JUVENILE BIPOLAR

DISORDER dr salman kareem

Junior resident

Controversial topic No clear cut definition Various different studies

Debate continues about itspresentation, course and co-morbidity patterns.

Signs and symptoms

The most common presentations among adolescents and youth with bipolar disorder in community settings were outbursts of mood lability, irritability and aggression

BD in children and adolescents has many symptoms which overlap with other disorders like attention deficit hyperactivity disorder and disruptive behavior disorder.

Recovery and relapse rates Recovery in BD is defined as eight

consecutive weeks without meeting any of the DSM-IV criteria for mania, hypomania, depression, or mixed affective state.

With these criteria, studies of childrenand adolescents with BD have reported that 50-100% will recover in a period of 1–2 years

longitudinalstudies of a cohort initially ascertained before puberty have found that children with BD tend to show lengthy episodes with frequent mixed states, and high rates of relapse following remission or recovery.

Issues of mixed episodes and rapid cycling course

DSM V

A proposed new diagnostic category, temper dysregulation with dysphoria (TDD), within the Mood Disorders section of the manual. The new criteria are based on a decade of research onsevere mood dysregulation, and may help clinicians better differentiate children with these symptoms from those with bipolar disorder or oppositional defiant disorder

Diagnostic Issues relevent to children

Comorbidity: Disruptive Disorders

ADHD Bipolar disorder is difficult to distinguish between ADHD The three major symptoms that they both share are:

Impulsiveness Distractibility Hyperactivity

Up to 30% of children diagnosed with ADHD are given a diagnosis of bipolar disorder Up to 50% of children with bipolar disorder fit the criteria for the diagnosis of ADHD Children with a bipolar parent have a higher than average rate of ADHD Symptoms of bipolar in children are often mistaken for ADHD and the symptoms of

bipolar are different in adults. 1/3 of children diagnosed with ADHD actually suffer from normal symptoms of bipolar

disorder

Oppositional Defiant Disorder Conduct Disorders Mood Disorders

Possible symptoms of pediatric bipolar disorder overlap with other mood disorders. Some of these include: rapid mood changes, inappropriate moods, and bursts of rage

Longitudinal Study

The National Institute of Mental Health funded Course and Outcome of Bipolar Illness in Youth (COBY) followed 263 children ages 7 to 17 for 2 years. They found that 70% recovered from their first episode of mania or depression. However, they relapsed an average of three times. These children only had symptoms 60% of the time but only were diagnosed with bipolar disorder 20% of the time. Many with no bipolar symptoms had other problems such as ADHD. Children originally diagnosed with bipolar disorder eventually developed typical adult bipolar symptoms.

The COBY study has also shown that children and adolescents with bipolar disorder (171, mean age of 13.2 years) continue to suffer from the same disorder 2 years later, with 68% recovering from their initial episode but 58% experiencing a recurrence. This shows stability of bipolar disorder through adolescence and, among some, into early adulthood.

86 patients with pre pubertal onset bipolar disorder for four years with a mean age of 10.8 years, 72% of them relapsed.

TREATMENT

MOOD STABILIZERS

FDA Approval Dose Monitoring

Lithium 12 y/o and older15-20 mg/kg/day

Divided dosesIncrease every 4-5

days

Level 0.6-1.4 MEq/L√TFTs; Renal function

Q3 months

Depakote Adults10-15 mg/kg/day

Divided dosesTotal dose should not

exceed 60 mg/kgs

Level 15-125 ug/mlLFTs, CBC w/ diff and

Plts Q6 months

Findling, 2008 & AACAP 2010

LITHIUM: ADVERSE EVENTS

Mild to Moderate Side Effects Rare Side Effects Long Term

Concerns Drug Interactions

NauseaDiarrheaAbdominal DistressSedationIncreased thirstTremorsWeight gainIncreased urinationAcne

