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Rasim Somer Diler, MD Professor of Psychiatry, Medical Director/Co-Director, Inpatient/Outpatient

Child and Adolescent Bipolar Services (In-CABS/CABS)University of Pittsburgh Medical Center,

Western Psychiatric Institute & Clinic, Pittsburgh, PA

www.pediatricbipolar.pitt.edu

Thursday October 07, 2021

Differential Diagnosis

in youth with Bipolar Spectrum Disorders

Disclosures

Funding from NIH

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Learning objectives• Importance of comorbidities in differential diagnosis

• Diagnostic criteria & areas of possible confusion

• Key concepts to differentiate bipolar spectrum

• Updates in DSM 5

Why is it important to differentiate

Bipolar Spectrum Disorder in Youth

Actual

BipolarMisdiagnosed

False -

ADHD

Unipolar

Depressed

Stimulant

Antidepressant

No

Antimanic

Very costly> 10 years for BP Dx

Agitation

Psychosis

Mania

Misdiagnosed

False +

Actual

ADHD

Actual

Unipolar

Depressed

Bipolar Antimanic

Costly

Bad Side Effects

Don’t get

better

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Diagnostic difficulties

Difficult, time consuming, & problematic:

• Differentiate from other psychiatric disorders

Moody ADHD/Disruptive Behavior Disorders

Disruptive mood dysregulation disorder

Non-bipolar depression

High functioning autism spectrum disorders

• Differentiate subtle symptoms from developing child

False statement: “Hey, she/he looks normal, she/he

cannot be bipolar!”

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Clinical presentation…

is usually not mania-related

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Comorbid disorders are very common

Mass

GeneralWASH-U

Case

Western

COBY

BP-IAge Adjusted

Attention-Deficit

Hyperactivity D/O87% 87% 70% 69 %

Oppositional

Defiant D/O86% 79% 47% 46%

Conduct D/O 41% 12% 17% 12%

Anxiety D/O 54% 23% 14% 37%

Substance Use

D/O7% 0% 7% 5%

Axelson et al., Arch Gen Psychiatry, 2006

Several mood symptoms are not specific

IrritabilityAnger

Bipolar Disorder

Depression

Autistic Spectrum Disorders

Anxiety Disorders

PTSD / History of

Abuse

Oppositional Defiant Disorder

ADHDSubstance Use

Disorders

DMDD

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DSM decision trees may help ?• In DSM 5

• No perfect fit in real life

Identify episode first & then symptoms

Symptoms must be:

• Concurrent (happen together)

• Present for sufficient duration (be around for long enough time)

• Occur episodically (different than usual self, or baseline pre-existing other

psychopathology such as autism)

• FOCUS ON LONGITUINAL COURSE OF MOOD

• OBTAIN COLLETERAL INFORMATION*

• WHEN IN DOUBT, PROVIDE PSYCHOEDUCATION & KEEP MONITORING..

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Let’s talk about mood episodes..

Mood Episodes and Bipolar Disorder (BD)-I and II

BD-I BD-II

Mania

Hypomania

Normal mood

Mild depression

Major depression

A hypomanic episode: • milder symptoms for four days (vs. 1 week in manic episode)

& have a “distinct change” from the baseline functioning (vs.

impairment in mania)

& patients may like or dislike these changes

❖ How about shorter episodes that looks like manic?

Pearls to help with diagnosis

• Mania-specific symptoms

✓ elation/euphoria

✓ grandiosity

✓ decreased need for sleep

✓ flight of ideas/racing thoughts

✓ hypersexuality (not due to sexual abuse/exposure)

• Distinct episodes within chronic problems

• **Symptoms must cluster together & be abnormal

for child’s level of development and environment

Bipolar

Not

Bipolar

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Bipolar vs ADHD: both can co-exist

Changes in DSM5

for manic/hypomanic episode

• Increased energy or activity level is a “MUST”

• This is in addition to “elated/irritable mood” during the

manic/hypomanic episode

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New DSM 5 mania criteria

Elevated/Expansive mood

or}Irritability

Increased goal-directed activity*or}

Motor hyperactivity*PLUS ≥3 Sx (4 if irritable) Associated with A Elevated/Irritable Mood & Increased

Activity/Energy:Inflated self-esteem, grandiosity

Decreased need for sleep

More talkative, pressured to keep talking

Flight of ideas or racing thoughts

Distractibility

Increased goal-directed activity or psychomotor agitation

Risky/dangerous behaviors done for pleasurable reasons

Other manic symptoms

• Inflated self-esteem, grandiosity

• Decreased need for sleep

• More talkative, pressured to keep talking

• Flight of ideas or racing thoughts

• Distractibility

• Increased goal-directed activity or

psychomotor agitation

• Risky/dangerous behaviors done for

pleasurable reasons

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Disruptive Mood Dysregulation Disorder

DMDD

• Starts before age 10, no later than 18 yo

• Developmental age at least 6

• Chronically irritable for at least 1 year,

without any good mood more than 3 months

• + verbal/physical anger outbursts 3x/ week

• DMDD alone is rare in the clinics, many youth

will have comorbid ADHD, opositonal defiant

(ODD), and conduct diagnoses

• Exclusion: They cannot have mania (>1 day),

ODD, or impulse control disorder

Bipolar Depression vs. Unipolar Depression

• More severe depression

• More hopelessness & more suicidality

• Lower functioning

• More comorbidity (disruptive behavior, anxiety, substance use)

• More inpatient psychiatric treatment

NOT SPECIFIC TO DIFFERENTIATE BP

So, keep asking about past mania!!!!

