4.1 bipolar disorder lifespan perspective

Question 1

bipolar I disorder DSM criteria

Answer 1

at least 1 lifetime manic episode is required - no need for depressive episode

criteria for manic episode:

A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy
- lasting at least 1 week
- present most of the day, nearly every day

During the period of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility
- Increase in goal-directed activity or psychomotor agitation
- Excessive involvement in activities that have a high potential for painful consequences

mood disturbance causes marked impairement

Question 2

bipolar II disorder DSM criteria

Answer 2

Criteria have been met for at least one hypomanic episode and at least one major depressive episode

There has never been a manic episode

hypomanic episode:
- at least 4 days
- same as manic episode but episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization
- less severe symptoms than manic episode

The diagnosis requires 1 or more hypomanic episodes (of at least 4 days), and 1 or more major depressive episodes (of at least 2 weeks)

Question 3

bipolar I vs II

Bipolar disorder (Carvalho, 2020)

Answer 3

bipolar I:
- mostly manic episodes

bipolar II:
- mainly episodes of depression
- alternates with hypomanic episodes

Question 4

cyclothymic disorder

Bipolar disorder (Carvalho, 2020)

Answer 4

Characterized by chronic, fluctuating mood disturbance that lasts for a distinct period of time

Patients must have exhibited subthreshold symptoms of hypomania and of depression

Adults must have had these symptoms for 2 years, and pediatric patients for 1 year

Patients cannot have been without symptoms for more than 2 months

Question 5

Genetic and neurobiological features

heritability

Bipolar disorder (Carvalho, 2020)

Answer 5

Estimates of heritability for bipolar disorder range from 70-90% - many genes with small effect sizes are considered to contribute to the group of disorders

common genetic variants are thought to interact with environmental risk factors - but the latter are also not well established

Question 6

Genetic and neurobiological features

kindling hypothesis

Bipolar disorder (Carvalho, 2020)

Answer 6

Has been suggested as a model to explain gradual stress sensitization that leads to recurring affective episodes

The first episode occurs after exposure to a stressors, and subsequent episodes can occur without exposure to an identifiable stressor

The mechanisms underlying this hypothesis may be strengthened if:
- The illness is not treated
- The person is exposed to substances
- They have lifestyle risks like smoking or sedentary behavior

Question 7

Genetic and neurobiological features

neuroprogression

Bipolar disorder (Carvalho, 2020)

Answer 7

Progressive changes in brain structure and cellular function (neuroprogression) have been observed

A long duration of illness has been associated with reduced cortical thickness of such brain regions like the PFC - may play a role in stress regulation

Neuroprogression may account for worsening cognitive and functional impairments

Question 8

treatment of acute episodes

Bipolar disorder (Carvalho, 2020)

Answer 8

acute mania:
- Pharmacological treatment with antispychotics or mood stabilizers
- Combination of antipsychitc and mood stabilizing agents for severe mania is more efficacious than either alone
- Bifrontal electroconvulsive therapy (ECT) in treatment-resistent cases

acute depression:
- During these episodes, patients have a greater number of unacceptable side effects of pharmacological treatments than they do during a manic episode = a low initial dose with gradual upward is generally used
- There is controversy regarding the efficacy and risks of antidepressant agents in managing bipolar depression

Question 9

maintenance treatment

Bipolar disorder (Carvalho, 2020)

Answer 9

Aimed at preventing the emergence of affective episodes and burdensome affective symptoms - often requires a combination of pharmacological, psychological, and lifestyle interventions

Lithium remains one of the most effective drugs for the prevention of both depressive and manic recurrences in bipolar disorder

Maintenance ECT may be considered with those with bipolar disorder who do not respond to pharmacotherapy

Question 10

differential diagnosis of ADHD & BD

(Marangoni, 2015)

Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions

Answer 10

The differential diagnosis between ADHD and BD offers several challenges - e.g.:
- The young age of onset of both
- Extensive symptomatic overlap
- Similar psychiatric comorbidities

general differentiation:
- In most uncomplicated cases, the discrete appearance of prominent mood, sleep and aggressive behaviors = BD
- On the other hand, fidgeting and restlessness and inefficient and disorganized performances steeming from inattentiveness, distractability and foregetlness = ADHD