ConvulsionsStuporSeizuresComa

HypothyroidismPolyuriaPolydipsia

Based on renal clearance

AACAP, 2010Findling, 2008

DEPAKOTE: ADVERSE EVENTS

Mild to Moderate Side Effects Rare Side Effects Drug Interactions

NauseaSedationWeight gainHeadacheTremor

Hepatic failurePancreatitis LeukopeniaThrombocytopeniaPolycystic ovarian syndrome

Increased valproate including erythromycin, fluoxetine, aspirin, ibuprofen

AACAP, 2010Findling, 2008

ATYPICAL ANTIPSYCHOTICS

Drug FDA Approval Dose (mg/d)

Risperdone 10-17 0.5-2.5

Ariprazole 10-17 15-30

Olanzapine 13-17 2.5-20

Quetiapine 10-17 400-600

Ziprasidone 17 and older 120-160

AACAP, 2010 & Findling et al., 2008 & Kowatch et al., 2005

ATYPICAL ANTIPSYCHOTICS: ADVERSE EVENTS

Mild to Moderate Side Effects

Rare but Serious Side Effects

Long-term Concerns

Metabolic Syndrome

AkathisiaDizziness or fainting due to orthostasisIncreased appetiteWeight gainTirednessNauseaNight tremorsDecreased sexual interestHeartburn

Tremor and muscle stiffnessProlongation of the QTc intervalIncreased risk for seizuresNeuroleptic malignant syndrome (NMS)

Tardive dyskinesia (TD)Weight gainChanges in blood fats and blood sugarIncrease in prolactin

Risk factors that increase the likelihood of a person developing cardiovascular disease and/or diabetes, including:Weight gainHigh blood sugarHigh blood fat

AACAP, 2010

Treatment for Bipolar Depression

Psychotherapy (First line) Cognitive Behavioral Therapy (CBT) Interpersonal Psychotherapy (IPT) Family Focused Therapy

Lithium SSRIs (as adjunctive treatment to mood

stabalizer) Bupropion (as adjunctive treatment to mood

stabilizer) Lamotrigine Divalproex ECTKowatch et al., 2005

ANTIDEPRESSANT INDUCED MANIA

Antidepressants may induce mania in children with a bipolar diathesis

In a survey of child and adolescent psychiatrists: 10/228 (4.4%) of children under 13 y.o. treated by psychiatrists switched to BD (Reichart & Nolen, 2004)

Treatment for Adolescent Depression Study (TADS), of 439 12-17 year olds: 0 switches to BD after 12-week follow-up (2004)

large private insurance database, 5.4% switch rates, increased risk for youth on antidepressants and risk greatest for age group of 10-14 y.o. (San Martin et al., 2004)

Frequency of Child Bipolar Disorder

Prevalence is largely unknown as there are no well accepted criteria for the diagnosis of Child Bipolar disorder.

This is because DSM IV criteria are generally viewed as inadequate for use with younger children.

The best guess is that the disorder occurs at least as often as adult bipolar disorder (e.g., about 1%)

However, many believe that this disorder is significantly under diagnosed in children.

Frequency of Child Bipolar Disorder

It is suspected that a significant number of children diagnosed with ADHD at an early age actually have early-onset bipolar disorder instead of (or along with) ADHD.

According to the American Academy of Child and Adolescent Psychiatry, up to one-third of children and adolescents with depressive disorders may actually have early onset of bipolar disorder.

20 to 40 % of adults with Bipolar Disorder report a childhood onset of symptoms.

Child/Adolescent Bipolar Disorder: Clinical Presentation

As with adults, Bipolar disorder in children is viewed a serious mental disorder

Characterized by recurrent episodes of depression, mania, and/or mixed symptom states.

Some evidence suggests that child bipolar disorder may be a different and possibly more severe form of the illness than older adolescent and adult-onset bipolar disorder.

Child/Adolescent Bipolar Disorder: Clinical Presentation

While older adolescents often have a clinical presentation that is somewhat similar to that seen with adults.

The clinical presentation of early-onset bipolar disorder in children can look quite different than that seen in older individuals.

