Pediatric Bipolar Disorder Flashcards
Types of Bipolar
Youngstrom (2006)
- Bipolar I
- Bipolar II
- Cyclothyia
- BD NOS
Bipolar I
- most serious form
- requires one manic or mixed episode during a perosn’s lifetime.
- If person is functioning well, the classification is bipolar I in remission. If a person develops major depression, even years after the mania, then the correct diagnosis is bipolar I, current episode: depressed.
- MUST CAUSE IMPAIRMENT
- Occurs much of theday for most days over a period of at least 1 week, or the mood disturbance is very extreme requiring hospitalization ( 1 week waived)
- Person need never be depressed to be diagnosed with bipolar I, depression is the more common phase of illness (which causes more problems than mania).
Bipolar II
- requires at least two lifetime mood states: both a major depressive episode and a hypomanic episode.
- Higher risk of suicide
- Much more difficult to diagnose than bipolar I because hypomania is by definition more subtle and less impairing than mania.
- Affected person less likely to seek treatment and clinician less likely to differentiate from just depression
- Bipolar and unipolar distinction is imporatant in terms of suicide risk, substance use, choice of meds and psychotherapy.
- Children who are seen as depressed might be bipolar II: Currently depressed.
Cyclothymia
- requires a period of mood disturbance last at least 1 year (2 years in adults), with no more than 2 months free of symptoms. The mood disturbance represents a clear change in the individuals typical pattern of behavior observable by others.
- Mood involves depressive or dysthymic symptoms, along with periods of hypomanic symptoms.
- It is possible to meet criteria for both cyclothymia and bipolar I disorder provided that the cyclothymic or dysthymic episodes come before the onset of more severe mood states.
- Year requirement blurs the line between episode and trait
Bipolar Disorder Not Otherwise Specified
is a residual category used to describe clinical presentations that appear to be on the bipolar spectrum but do not fit into any of the three aforementioned categories.
Examples
o Repeated episodes of hypomania without lifetime history of manic, mixed, or depressive episodes—a presentation that is unlikely to come to clinical attention but ahs been described n studies of nonclinical adolescents and young adults.
o Manifesting an inadequate number of “B criteria” symptoms in the context of episodic mood disturbance, or showing sufficient symptoms, but for an insufficient duration to meet established criteria for a diagnosis.
Comorbidity
- high cormidity with other mental disorders and substance abuse
- 99% of adults meeting criteria for bipolar I illness met full criteria for at least one other lifetime Axis I diagnosis
- ADHD
- Most common
o ADHD, ODD, CD, and anxiety disorders
o Pediatric onset = higher risk
o ADHD →90% (or 60%%)
• ADHD and manic symptoms look similar
• Distractibility, high motor activity, talkativeness, impulsive behavior
• Worse course
o Pure bipolar rare
Rapid Cycling
- BD is a recurrent illness
- Years, even decades, can go between episodes
- “Rapid –cycling” mood disorder mean that a person has at least four distinct mood episodes over the course of a year.
o More chronic course
o Great comorbidity
o Less responsiveness to lithium
o Higher risk of mortality - A switch in polairtyfo mood may often occur within the course of a single episode.
- “ultradian” cycling or polarity switches in the course of the same day.
Mixed States
- involve symptoms of mania and major depression during the same mood episode.
- Duration is set at a week, unless symptoms are severe (hospitalization)
- Symptoms required to be present for “much of the day, nearly everyday during at least a 1-week period.”
- Depressive + manic in same mood state → black mania
o Combining the hoplessness, low self-esteem, pathological guilt, and despair of depression with the high energy, racing thoughts, and impulsivity of mania.
• Higher risk of suicide - Mixed presentation, mood oscilates rapidly between depressed and manic states over the course of the week, or even within the same day (some call this ultradian cycling).
- “rapid cycling” refers to the number of distinct mood episodes within a 1-year period rather than the number of polarity shifts of mood within a single episode.
- Rare for children or adolescents to experience multiple remissions for their mixed state, then multiple relapses within the same year.
- Rapid cycling rare in children, but there is a high rate of oscillating missed states.