Biggest challenge: occurs when ADHD is comorbid with CD and/or ODD - as their presentation (temper tantrums, aggressive behavior) can overlap with symptoms of manic or mixed state

Question 11

epidemiology BD vs ADHD

(Marangoni, 2015)

Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions

Answer 11

prevalence:
- ADHD: range from 1.7-16% in school-age youths, and 1-5% of adults
- BD: 2.1% in adults and 1.8% in children
- Both disorders are more prevalent in males (at least BD-I and ADHD with hyperactivity), but ADHD inattentive type might be more common in girls

both typically begin in childhood (especially ADHD) or adolesence

comorbidities:
- BD youths tend to suffer from comorbid disorders like anxiety, ADHD, disruptive behavior, and substance use disorders
- Comorbidity between adolescent ADHD and CD, ODD, anxiety disorders, or SUD significantly increases the odds of developing later BD

Question 12

3 approaches to the clinical differentiation of ADHD from BD

(Marangoni, 2015)

Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions

Answer 12

1. Eliminating overlapping symptoms to compare and contrast both disorders
2. Chronological appearance of symptoms on a developmental continuum in children with clinical or structured diagnosis of BD and ADHD
3. Child Behavior Checklist (CBCI) scores in children with either BD or ADHD were compared to assess how well CBCI could differentiate the two

Question 13

Differences in specfic symptoms

hyperactivity

(Marangoni, 2015)

Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions

Answer 13

The temporal distribution of hyperactivity can be helpful in differentiating both

BD: circadian rhythms are altered → greater fluctuations of energy and activity, from very high to very low, as well as improved mood and energy in the later part of the day, interfering with sleeping

ADHD: the levels of locomotor activities are high but relatively stable

Question 14

Differences in specfic symptoms

disturbances of sleep & circadian rhythms

(Marangoni, 2015)

Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions

Answer 14

Early insomnia and sleep resistance have been reported in both ADHD and BD → differentiating value is limited

Middle and late insomnia are more useful, which are commonly observed among mood-disordered children than in ADHD ones

Question 15

Differences in specfic symptoms

aggressive & hypersexual behavior

(Marangoni, 2015)

Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions

Answer 15

Aggression is common in BD → can be present in severe temper tantrums, or as deliberate aggression sometimes with lack of remorse

In ADHD, verbal and physical aggression can result from irritability, but the actions tend to be accidental, related to inattention, impulsivity, and poor coordination or impaired motor skills

Question 16

Differences in specfic symptoms

academic functioning

(Marangoni, 2015)

Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions

Answer 16

ADHD: difficulties with inattention, resistance to completing the homework, and poor concentration often interfere with academic achievement consistently over time

Children with BD: more likely to have more variable, uneven performances, at times doing very well and others not

Question 17

family history

(Marangoni, 2015)

Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions

Answer 17

The most significant risk factor for developing BD is a positive family history
- Studies suggest that the recurrence risk for BD in first-degree relatives of BD patients is approx. 90% (almost 10x that of the general population)

Adoption and twin studies estimate that 60-80% of the risk for ADHD is heritable

Question 18

treatment response

(Marangoni, 2015)

Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions

Answer 18

Stimulants: prevent the reuptake of dopaminergic and noradrenergic systems implicated in cognitive deficits - are helpful in reducing the impact of these deficits on academic performance and social interaction, improve classroom behavior, and increase time on task

Therapeutic approaches are often quite different depending on the primary diagnosis

When BD and ADHD are comorbid → a combination of treatment is often required

Stimulants have been shown to be ineffective in the treatment of BD, can cause disruption of sleep and circadian rhythms, etc

Question 19

conclusion

(Marangoni, 2015)

Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions

Answer 19

BD and ADHD share more than overlapping symptoms:
- Similar ages of onset and comorbidities
- Chronic lifelong course of illness that disrupts educational, vocational, and especially developmental milestones → sets the stage for significant morbidity and mortality
- For both disorders there is evidence of diagnostic error

Question 20

method

(Uchida, 2015)

Can unipolar and bipolar pediatric major depression be differentiated from each other?