Clinicians may fail to diagnose this disorder when using DSM IV criteria for the diagnosis of this condition.

Child/Adolescent Bipolar Disorder: Clinical Presentation

Most cases of child bipolar disorder do not present with the sudden or acute onset often found with adults.

Most do not show the improvement between episodes, often found with adult bipolar disorder.

With children the symptom onset may be more insidious.

Child/Adolescent Bipolar Disorder: Clinical Presentation

With children, initial symptoms of the disorder can be

depressive in nature With these being confused with and treated as MDD.

In other cases, ADHD like symptoms appear first with these symptoms being followed later by a full

manic episode.

Unlike adults - children in a manic state are more likely to be irritable and prone to destructive outbursts than to be elated or euphoric.

Child/Adolescent Bipolar Disorder: Clinical Presentation

Children, more often show rapid cycling and mixed states rather than

clear manic or clear depressive episodes, and an “ongoing and continuous mood

disturbance that is a mix of mania (or hypomania) and depression”.

The rapid and severe cycling between moods produces chronic irritability and few clear periods of wellness between episodes.

Child/Adolescent Bipolar Disorder: Clinical Presentation

Depression and dysphoria are an almost constant part of pediatric bipolar disorder.

As noted earlier, hyperactivity is often the first manifestation of early-onset bipolar disorder.

When children are initially seen because of bipolar symptoms, approximately 90% of early-onset, and 30 % of adolescents with bipolar disorder meet criteria

for a diagnosis of ADHD. Comorbid conduct disorder is also quite

common.

Bipolar Disorder vs. ADHD

Bipolar Disorder (Mania)

1. More talkative than usual, or pressure to keep talking

2. Distractibility3. Increase in goal

directed activity or psychomotor agitation

ADHD1. Often talks excessively2. Is often easily

distracted by extraneous stimuli

3. Is often “on the go” or often acts as if “driven by a motor”

Differentiation: Elated mood, Grandiosity, Decreased need for sleep, Hypersexuality, and

Irritable mood. Hart (2005)

Child Bipolar Disorder: Comorbidity

Attention Deficit Hyperactivity Disorder (ADHD) Between 60 - 80% display symptoms

Oppositional Defiant Disorder (ODD) & Conduct Disorder (CD) 70 - 75%

Substance Abuse (adolescents) 40 - 50%

Anxiety Disorders 35- 40%

Child Bipolar Disorder: Genetics

Bipolar Disorder has a heavy genetic loading

In the general population, a conservative estimate of an individual's risk of bipolar disorder is about 1.2 %.

More than two-thirds of those with bipolar disorder have at least one close relative with the disorder or with unipolar major depression

Child Bipolar Disorder: Genetics

When one parent has bipolar disorder, the risk to each child is about 15 – 30 %

When both parents have bipolar disorder, the risk increases to 50 – 75 %

The risk to siblings and fraternal twins is 15 – 27 %

The risk in identical twins is approximately 70 %

Note. Despite these figures only about 5% of children with a parent with Bipolar disorder would be expected to develop the disorder in childhood.

Etiology :What is Inherited?

A significant question is What is Inherited?? The answer is not entirely clear, but …

It's believed this condition is caused by an imbalance in neurotransmitters.

a low or high level of a specific neurotransmitter such as serotonin, norepinephrine or dopamine is the likely cause.

Others have suggested that it is an imbalance of these substances that may be the problem

Here, a specific level of a neurotransmitter may not as important as its amount in relation to the other neurotransmitters.

Still other studies have found evidence that a change in the sensitivity of the receptors may be the issue.

It seems likely that the neurotransmitter system is at least part of the cause of bipolar disorder, but further research is still needed to define its exact role.

Etiology of Bipolar DisorderEnvironmental Factors

That more than hereditary is involved in Bipolar Disorder is indicated by the fact that in studies involving identical twins, raised in the same home, one twin sometimes develops bipolar disorder while one does not .

