Pallav Pareek M.D.Revisions made on

9/16/2012

Case presentation

OT is a 7 yo Caucasian male, who currently lives with his biological mother & step father. He attends 2nd grade in special education

C/C Per OT: “I choked my younger brother” Per Mother: “OT has been very unpredictable, impulsive , aggressive towards family members, and threatening to kill himself”

Went to doctor’s office for his scheduled appointment, argued, refused physical

At his return home, he was upset , argued with mother, broke step father’s laptop

Tried to choke his brother PT, when mother tried to interrupt him, threatened to kill mother, and then kill himself

No behavioral issues during first 3 years, described as “a very good baby”

Behavioral problems started around age 3, after father’s physical assault on mother

Patient started exhibiting aggressive behaviors at home and school, that have continued to the present without any improvement

Violent behavior at home, threatening to use knives/toys as his weapons

Multiple episodes of suicidal threats in the past (most serious attempt : trying to grab a knife from the kitchen to kill himself)

History of making threats to hurt others w/wo any accessible weapon nearby

Destruction of property : when angry would break anything in his vicinity

At school, pushing everything off the teacher’s desk. Turning it upside down

Mother describes no precipitating factors to his anger and his outbursts which are episodic. During a typical episode (3-4episodes/week), OT will scream, curse at others, throwing objects, often threatening to kill himself and others

Mother says that he is usually remorseful and apologetic a few hours after such episodes, and promises to mend his behavior in future

Mother also reports has had chronic difficulties falling asleep. OT ( if not medicated) would keep awake till 2 -3 am , and then usually gets up on his own about 7-7.30 am , and does not report feeling tired

History of inappropriate sexual behaviors, starting 3 wks before current admission

OT is irritable most of the time when he is awake, most days of the week

Per mother , it’s very difficult for OT to focus on a thing Usually would not listen to her , when she is talking to him It’s very difficult for him to sit still Usually talks “superfast”, and jumps from one topic to the

other Mother denied any symptoms suggestive of grandiosity Mother describes occasional episodes , where OT will slow

down, isolates himself, does not talk “that much”, shows reduced interest in paying video games, would prefer to watch TV. No explicit sadness or crying has been observed during these episodes. These episodes are few and far between ( 1-2 times every month)

No problem reported with sleep or appetite. No suicidal ideations during these times

Multiple (>7) admissions between 07 and 09.

Past Medications: Abilify, Adderall, Cogentin, Concerta, Depakote, Elavil, Geodon, Lithium, Risperdal, Ritalin, Seroquel, Strattera, Trileptal

Medical: Seasonal asthma, occasional use of Albuterol inhaler

Surgical : Tonsillectomy and Adenoidectomy 03/08

PREVIOUS DIAGNOSES: Oppositional Defiant

Disorder Conduct disorder

(childhood onset) PTSD Munchausen by proxy

syndrome (MBPS) Mood disorder NOS Adjustment disorder Reactive attachment

disorder Intermittent Explosive

Disorder

None Patient has more

knowledge about sexual activities than would be expected for his age

Inappropriate sexual behaviors began about 3 wks prior to admission, exposing himself in the unit during current admission

Maternal side Paternal side

Mother suspects that she has depression (never treated, no medications)

Maternal Aunt has depression, being treated

Father had BP per mother

Father has had problems with Alcohol

Father has been in Jail about 8 times ( domestic violence, destruction of property, beating up people)

Questionable hx of BP in Paternal GF

OT was born via NSVD. No post-natal complications

Developmental milestones were appropriate for age

Described as a warm and cuddly infant

Aware of Physical violence towards the mother by biological father

No other physical/emotional/sexual abuse reported

Problems began during Head start at around age 4

Had to change school about twice

Currently goes to a day program(Tu,Th,Fr)

Face to face (M, W) Is in the 2nd grade (IEP*) Behind in reading and spelling

per mother ( per testing done at Hawthorn Grade levels are: )

Reading = 1.2 Spelling = 1.0 Math = 1.2*= Individual Education Plan

OT is a 7 yo Caucasian, slightly obese male, appears stated age. Fair grooming and hygiene . Pleasant and co-operative to begin with the interview, soon gets distracted, infrequently answering the questions in the first time. Fidgety and restless throughout the interview. Keeps jumping out of the chair. Speech had an increased volume and flow, normal syntax and grammar. Mood anxious and elated, affect labile .Thought process was logical & goal directed, whenever he chose to answer, but illogical during most part of the interview frequently derailing from the topic. Switching topics often. Denied any abnormal perceptual experiences. No delusions. AA Ox3. Memory : on recent recall 2/3 words after 5 minutes, able to recall past events with reasonable accuracy. Appeared to have average intelligence. Poor attention & concentration. Poor impulse control, Judgment poor. No insight into his problem.

