Bipolar Disorder in Children and Adolescents Flashcards Preview

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Flashcards in Bipolar Disorder in Children and Adolescents Deck (20):
1

Bipolar, General

One of the leading causes of disability

One of the leading causes of suicide

Increased substance abuse

Increased incarceration
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Biologically-based

Unusual shifts in a person's mood & energy

Impairs ability to function

Dramatic mood swings – from overly high and/or irritable, to sad and hopeless, and then back again

Mood related changes are accompanied by severe changes in energy and behavior

*In older adolescents and adults there are often periods of normal mood in between

2

Child/Adolescent Bipolar Disorder [onset / temperament]

Symptoms can emerge in early childhood

Some evidence that children diagnosed with early onset bipolar disorder were:
*difficult to soothe
*slept erratically
*seemed extraordinarily clingy
*from a very young age often displayed uncontrollable seizure-like tantrums or rages – out of proportion to any event

Severe tantrums often appear to be without provocation

Conflict in the field – what are the true symptoms of mania? e.g. sexual promiscuity, elevated mood, grandiosity
[If only rages = DMDD]

3

Bipolar I vs. Bipolar II dx

Bipolar I:
Recurrent episodes of both mania and depression – although Bipolar I can be diagnosed if mania is present without depression
* usually results in hospitalization

Bipolar II: **more common in children**
Milder episodes of hypomania that alternate with depression

Some people experience multiple episodes within a single week, or within a single day – rapid cycling

4

Bipolar Disorder: Mixed States

Symptoms of mania and depression may occur together in what is called a mixed state

Suicide is more likely, due to increase in energy
*sad, hopeless mood while feeling extremely energized

Agitation

Trouble sleeping

Significant change in appetite

Psychosis

Suicidal thinking

5

Mania versus Hypomania

Duration:

Manic Episode:
1 week OR any duration if hospitalization is necessary

Hypomanic Episode:
At least 4 days but less than 1 week
Clearly different from non-depressed mood
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Impairment/Features:

Manic: severe enough to cause marked impairment in occupational function or an usual social activities – may require hospitalization to prevent harm to self or others, or if there are psychotic features

Hypomanic: definite change in level of functioning, but not so severe to cause marked impairment that would necessitate hospitalization – *NO psychotic features**

6

Bipolar I

Presence of at least one manic or mixed episode
**With OR Without depressive episodes**

Symptoms significantly interfere with psychosocial functioning and must last at least a week or require hospitalization

7

Bipolar II

Presence of one or more major depressive episodes

Presence or history of at least one hypomanic episode

No prior history of a manic or mixed episode (=bipolar I)

Symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning

8

Cyclothymia

For at least 1 year, presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for major depressive episode

During this 1 year period, person has not been without symptoms more than 2 months at a time

Exclusionary:
No major depressive episode, manic episode, or mixed episode has been present during the first year of the disturbance

*Dr. Ohr: keep in mind that it's difficult to get the full picture for diagnosis since most information is based on parental report

9

Controversies in Child Criteria

Rages – different opinions in the operational definition

Chronic irritability versus cycling, what are the rates of cycling

Role of irritability as a diagnostic symptom

Elation & Grandiosity in child presentation of mania: is it truly grandiosity or simply imagination?
e.g. Does the child really believe that he can fly?

10

Epidemiology

Children and Adolescents
Bipolar I: 0.06-0.10%

Bipolar II Cyclothymia: 0.85%

Bipolar spectrum: 5-10%

Pre-pubescence
boys/girls 3.85 : 1

Bipolar disorder occurs equally in males and females in late adolescence and adulthood

Incidence is greater after puberty

Bipolar II and Cyclothymia may be 5x more common

11

Biological Causes of Bipolar Disorder

Genetic factors:
*5x risk when clear BP in one parent

*2.5x risk when BP in extended family

*Even if not diagnosed with BP, children of parents with BP 2.7x more likely to have mental health diagnosis and 4x more likely to have a mood disorder

Physiological Factors {theorized}:

*a low or high level of a specific neurotransmitter, e.g. serotonin, norepinephrine and dopamine, or the imbalance of NT's

* change in the sensitivity of receptors may be the issue

12

Environmental Factors

Genetic predisposition is not a guarantee

MZ Twin Studies, only 65% chance when 1 twin has BD

Suggests that environmental factors play significant role

13

Overlapping Diagnoses

ADHD

CD

ODD

Sexual abuse

Specific language disorders

Schizophrenia/schizoaffective disorder

Substance abuse

Anxiety

14

ADHD and Bipolar Disorder Similarities

Impulsivity

Hyperactivity

Emotional/behavioral lability

Comorbidity of CD and ODD

Sleep problems

15

ADHD and Bipolar Disorder Differences

Destructiveness
ADHD: non-angry
BP: angry, destructive

Duration and intensity of tantrums

Trigger for tantrum
ADHD: sensory and affective overstimulation (transitions, insults)
BP: limit-setting, conflict

Children with ADHD do not generally show dysphoria

Conflict with peers
ADHD: stumble into a fight
BP: looks for a fight and enjoys power struggle

Psychotic symptoms
BP
*Child exhibits gross distortions in perceiving reality or interpreting affective (emotional) events
*They may even exhibit paranoid-like thinking or openly sadistic impulses.

16

Treatment

Medications – mood stabilizers, antipsychotics

Several child and family focus strategies including:
*Problem-solving
*Communication training
*CBT
*Social skills training
*Affect regulation

17

Assessment

Few standardized measures for children

Thorough interview is required-- observation, videos

*See class handouts:

Child Bipolar Questionnaire
*captures DMDD--low on irritability, rage
*mania--excitability, sexual curiosity
*for certain measures, look to see what is the goal of the behavior?
e.g. "Tells tall tales; embellishes or exaggerates"
Ok, but why?...attention; getting out of trouble, just feel good; avoiding anxiety

Affective Reactivity Index ARI– measures irritability as a means to distinguish BPD from DMDD

Ohr DMDD scale

18

Child: Differential Diagnoses and/or Comorbid Conditions

Specific Language Disorders [Child only]
ADHD
ODD
CD
Sexual Abuse

19

Adolescent: Differential Diagnoses and/or Comorbid Conditions

ADHD
ODD
CD
Sexual Abuse
Schizophrenia
Substance Abuse

20

Adult: Differential Diagnoses and/or Comorbid Conditions

Schizophrenia
Substance Abuse
Antisocial personality [Adult Only]