Answer 20

Problem in the diagnosis and management of pediatric MDD is distinguishing children affected with bipolar forms of MDD and those with unipolar forms

Uchida et al. (2014) - found that manic switches in pediatric depression can be predicted by several risk factors:
- Positive family history of mood disorders
- Emotional and behavioral dysregulation
- Subthreshold mania
- Psychosis

Method: systematic literature search was conducted on studies assessing the clinical characteristics and correlates of unipolar MDD and bipolar MDD in youth - 4 studies total

Question 21

results

Clinical differences between bipolar & unipolar MDD

(Uchida, 2015)

Can unipolar and bipolar pediatric major depression be differentiated from each other?

Answer 21

4 significant distinguishing clinical factors were found to be overrepresented in children with bipolar MDD compared to those with unipolar:
- High rates of psychiatric comorbidities
- High rates of family history of psychiatric illness
- Higher severity of depression
- Higher level of impairment

Question 22

results

Psychiatric comorbidity

(Uchida, 2015)

Can unipolar and bipolar pediatric major depression be differentiated from each other?

Answer 22

3 studies found significant associations between high levels of comorbidity and bipolar MDD

Reported that children with bipolar MDD had higher rates of ODD, CD, and anxiety disorders

Question 23

results

family history of psychiatric illness

(Uchida, 2015)

Can unipolar and bipolar pediatric major depression be differentiated from each other?

Answer 23

3 studies found significant associations between higher levels of family history of psychiatric disorders in children and teens with bipolar MDD as compared to those with unipolar

Question 24

results

severity of depression

(Uchida, 2015)

Can unipolar and bipolar pediatric major depression be differentiated from each other?

Answer 24

Studies found significant associations between a greater number of symptoms and higher severity in children with bipolar compared to those with unipolar

Accordingly, children with bipolar MDD experienced greater levels of sadness; irritability; hopelessness; and suicidal or self-injurous behaviors

Question 25

results

conclusion

(Uchida, 2015)

Can unipolar and bipolar pediatric major depression be differentiated from each other?

Answer 25

this review indicates that bipolar MDD can be distinguished from unipolar depression by:
- Strong family history
- High levels of disease severity and associated dysfunction
- High levels of behavioral difficulties
- High rates of psychiatric comorbidity

Question 26

cycles vs episodes

(Kowatch, 2016)

Diagnosis, Phenomenology, Differential Diagnosis, and Comorbidity of Pediatric Bipolar Disorder

Answer 26

Cycles = pronounced shift in mood and energy from one extreme to another (do not confuse w rapid cycling)

Episode = extended period of mood dysregulation often encompassing multiple cycles in polarity

Question 27

rapid cycling

(Kowatch, 2016)

Diagnosis, Phenomenology, Differential Diagnosis, and Comorbidity of Pediatric Bipolar Disorder

Answer 27

DSM defines it as the occurrence of 4 or more mood episodes in a year

The episodes meet both the symptom & duration criteria for a manic, hypomanic or MDE

Episode are demarcated by a period of partial or full remission for at least 2 months, or by a switch to an episode of opposite polarity

Manic & hypomanic episodes are counted as being on the same pole = a switch in polarity involves one of these episodes & an episode of MD

Question 28

indicators of BD in pediatric patients

(Kowatch, 2016)

Diagnosis, Phenomenology, Differential Diagnosis, and Comorbidity of Pediatric Bipolar Disorder

Answer 28

Rage and aggression - a bipolar disorder should be considered if the child displays aggression several times a day for hours with seemingly little provocation

Decreased need for sleep - children with BD may have a reduced need for sleep, while those with ADHD may instead have insomnia

Spontaneous mood shifts - children without BD may tend to be generally moody with parents and siblings, but they usually do not have mood swings out of context of their surrounding

High risk actions - those with BD may engage in inappropriate risky behaviors, and they usually do so regularly