Week 10 Pediatric bipolar

Question 0

Manic Episode: has to last for 7 days or they go to hospital
need 4 unless?

Answer 0

 A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary).

 During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
inflated self-esteem or grandiosity

decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
 more talkative than usual or pressure to keep talking
 flight of ideas or subjective experience that thoughts are racing
 distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
 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)

Question 1

Pediatric Bipolar Disorder manifestations,
Also think rela. To CD odd. IT LOOK DIFFERENT THOUGH ON. PRESCHOOLERS
AS WITH DEPRESSION so what does bipolar disorder look like?

Answer 1

 Different manifestations of the same underlying problem we see in adults
 Fundamental debate in child psychology: How do we ensure that symptoms are developmentally appropriate
 CD/ODD
 Depression

Question 2

Specifies:
Depressive Episode
 Meets criteria for a major depressive episode
Hypomanic Episode

Answer 2

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

Question 3

Bipolar 1
do not need to have depression.

Need manic episode(s)

Answer 3

 Manic episode or a mixed episode (mania and depression) lasting 7 days
(unless hospitalization is required)

 May or may not show depression (note that textbook is mistaken)

 Specifier – with mixed features
Person is experiencing episodes that include symptoms of both mania and depression (e.g., a manic episode in which some symptoms of depression are present)

Question 4

Bipolar 2

Answer 4

 Major depressive episodes and hypomanic episodes
 Does not ever have a full manic episode or mixed episode  Specifier – with mixed features

Question 5

Cyclothymia (sim. To dysthymia) ?

Answer 5

 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

Question 6

Between 1990 and 2000 diagnoses of bipolar disorder in children quadrupled!
Why?
Epidemiology…

Answer 6

 1999 saw the publication of a book entitled the Bipolar Child by a New York psychiatrist
 Argued that bipolar disorder in children was overlooked
 Provided a vague and general list of behaviors
 Poor handwriting
 Complains of being bored
 Is very intuitive or very creative
 Excessively distressed when separated from family  Has difficulty arising in the A.M
 Elated or silly, giddy mood states
 Curses viciously in anger
 Intolerant of delays

But they are not specific! All children have this occasionally.

So

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 discrete episodes; have it, return to normal for a while, have it)
 In children, may see changes in mood even within
the same day
 Tend to have long episodes like this (1 to 4 years) (same day rips switches eg.)

Question 7

How narrow or broad should the criteria be? For bipolar disorder in children?

Answer 7

 Narrow phenotype
 “Classic” adult symptoms
 Mania, grandiosity
 Some children/adolescents meet the full diagnostic criteria meant for adults

Broader phenotype
 Irritability, mood lability
 Irritability is much more common than mania
 However, irritability occurs in other disorders as well
Depression
ODD

 Is this actually bipolar disorder?

Question 8

Diagnostic challenges pertaining to bipolar disorder in children?

Answer 8

 Children may not show discrete episodes:
 Children often show rapid mood changes (between depression and mania on the same day)
 Also see youth with chronic mania
 Irritability, rather than euphoria, can be the
predominant mood state

Differential diagnosis
 Depression, ODD, CD, ADHD

Due to this overlap, some authors have argued that to be diagnosed with bipolar disorder, children must show core features of mania:
 Grandiosity, elevated mood
 These features do occur in a significant number of youth who have been identified as having bipolar disorder

Question 9

Where we are now in diagnosis?

Practice Parameters of the American Academy of Child and Adolescent Psychiatry

Answer 9

 DSM criteria for adults should be applied to children and adolescents
 Mania, which may include irritability, must be present as a marked change in the individual’s state
 Illness represents a departure from baseline functioning
 Note that many children do not meet the duration criteria for a full manic episode, which is required for bipolar I, so bipolar 2 and cyclothymia are more common diagnoses
 Diagnostic validity of bipolar disorder in preschool children has yet to be established

Question 10

DSM-5
 Concerns about over-diagnosing bipolar disorder in childhood
 Frequent severe tantrums and chronic irritability
 Irritability is included in many DSM diagnoses
 ODD
 Depression

To address this what was added?
inclusion of new disorder.