GRAY’s behavioral inhibition system (BIS) and behavioral activation system (BAS)
o These models put anxiety, depression, and mania within a larger evolutionary and neurobehavioral framework, where the clinical disorders are pathologically extreme or situationally inappropriate expressions of systems that otherwise serve important roles in the development of personality and healthy functioning.
o Also these models suggest linkages between mania and dopaminergic systems related to reward, extroversion, and approach-oriented behaviors.
o BIS-BAS models also predict a high degree of overlap between anxious and depressive symptoms, because both anxiety and depression involve high levels of BIS activation, also conceptualized as high levels of “negative affectivity”.
o According to the tripartite model of depression and anxiety, negative affect, or high BIS activity, is a shared component of both anxiety and depression, whereas physiological hyperarousal is specific to anxiety, and low positive affect (or low BAS) is specific marker for depression.
o Also explains frequent co-occurrence of anxious and depressive symptoms, which might otherwise be perceived as “comorbidity” of multiple disorders.
Kraeplin’s Model: 3 clusters
o Three clusters
• cognitive or intellective, cinluding racing thoughts and heightened creativity at one extreme, and slowed thinking or dulled perceptions at the other
• vegetative, including motor agitation and heightedned energy at one extreme, and fatigue or psychomotoral retardation at the other;
• affective, ranging from manic excitement, expansiveness, and grandiosity to depressive hopelessness and despair.
o Kraepelin observed that these three clusters of symptoms were frequently out of phase with each other, giving rise to eight possible permutations of clinical presentation. Classic manic presentations entailed elevation of all there clusters, and classic depression reflected low levels of all three clusters. Agitated depression, in Kraepelin’s model, involved high levels of the motor activity cluster of symptoms, whereas levels of the affective and cognitive dimensions remained low.
o Kraepelin provided an elegant and parsimonious way to describe clinically varied phenomena using a dimensional model. This framework also provided a means for integrating neuropsychological performance into a broader conceptual model of mood disorder.
Age of onset
More recent epidemiological studies suggest that the median age of onset is currently around age 16 years.
Prevalence
Table 6.3 base rates of PBD in different clinical settings
- high school -0.6%
Community mental health center-6%
Gen. outpatient clinic-6 to 8%
County wards-11%
Specialty outpatient service 15 to 17%
Incarcerated adolescents-2%
Incarcerated adolescents-22%
Acute psychiatric hospitalizations-21%
Inpatient service-30% manic symptoms, less than 2% strict DPI
Acute psychiatric hospitalizations-40%
Domains of impairment
Manic episodes involved externalizing behaviors, along with the increased motor activity and poor concentration that are often typical of ADHD. Extreme mood state degrade executive function and cognitive performance, although these deficits do not appear to be specific to the PBD. Both depression and mania are associated with academic underachievement, for educational attainment, peer rejection, and increased family conflict. PDD is also linked to increased use of alcohol and street drugs, and a combination of substance use and other impulsive behaviors greatly increases the risk of youth with PBD coming into contact with the justice system is also a well established risk factor for suicide. Earlier age of onset is related to elevated risk of suicide and of violent behavior in general. Overall, PBD involves pervasive impairment across most social, emotional, cognitive, and vocational – educational areas of functioning.
increase substance use, delinquency, and suicidality (Lewinsohn et al., 2000)
Sex differences
Bipolar one disorder occurs equally opting in men and women. Pediatric data indicate no sex differences in the diagnosis of bipolar one disorder after adjusting for the fact that more young males present to clinics for externalizing problems in general. Bipolar to disorder and maybe more prevalent among adult women then In men. The evidence on sex differences in rate of juvenile bipolar II disorder is similarly mixed, with some data showing a possibly higher rate of bipolar to disorder in female van in male adolescents.
Etiological Factors
Genetic factors have received the most attention. However, even monozygotic twins show roughly 80% concordance for BD, indicating that environmental factors play a role in the expression of illness even when jeans are completely identical.
BD involves multiple genes, which means that pre-mutations or degrees of loading maybe present in any given individual.
Genetic factors have received the most attention. However, even monozygotic twins show roughly 80% concordance for BD, indicating that environmental factors play a role in the expression of illness even when jeans are completely identical.
BD involves multiple genes, which means that pre-mutations or degrees of loading maybe present in any given individual.