Axis I : Bipolar disorderNOS(?)

Hx ADHD (C)

Axis II : None

Axis III : Seasonal Asthma

Obesity

Axis IV : Problem with primary support group, Educational problems

Axis V : 20-25

Day 1 : OT has difficulty falling asleep.

Day 4 : Behavioral issues continue, sent to the QR 3/4days. Fighting peers, provoking, not following directions

Day 6 : Depakote level is 93mmol/liter

Day 7 : Reports A/V hall. the “Grim Reaper”

Day 8 : Geodon is increased to 40mg bid

Day10: Sexually inappropriate behavior

Day14: Lithium is added to the medication regime

Day15: “My mind runs faster than the Mustang”

Day 21: Geodon+ Lithium+ Depakote, ongoing Rx . No response to medications. Li+2 level awaited

The essential feature of Bipolar I Disorder is a clinical course that is characterized by the occurrence of one or more Manic Episodes or Mixed Episodes. Often individuals have also had one or more Major Depressive Episodes. Episodes of Substance-Induced Mood Disorder (due to the direct effects of a medication, or other somatic treatments for depression, a drug of abuse, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Bipolar I Disorder. In addition, the episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified

The essential feature of Bipolar II Disorder is a clinical course that is characterized by the occurrence of one or more Major Depressive Episodes accompanied by at least one Hypomanic Episode. Hypomanic Episodes should not be confused with the several days of euthymia that may follow remission of a Major Depressive Episode. Episodes of Substance- Induced Mood Disorder (due to the direct effects of a medication, or other somatic treatments for depression, a drug of abuse, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Bipolar I Disorder. In addition, the episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

1. inflated self-esteem or grandiosity

2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

3. more talkative than usual or pressure to keep talking

4. flight of ideas or subjective experience that thoughts are racing

5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The symptoms do not meet criteria for a Mixed Episode. D. The mood disturbance is sufficiently severe to cause marked impairment in occupational

functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatments) or a general medical condition (e.g., hyperthyroidism).

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.

B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

1. inflated self-esteem or grandiosity

2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

3. more talkative than usual or pressure to keep talking

4. flight of ideas or subjective experience that thoughts are racing

5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.

D. The disturbance in mood and the change in functioning are observable by others. E. The episode is NOT severe enough to cause marked impairment in social or occupational

functioning, or to necessitate hospitalization, and there are NO psychotic features. F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug

of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder.  

A. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.

B. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

The Bipolar Disorder NOS category includes disorders with Bipolar feature that do not meet criteria for any specific Bipolar Disorder.

Examples include

1. Very rapid alternation (over days) between manic symptoms and depressive symptoms that meet symptom threshold criteria but not minimal duration criteria for Manic, Hypomanic, or Major Depressive Episodes

2. Recurrent Hypomanic Episodes without intercurrent depressive symptoms

3. A Manic or Mixed Episode superimposed on Delusional Disorder, residual Schizophrenia, or Psychotic Disorder NOS

4. Hypomanic Episodes, along with chronic depressive symptoms, that are too infrequent to qualify for a diagnosis of Cyclothymic Disorder

5. Situations in which the clinician has concluded that a Bipolar Disorder is present but is unable to determine whether it is primary, due to a GMC, or substance induced

Date of download: 9/20/2012Copyright © 2012 American Medical

Association. All rights reserved.

From: Recent Progress in Understanding Pediatric Bipolar Disorder

Arch Pediatr Adolesc Med. 2012;166(4):362-371. doi:10.1001/archpediatrics.2011.832

Figure. Risks of false-positive and false-negative diagnoses of bipolar disorder. ADHD indicates attention-deficit/hyperactivity disorder.

Opinion 1 : Trying to use the course modifier “rapid cycling” , because children often do not have clearly demarcated episodes, but seem to be chronically cycling1-4

1. Pediatric bipolar disorder: emerging diagnostic and treatment approaches: Kowatch RA, DelBello MP.Child Adolesc Psychiatr Clin N Am. 2006 Jan;15(1):73-108. Review.