Answer 10

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

Question 11

DMDD definition

8 items

Answer 11

 A. Severe recurrent temper outbursts 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.

 B. The temper outbursts are inconsistent with developmental level.

 C. The temper outbursts occur, on average, three or more times per

 D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers)

 E. Symptoms are present for 12 months or more

 F. Not diagnosed before age 6 or after age 18

 G. Age at onset of the outbursts and irritable mood is before age 10

 H. Child has never met criteria (except duration) for a manic episode (even lasting one day)

Question 12

DMDD
 Is not diagnosed concurrently with:

Answer 12

 ODD
As DMDD is more severe

Also:
 Bipolar disorder

Question 13

Research on DMDD is very limited

Answer 13

 More research has focused on related on construct –
severe mood dysregulation (SMD)
 Also includes symptoms of hyperarousal (e.g., flight of ideas, agitation, insomnia)
 Work has been done primarily on one sample

Question 14

Phenotypic contiur amity of mood disorders?

Answer 14

Children diagnosed with bipolar disorder much more likely to have future manic episodes than children with SMD
 Children who meet criteria for SMD more likely to go on to develop major depression
 Suggests that SMD and bipolar disorder are distinct

Question 15

Research team worked retrospectively by applying new criteria to data already collected, looking at DMDD and found?

Answer 15

 Found that DMDD was not well-differentiated from CD or ODD
 58% of youth with ODD and 62% of youth with CD met criteria for DMDD
 No difference between youth with and without DMDD diagnosis in symptom severity or functional impairment
 Showed poor stability, might not meet it later iow

Question 16

Second study using retrospectively applied criteria related to DMDD found

Answer 16

that the frequency and duration criteria are very important

 Half of the sample was reported to have severe temper outbursts
 When frequency criteria (3 x week) applied, number drops to 6% to 7%
 Irritability present in 8-13% of children

 When duration criteria (1 year) applied drops to 1.5-2.8%

 All criteria yields a prevalence of about 1%, not common

Validity is not established, odd and cd similarity an issue, as is possibility over diagnosis.

Question 17

DMDD considerations?

Answer 17

DMDD
 Validity of this diagnosis not firmly established
 Risk of over-diagnosis
 Irritability is an important construct in child psychopathology!
DMDD highlights this.

Question 18

Prevalence of Bipolar Disorder

Answer 18

 Lifetime prevalence of bipolar disorder in children and adolescence is about 0.4% to 1.2%
 Very rare prior to puberty  Rates rises in adolescence

Question 19

Presentation of bd in Dolescents?

Answer 19

 Adolescents
 About 60% of people with bipolar disorder experience their
first episode in adolescence (i.e., prior to 19-years-of-age)

 Peak age of onset between 15 and 19

 Most people report first episode was major depression

 Mania in adolescence associated with psychosis, mixed episodes (mania/depression), extreme mood lability

Question 20

Recovery course of bd

Answer 20

Recovery
 8 consecutive weeks in which an individual does not meet the DSM criteria for manic episode, hypomanic episode, or depressive episode

 40% to 100% of children and adolescents with bipolar disorder will recover within a year

 60% to 70% of the children who recover will show recurrence within a year

 Children with pre-pubertal onset bipolar disorder are two times less likely to recover than those with adolescent onset

Question 21

Suggestion of homotypic continutioy of bd

Answer 21

Rate of mania in adults who had Bipolar I as a child are 13 to 44 times higher than population prevalences
 Suggests homotypic continuity
 Taken together then, the evidence suggests a chronic course

Recurrence quickly is likely

Question 22

Clinical Correlates: Comorbidity of BD with

Adhd, disruptive Behaviour disorders like CD

Answer 22

 ADHD
 60% to 90% of children, 30% of adolescents with bipolar meet
criteria for ADHD
 Note similarity in symptoms
 This is a challenging and critical differential diagnosis
 Possible that stimulant medications may exacerbate bipolar symptoms

 Disruptive behavior disorders
 20% of children with bipolar disorder meet criteria for conduct
disorder
 Again, note overlap in symptoms

 Conduct symptoms may be a consequence of bipolar presentation
 Risk-taking activities associated with mania

Remember no inhibit actions in manic episodes.

Question 23

Clinical Correlates: Social Functioning of BD

Answer 23

 Marked social impairment, interpsonal skills issues.

 Peers
 Poor social skills
 Frequently teased and victimized by peers
 Few friends, instability of trust?

 Families
 Poor relationships with siblings
 Frequent hostility and conflict with parents

Hard for child too!

