Bipolar Disorder Flashcards
Recognize the increase in prevalence in hospital discharge diagnoses and outpatient diagnoses but no increase in large scale epidemiological studies
.
the importance of Emil Kraepelin’s findings regarding onset and mixed states
- in his observations of over 900 patients with manic depression in 1917, he reported that the illness most frequently set on between 1 and 20 of age
Also reported that the onset prior to 10 years of age was rare and mild, if it occurred at all. - children lack the higher cognitive structures required for a diagnosis of bipolar disorder
- nearly 60% of bipolar adults recall having symptoms prior to age 19 and up to 20% prior to age 10
- mixed states appear to happen more commonly in children and adolescents with bipolar disorder than adults. Mixed emotional presentations with more common in children than adults even in the absence of psychopathology of that elevated and mixed emotions alone are not diagnostic.
DSM-5 diagnostic criterion A
Distinct period of elevated, expansive or irritable mood less than or equal to 1 week ( or any duration if hospitalization required)
- marked impairments ( eg functioning, hospitalization or psychosis)
- 3 of 7 symptoms if euphoric mood, 4 of 7 symptoms of irritable mood only
- at least 1 week in duration = BP I
- at least 4 days = hypomania (BP ii)
- Psychosis or hospitalization= BP I
Symptoms at the same time as criterion A
3 or 4 if irritable mood only:
- decreased need for sleep
- increase in risk taking/pleasurable activities
- pressured speech ( more talkative than usual)
- grandiosity or inflated self-esteem
- extreme distractibility
- flight of ideas, racing thoughts
- increase in goals directed behavior/psychomotor agitation
Mood Cycles
- Dysthymia- chronic, low grade depression which can be as severely disruptive for a child as MDD
- Mixed episodes- mania and depression at the same time
- normal mood -> drops to depressions -> rises to mania -> drops a little -> rises to hypomania -> mixed episode ( up and down)
- GRAPH*
Pediatric Bipolar Disorder diagnostic dilemmas
- the centrality of irritability
- recommending a diagnosis of BP if the child meets DSM criteria with irritability as a core symptom, even in the absence of elation, grandiosity and episodicity (versus unmodified DSM criteria)
- absence of “pure” BP disorder
- almost always comorbid, making it difficult to discern what’s really going on
- Episode Length
Most salient characteristics thought to separate BP Disorder in children from other psychiatric conditions
- neurologic conditions - brain tumors, CNS infections, MS, temporal lobe epilepsy
- systemic conditions- hyperthyroidism
- numerous medications
Ubiquity of irritability in child psychiatric disorders and common comorbidities
- ADHD
- ODD
- CD
- MDD
- Anxiety Disorders and PTSD
- Autism Spectrum Disorders
- Substance Use Disorders
- Psychotic Disorders
- virtually all child and adolescent psychiatric conditions
Comborbidites (70-90%)
- ADHD (10-75%)
- Psychosis ( 16-60%)
- ODD (46-75%)
- CD (6-37%)
- Anxiety (13-56%)
- Substance Abuse (0-40%)
Increase in comorbidities in earlier onset Bipolar Disorder
Depression, first episode
- less than 13 y.o : 63.6%
- 13-18 y.o: 58.7%
- more than 13 y.o 49.3%
Anxiety disorder, lifetime
- less than 13 y.o: 69.2%
- 13-18 y.o: 53.9%
- more than 13 y.o: 38.3%
Alcohol use disorder:
- less than 13 y.o: 47.3%
- 13-18 y.o: 46.6%
- more than 13 y.o: 31.9%
Drug use disorder:
- less than 13 y.o: 34.2%
- 13-18 y.: 33.4%
- more than 13 y.o: 15.1%
ADHD:
- less than 13 y.o: 20.4%
- 13-18 y.o: 7.6%
- more than 13 y.o% 5.7%
Suicide Attempt:
- less than 13 y.o: 49.8%
- 13-18 y.o: 37.0%
- more than 13 y.o : 24.6%
ADHD versus Bipolar Symptoms
ADHD:
- NO elevated/expansive mood
- common irritability
- NO grandiosity
- mild need for sleep (usually restless sleep)
- more talkative
- NO racing thoughts
- hyperactivity/goal directed
- common high risk activities
- distractibility
Atypical presentation of child Bipolar Disorder
- predominant mood often irritable
- irritability may be persistent, severe, violent
- “complex Cycling” (>80% are rapid cycling)
- pattern of cycling may be ultrarapid (5-364 cyc/yr) or ultra radian (>365 cyc/yr)
- ultraradian cycling is not considered an episode or cycle of mania, hypomania, or depression per DSM
- recall that unstable and labile moods are typical of children <10 y.o - Comorbidity and family history are common (15% of first degree relatives
- poor treatment response and recurrence