2. Diagnostic characteristics of 93 cases of a prepubertal and early adolescent bipolar disorder phenotype by gender, puberty and comorbid attention deficit hyperactivity disorder :Geller B, Zimerman B, Williams M, Bolhofner K, Craney JL, Delbello MP, Soutullo CA. J Child Adolesc Psychopharmacol. 2000 Fall;10(3):157-64.

3. Rapid, continuous cycling and psychiatric co-morbidity in pediatric bipolar I disorder: Findling RL, Gracious BL, McNamara NK, Youngstrom EA, Demeter CA, Branicky LA, Calabrese JR: Bipolar Disord. 2001 Aug;3(4):202-10.

4. Childhood mania: insights into diagnostic and treatment issues: Wozniak J, Biederman J: J Assoc Acad Minor Phys. 1997;8(4):78-84. Review.

Opinion 2: Prepubertal BP I patients have multiple mood swings each day, have mixed episodes with short periods of euphoria mixed with longer periods of irritability.5,6

5. Mania-like symptoms suggestive of childhood-onset bipolar disorder in clinically referred children: Wozniak J, Biederman J, Kiely K, Ablon JS, Faraone SV, Mundy E, Mennin D: J Am Acad Child Adolesc Psychiatry. 1995 Jul;34(7):867-76.

6. Four-year prospective outcome and natural history of mania in children with a prepubertal and early adolescent bipolar disorder phenotype: Geller B, Tillman R, Craney JL, Bolhofner K: Arch Gen Psychiatry. 2004 May;61(5):459-67.

Opinion 3: Geller in her classic paper of 2002 7 describes “Children are developmentally incapable of many manifestations of bipolar symptoms described in adults e.g., children do not “max” out on credit cards or have four marriages” and has discussed age equivalents of adult mania behaviors.

7. Phenomenology of prepubertal and early adolescent bipolar disorder: examples of elated mood, grandiose behaviors, decreased need for sleep, racing thoughts and hypersexuality: Geller B, Zimerman B, Williams M, Delbello MP, Frazier J, Beringer L: J Child Adolesc Psychopharmacol. 2002 Spring;12(1):3-9.

Normal Child Child Mania Adult Mania

Child was super happy on days family went to Disneyland, on Christmas morning, and during grandparents’ visits. Child’s joy was appropriate to context. Child’s behavior was not impairing

A 7-year-old boy was repeatedly taken to the principal for clowning and giggling in class (when no one else was) and was suspended from school. He had to leave church with his family for similar behaviors. A 9-year-old girl continually danced around at home stating, “I’m high,over the mountain high” after suspension from school.

A 40-year-old man giggled infectiously while being placed in restraints in the emergency room. A50-year-old man in the emergency room was infectiously amusing as he described multiple hospitalizations, losing jobs, and losing family ties.

Normal Child Child Mania Adult Mania

A 7-year-old boy played at being a fire fighter, directing other fire fighters and rescuing victims. The child was not calling the fire station to tell them what to do. Play was during afterschool hours; it wasage appropriate and not impairing.

A 7-yo boy stole a go-cart because he just wanted to have it, even though he knew stealing was wrong. He did not, however, believe it was wrong for him to steal. When the police arrived, the child thought the officers were there to play with him. An 8 yo girl opened a paper flower store in her classroom and was annoyed and refused toclass work when asked by the teacher. An 8 yo girl, failing at school, spent her evenings practicing for when she would be the first femalepresident. She was also planning how to train her husband to be the First Gentleman. When asked how she could fail school and still be president, she said she just knew it

An adult man kept his family in increasing debt due to multiple unrealistic business ventures. A 21 yo man believed he could commit a homicide and not be arrested because the laws would not pertain to him. An 18 yo woman rang the mayor’s home doorbell because she knew they were engaged. When asked if she had ever met the mayor, she stated it did not matter

Normal Child Child Mania Adult Mania

Normal Children sleep approx 8-10 hours a night and are tired if they sleep fewer hours than usual

An 8 yo boy chronically stayed up until 2 a.m., rearranging furniture or playing games. Then he awoke at 6 a.m. for school & was energetic during the day without evident tiredness, or fatigue. A 7 yo girl, daily, knocked on a friend’s door at 6 a.m. ready to play.

