Pediatric Bipolar

Kelly Subramanian

Spring 2009

Psych 493C

Is it really a valid disorder?

Outline

• Key People

• DSM-IV-TR criteria• Symptoms

• Diagnosis• Diagnostic Guidelines• ICD vs. DSM

• Comorbidity• Drug-induced Symptoms

• International Views• Research

• Human Condition

Increased Diagnoses

• From 1994-2003, the early onset bipolar disorder percent of psychiatric diagnoses increased by 15-fold.

• In 2007, estimates of prevalence were as high as 6%.

Demitri Papolos, MD• Co-author to The Bipolar Child with his wife, Janice• Albert Einstein College of Medicine

John Rosemond and Bose Ravenel • Authors to The Diseasing of America’s Children• Say that Papoloses claims are:

• Arbitrary, ill-defined, and unscientific diagnostic criteria• Unproven theories about causation • Treatment recommendations that presume “chemical imbalances” and other unverified brain pathologies

Publication • Bipolar Children: Cutting-Edge Controversy, Insights, and Research

Key People

DSM-IV-TRBipolar I Disorder with manic episode• Occurrence of one or more Manic Episodes, lasts a minimum of 7 days• Depression is not a requisite part of the symptom picture

Bipolar II Disorder• Occurrence of one or more Major Depressive Episodes accompanied by

at least one Hypomanic Episode (less intense form of mania), needs to be present for 4 days

“Rapid Cycling” Bipolar Disorder• Based on occurrence of at least 4 mood episodes per year

Bipolar Disoder NOS (not otherwise specified)• Symptoms do not meet criteria for other diagnoses

Manic Episode• Distinct period of abnormally and persistently elevated, expansive, or irritable mood at least 1 week.

• Three of more persist (four if mood is only irritable) and present to a significant degree:

• 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 pleasure activities that have a high potential for painful consequences

Major Depressive Episode• Five (or more) symptoms present during same 2-week period occurring nearly every day and represent change from previous functioning; at least one is either (1) depressed mood or (2) loss of interest or pleasure.

• depressed mood most of day (Note: In children and adolescents, can be irritable mood.)• markedly diminished interest or pleasure in all, or almost all, activities most of day• significant weight loss or gain, or decrease or increase in appetite (Note: In children, consider failure to make expected weight gains.)• insomnia or hypersomnia• psychomotor agitation or retardation• fatigue or loss of energy• feelings of worthlessness or excessive or inappropriate guilt • diminished ability to think or concentrate, or indecisiveness• recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, suicide attempt, or specific plan for committing suicide

 In its practice guidelines for pediatricians, states:

“DSM-IV criteria remain a consensus without clear empirical [research] data supporting the number of items required for the diagnosis. . . Furthermore, the behavioral characteristics specified in DSM-IV, despite efforts to standardize them, remain subjective.”

American Academy of Pediatrics

SymptomsFrom the Papoloses Explanations from Rosemond

and Ravenel Separation anxiety Agitation over impending separation from

parents has been recognized as normal

Rages and explosive temper tantrums

Emotional meltdowns not unusual for two and three year olds

Oppositional defiant behavior Terrible twos

Distractibility Children are easily distracted

Hyperactivity Parents say their children get into eveything and wear them out

Risk-taking behaviors Children do not always know that what they do involves significant risk

Difficulty getting up in the morning

Really? Not seriously a sign of a biological defect.

Diagnosis

• Children’s imagination or mania?

• Other influences

• Symptoms are subjective

• Symptoms overlap with different disorders

• Comparison of diagnostic guidelines for juvenile bipolar disorder

• Looked at 3 main sets of guidelines issued• The National Institute of Health and Clinical Excellence (UK)• The National Institute of Mental Health (USA)• Child Psychiatric Workshop (USA)

• Concluded that there is a need to develop diagnostic guidelines that give the same results.

• There is widespread uncertainty about which guidelines are best to use.

Diagnostic Guidelines

• Developed in 2002 by Demitri Papolos, MD

• 65 item questionnaire

• Rate Frequency 1- Never or hardly ever 3- Often 2- Sometimes 4- Very often or almost constantly

• Symptom/Behaviors:• has difficulty arising in the AM• has difficulty settling at night• has difficulty making transitions• interrupts or intrudes on others

The Child Bipolar Questionnaire

ICD vs. DSM

• International Statistical Classification of Diseases and Related Health Problems, in 10th edition.

• More strict criteria

• Barbara Geller, Washington University  • Criteria used: euphoria, grandiosity, lack of sleep, herpersexuality, and other mania symptoms.

• Biederman, Harvard Medial School• Criteria generalized: brief stormy episodes of mania lasting only minutes, extremely moody, irritable, aggressive, or emotionally explosive children

Comorbidity

• Similar symptoms as ADHD, ODD, OCD, substance misuse disorders, and anxiety disorders.

• Comorbidity with these disorders is also claimed.

• Majority of kids diagnosed with ADHD.

• Drugs used to treat one disorder can result in criteria that causes a manic episode.

• Arousal

• Increased energy• Intensified focus• Heperalterness• Euphoria• Agitation, anxiety• Insomnia• Irritability• Hostility• OCD• Hypomania• Mania• Psychosis

• Dysphoric

• Somnolence• Fatigue, lethargy• Social withdrawal and isolation• Decreased spontaneity• Reduced curiosity• Construction of affect• Depression • Apathy• Emotional lability

Drug-induced Changes

• No genetic markers or brain imaging tests that can definitively diagnose.

• Longitudinal studies still remain to be inconclusive. • Relatively small sample size.

• Participants in studies are taking medications.

• Lack of research literature.

Research

• As of 2007, European articles still express doubt about existence of prepubescent bipolar disorder.

• Dutch, 2001: Study with adolescents with bipolar parents• For U.S., 39% said to develop before 20• For Dutch, only 4%

• Canadian Journal of Psychiatry, 2007• Full-blown bipolar does not occur until at least adolescence.

• Australian Psychiatry, 2008: Study with 203 boys ages 9-13• 125 had ADHD,25 met criteria for mania• 6 years later: only 1 out of 25 said to have possible bipolar

• New Zealand, 2008• Cultural differences are becoming increasingly apparent in the diagnosis.

International Views

Emotions• highs and lows, anger and frustration, humiliation, irritation, giddiness, joy, and enthusiasm

Attribution theory• Poor math score is associated with lack of talent in math.

• More likely to zone out, not do homework, and not study very hard for tests.

• Potential to achieve excellent results.• Will increase and intensify her efforts in future.  

Human Condition

• Pediatric Bipolar is not in the DSM-IV, so it does not exist!

• Symptoms claimed are more broad and general

• Research does not provide conclusive evidence

• Outside of the U.S., bipolar disorder is not believed to occur before puberty

Conclusion