• Wozniak et al. J Affective Disord 82 Suppl 1: S59-69, 2004.

• Carlsson et al. Depress Anxiety 23: 1-12., 2006

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What suggests Bipolar

during a depressive episode?

• Psychosis features

• Atypical symptoms such as

✓ psychomotor retardation

✓ fatigue

✓ hypersomnia/hyperphagia

• Medication induced hypomania

• Family history of bipolar disorder (*)

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Changes in DSM5 for depressive & manic/hypomanic episodes

• No “mixed episode” anymore

• New “mixed features for manic episode” (≥3 depressive

symptoms within manic episode)

• New “mixed features for major depressive episode” (≥3

manic symptoms within depressive episode)

• Medication induced mania

= New “Medication/Substance induced bipolar and related

disorder”

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NEW DSM 5 diagnosis:

*Unspecified/Other Specified

Bipolar and Related Disorder

?Formerly “Bipolar Not Otherwise Specified (NOS)”

Differential diagnosis is a continuous process

Unspecified

BP (NOS)Bipolar I/II

Comorbid conditions may change

1. Diler in prep, 2. Yen 2016

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Our novel

“Mood & Energy Thermometer”

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Take-Home Messages

• Difficult to diagnose & differentiate from other conditions

• Differential diagnosis has significant implications for

treatment

• Pay more attention to identify episodes and changes from

baseline

• Increased activity and energy level are now required for

mania episode

• Differential diagnosis is a continuous process with

developmental progression & changes in clinical presentation

• Pay attention to medical conditions

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• All families & youth for their participation

• Course and Outcome of Bipolar Youth (COBY) Study:

➢ Pittsburgh: David Axelson, Boris Birmaher (PI), Renee Clark, Josh Feldmiller, Mary Kay Gill, Ben Goldstein, Tina Goldstein, Heather Kumar, Fangzi Liao, John Merranko, Sharon Nau, Neal Ryan, Raeanne Sylvester, Vicky Tzanakos

➢ Brown: Daniel Dickstein, Heather Hower, Jeff Hunt, Matthew Killam, Martin Keller (PI), Claire Walker, Shirley Yen

➢ UCLA: Michael Strober (PI)

• The Pittsburgh Bipolar Offspring Study (BIOS): David Axelson, Boris Birmaher (PI), David Brent, Renee Clark, Nicholas Curcio, Ronna Currie, Rasim Diler, Tina Goldstein, Danella Hafeman, Mary Beth Hickey, David Kupfer, Cecile Ladouceur, John Merranko, Kelly Monk, Mary Phillips, Brian Rooks, Dara Sakolsky, Rita Scholle, Lindsay Virgin

• Longitudinal Assessment of Manic Symptoms (LAMS) Study: David Axelson, Boris, Birmaher, Rasim Diler, Mary Kay Gill, C.H. Jaquette, Dawn Rice, Leslie Wehman

• Mood and Brain Circuitry in Adolescence Research Study (MBA): Allison Brown, Pat Brosseau, Rasim Somer Diler (mPI), Cecile Ladouceur (mPI), Han-Tsung Marcus Min, Nicole Gonzalez, Kate Thurston-Griswold.

• InCABS Imaging Study: Maria Wolfe, Halimah Abdul-waalee, Michele Bertocci (mPI), Rasim Somer Diler (mPI), Mariah Chobany, Jon Hart, Greeshma Malgireddy.

• Ways for Adolescents to Validate Emotions (WAVE) Study: Rachel Fersch-Podrat, Nina Hotkowski, Tina Goldstein (PI), Matt Garcia, Megan Krantz, Jessica Levenson, Dawn Rice, Sue Wassick, Tim Winbush, Christine Hoover, Stacy Simon, Barbara Pane

• Children and Adolescents Bipolar Services (CABS) (Outpatient and Inpatient): Boris Birmaher, Donna Barham, Sherri Brunner, Rasim Somer Diler, Rachael Fersch-Podrat, Olivia Flood, Tina Goldstein, Danella Hafeman, Christine Hoover, Nina Hotkowski, Tara Krelic, Megan Nase, Mary Kaye, Leslie Phillips, Kevin Rico, Dara Sakolsky, Amy Schlonski, Rita Scholle, Susan Wassick, Tim Winbush

• The National Institute of Mental Health

• The Koplowitz Foundation (Spain) and The Fine Foundation (Pittsburgh)

Thank You

www.pediatricbipolar.pitt.edu

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THANK YOU FOR YOUR ATTENTION!

Rasim Somer Diler, MD Professor of Psychiatry, Medical Director/Co-Director, Inpatient/Outpatient Child and Adolescent Bipolar Services (In-CABS/CABS) Western Psychiatric Institute & Clinic,

Pittsburgh, PA

www.pediatricbipolar.pitt.edu

dilerrs@upmc.edu

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