A 25 yo woman worked both day and evening full time jobs, seemingly without fatigue. A father described his daughter as “she parties” for days in a row, and then “sleeps” for days in a row

Normal Child Child Mania Adult Mania

A 7 yo child played doctor with the same aged friend. A 12 yo boy looked at his father’s pornographic magazines

An 8 yo boy imitated a rock star by gyrating his hips, and rubbing his crotch during a research interview. A 9 yo boy drew pictures of naked ladies in public, stating these were drawings of his future wife. A 14 yo girl passed notes to boys in class asking them to f *** her. A 7 yo girl touched the teacher’s breasts and propositioned the boys in the class. Another child called the “1-900” sex lines, which the parents discovered when the phone bill arrived at the end of the month.

Numerous adults who had four or more marriages not due to death of spouses or who had multiple extramarital affairs.

Normal Child Child Mania Adult Mania

Normal subjects did not give affirmative response to inquiries about racing thoughts

Unlike Manic adults, children gave concrete answers to describe their “racing thoughts.” Examples are: A girl pointed to the middle of her forehead and stated “I need a stoplight up there.” Other children noted the following: “It’s like an energizer bunny in my head.” “Too much stuff is flying around up there.” “I don’t know what to think first.” “My thoughts broke the speed limit.”

Adults conceptually understand “racing” thoughts and can describe them using the word racing

Opinion #4: Dr. Leibenluft’s NIH lab has given a demarcation between various phenotypic expressions of Mania/Hypomania

8: Defining clinical phenotypes of juvenile mania: Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS: Am J Psychiatry. 2003 Mar;160(3):430-7. Review.

The co-occurrence of additional disorders complicates both the accurate diagnosis of BPD and it’s treatment

The presence of comorbidity compounds disability, complicates RX, and worsens the prognosis

If comorbidity is not acknowledged, misattribution of impairing symptoms could lead to inappropriate therapeutic interventions, unnecessary exposure to neuroleptics, worsening of symptoms, and misuse of mental health resources

9. Comorbidity in pediatric bipolar disorder: Joshi G, Wilens T: Child Adolesc Psychiatr Clin N Am. 2009 Apr;18(2):291-319, vii-viii. Review.

ADHD is comorbid with BPD : 60-90% ADHD comorbidity more often associated

with early onset BPD Recognition of this comorbidity is very

important because- Medications with Manicogenic potential- Atypical response- Less than expected antimanic response to

thymoleptic agents- If the symptoms of inattentiveness,

distractibility, talkativeness, and impulsivity are not recognized as comorbid ADHD, they may be inappropriately treated as residual symptoms of mania

Symptoms which are not mania specific : occur in both categories

- Irritable mood- Accelerated speech- Distractibility- Increased energy Criteria which provide best discrimination- Elated mood- Grandiosity- Flight of ideas/Racing- Decreased need for sleep Of the poor judgment criteria (total poor judgment,

hypersexuality, daredevil acts, silliness, uninhibited people seeking) only hypersexuality provides good discrimination between ADHD & PEA-BP

* = Pediatiric and Early Adolescent

10. DSM-IV mania symptoms in a prepubertal and early adolescent bipolar disorder phenotype compared to attention-deficit hyperactive and normal controls: Geller B, Zimerman B, Williams M, Delbello MP, Bolhofner K, Craney JL, Frazier J, Beringer L, Nickelsburg MJ: J Child Adolesc Psychopharmacol. 2002 Spring;12(1):11-25.

There are no FDA approved medications for children younger than 10 years

Several antipsychotics are approved 10-17

Lithium is approved for 12 and above Contrast to 19 meds for ADHD

Need for NIMH or Private foundation to fund research

Studies without a placebo arm are wanted by Parents, when considering entering their children in clinical trials12

Practical randomized, open comparative trials of two active agents could be performed at a single site or several sites, and not involve the expense of traditional Multi-site RCT’s13

12. Parental attitudes towards early intervention in children at high risk for affective disorders: Post RM, Leverich GS, Fergus E, Miller R, Luckenbaugh D: J Affect Disord. 2002 Jul;70(2):117-24.

13. Childhood-onset Bipolar Disorder: The Perfect Storm :Robert. M Post: Psychiatric Annals (Editorial): October 2009

AACAP Practice Parameters for BD Include screening questions for BD

during psychiatric evaluation Use “unmodified” DSM-IV-TR criteria for

diagnosis If + make sure you screen for all the

comorbidities viz. substance, suicidality and medical problems

Be cautious in diagnosing in pre-schoolers (refer/second opinion)

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