiple ___ problem

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-heritable
-5
-variability is not entirely due to genetics
-65%
-early onset cases
-gene

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medication:
lithium (6)

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-Common treatment for adult bipolar disorder
-Mood stabilizer
-Approved for use in children aged 12 and older
-Serious side effects: toxic, renal and thyroid problems, weight gain
-Compliance with instructions VERY important
-Have to visit physician regularly to monitor side effects

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lithium and evidence to support its use

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-One RCT demonstrated lithium was efficacious at reducing bipolar symptoms, compared to placebo, in adolescents
-An second did not demonstrate a positive effect of lithium, relative to placebo
ie) no strong evidence

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medication:
atypical antipsychotics
some evidence from RCT's that they are effective in youth
Two of these approved for treating ___in youth

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mania

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atypical vs typical antipsychotics

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atypical: do not carry the motor side effects typical do

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Practice recommendations for using medication to treat bipolar disorder in children and adolescents

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-Start with monotherapy with either a mood stabilizer or an atypical antipsychotic, if dont fully respond add 2nd mood stabilizer or atypical antipsychotic (augment)
-if no response, may change primary target (again may need to augment)

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For patients presenting with psychosis, start with

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combination of a mood stabilizer and an atypical antipsychotic

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medication:
SSRI's

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-May exacerbate symptoms of mania
-Have to monitor children and adolescents receiving SSRIs for a first depressive episode