Here it is suggested that environmental factors may play a role in bipolar disorder.

For some, stresses such as a death in the family, divorce, or other traumatic events seem to trigger a first episode of mania or depression.

Etiology of Bipolar DisorderEnvironmental Factors

Puberty may trigger the disorder in adolescent females.

Stressful life events can lead to the onset Once the disorder is triggered and progresses, it

seems to develop a life of its own. Once the cycle begins, a psychological or

pathophysiological process takes over and ensures that the disorder will continue.

The best explanation for this disorder seems to be reflected in the "Diathesis-Stress Model."

Genetics PLUS environmental percipients.

Treatment of Child Bipolar Disorder

Treatment of children and adults with bipolar disorder is generally similar to adults with this disorder. Less is known about the effectiveness &

safety of the medications used. Lithium appears to frequently have a strong

prophylactic effect against mania, and is sometimes used with children.

However, in very early onset bipolar disorder, with a heavy family loading, children may not respond as well to lithium as do adults.

Treatment of Child Bipolar Disorder

As with adults, anti-convulsants are often used to control rapid cycling and aggressive behavior. Depakote – an anti-convulsant – used to

control rapid cycling. Tergetol – an anti-convulsant – has anti-

manic and anti-aggressive qualities. Other anti-convulsants (Neurontin,

Lamictal, Topamax)

Sometimes these are used in combination with Lithium.

Treatment of Child Bipolar Disorder

As with adults, certain antipsychotic drugs may also be used to control symptoms.

Included here are atypical antipsychotic medications such as Clozaril®, Zyprexa®, Risperdal®, and Seroquel®.

Such drugs have been shown to sometimes function as mood stabilizers in cases were drugs like lithium and anticonvulsants may not work

They are used to deal with acute mania, and/or to treat psychotic depression.

Issues in the Pharmacological Treatment of Child Bipolar Disorder

Bipolar youth often require multiple medications for mood stabilization, treatment of attention problems, depression, and sometimes psychotic symptoms.

There can, however, be risks with drug treatments

Problems can arise in cases of misdiagnosis.

Sometimes children with undiagnosed bipolar disorder are mistakenly treated for MDD with antidepressants.

Issues in the Pharmacological Treatment of Child Bipolar Disorder

Treating such children with antidepressants (in the absence of a mood stabilizer) can actually precipitate or exacerbate manic symptoms.

In children with ADHD symptoms, treatment with stimulant drugs (in the absence of a mood stabilizer) can result in manic symptoms and/or worsen symptoms.

Issues in Pharmacological Treatment of Child Bipolar Disorder

It is difficult to determine which children will become manic or experience a worsening of symptoms

There is a greater likelihood among children with a strong family history of bipolar disorder.

It has been suggested that if manic symptoms develop or markedly worsen

during antidepressant or stimulant use, the diagnosis and treatment for bipolar disorder should be considered.

Proper diagnosis of Child Bipolar Disorder is necessary to avoid these problems.

Additional Treatment Approaches As with adults, treatments in addition to

medication are often necessary to assist children with bipolar disorder and their families.

These interventions may involve Educating the family about the nature of

childhood bipolar disorder and involving the family in treatment.

Insuring that children receive the special educational services necessary to prevent them from falling behind academically

Appropriate classroom accommodations to help them function effectively in the academic environment.

Family and individual approaches to therapy should be provided as necessary.

Psychotherapy for BPD

Psychoeducation-based approaches Multi-Family Psychotherapy Group and

Individual Family Therapy (Fristad 2002, 2005)

Family-Focused Treatment (Miklowitz, 2004)Links to fewer relapses, longer delay to

relapse Child and Family Focused CBT

Manualized PT, CBT+FFT Dialectic Behavior Therapy Supportive Therapy Interpersonal and social-rhythm therapy

(IPSRT) AACAP, 2010

QUESTIONS!!!!????

“If uncertainties make you anxious, don’t think about being a child psychiatrist” Dr. Elizabeth McCullough