Question 24

Etiology and Maintenance of BD

Environmental factors likely play a role
 Diathesis-stress model
 Genetic risk and environmental stressor
 Problematic family interactions

 Hostility, conflict
 Contributes to expression of bipolar symptoms

As research in genes shows?

Answer 24

 Very little work done on this topic

Work with adults suggests that bipolar is highly heritable
 If one or both parents have bipolar, chances are 5 x greater that child will develop bipolar or another mood disorder (e.g., depression)
 However, twin studies suggest that variability is not entirely due to genetics
 If one identical twin has bipolar disorder, 65% chance that the other twin will have it as well
 Genetics appear to play a bigger role in early onset cases
 Multiple gene problem (again)

Question 25

Medications most often used with bd

Answer 25

Mood stabilizer lithium: approved by fda but

Or antipsychotic or

Combination

Question 26

Mood Stabilizers: lithium for bd considerations?

Answer 26

 Common treatment for adult bipolar disorder
 Approved for use in children aged 12 and older
 Serious side effects  Toxicity
 Difference between an effective dose of lithium and a toxic dose is very small
 Renal and thyroid problems  Weight gain
 Compliance with instructions VERY important
 Have to visit physician regularly to monitor side effects

Need to take drug in appropriate dose

Question 27

Open-label trials have also shown that lithium is

Answer 27

Open-label trials have also shown that lithium is effective for treating mania in adolescents, not blind to condition!

 One RCT demonstrated lithium was efficacious at reducing bipolar symptoms, compared to placebo, in adolescents
 A second did not demonstrate a positive effect of lithium, relative to placebo

Question 28

Atypical antipsychotics used for bd?

Answer 28

 Wide-ranging class of antipsychotics
 Some evidence from RCTs that these are effective in
 Two of these have been approved for treating mania in youth aged 10 and older

Question 29

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

Answer 29

 Start with monotherapy with either a mood stabilizer or an
atypical antipsychotic

 For patients who do not fully respond, add a second mood stabilizer or atypical antipsychotic (augmentation)

 If no response, change primary agent
 Again, may need to augment

 For youth who do not respond to two medications, recommendation is to add a third
 Note that limited data is available for combination therapy
 For patients presenting with psychosis, start with a combination of a mood stabilizer and an atypical antipsychotic

Question 30

SSRIs for BD

Answer 30

 May exacerbate symptoms of mania
 Note that many people will present with a major depressive episode at the outset of bipolar disorder
 Have to monitor children and adolescents receiving SSRIs for a first depressive episode carefully because of this

Question 31

Psychosocial Treatments for bd considerations?

Answer 31

 Medication is first line treatment, unlike anx!

 Family Education:
Help Understanding disorder and symptoms
Help Reducing conflict in the family
Help Medication management
 Poor compliance to medication regimes is a major source of
relapse
 Medications can be toxic
 Important for family to be educated about the medications

Question 32

Evidence for Psychosocial Treatment

Answer 32

 Two RCTs have shown support for two family treatments
 (1) Multifamily Psychoeducational Psychotherapy (Fristad et al., 2009)
 (2) Family-focused therapy (Miklowitz et al., 2014)
 Education, communication, problem-solving skills

Question 33

Child- and Family-Focused CBT for BD

Answer 33

 RAINBOW
 Routine
 Establish a predictable routine that will reduce tantrums, negativity, conflict
 Affect regulation
 Parents taught behavior management techniques  Children taught to monitor and recognize moods

 Icandoit!
 Increase childrens’ and parents’ beliefs that they can manage bipolar symptoms
 No negative thoughts
 Retraining cognitive distortions associated with depression

 Be a good friend and balanced lifestyle
 Taught skills necessary to be a good friend and given opportunities to practice
 Help parents learn to develop a balanced lifestyle

 Oh, how can we solve this problem?
 Help parents and children learn to problem-solve together

 Ways to get support
 Help parents learn how to seek help, as well as advocate for their child at school

Question 34

Pre treatment post

Answer 34

Overall functioning went up.
Booster sessions helped maintenance maintained.

Limitations,
Treatment shows promise but did not have a control group.
Time, age confound,
Rather were also NOT blind. Needs an rct which has been done!
Evidence cbt was effective.

Below cutoff
Similar to parent reported depression

Adjunc to meds, promising.

Question 35

Parent report for mania

Answer 35

More reliable