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Flashcards in Week 9: Bipolar Basics Deck (20)
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1
Q

Pediatric Bipolar Disorder

A

Different manifestations of the same underlying problem we see in adults

Fundamental debate in child psychology: How do we ensure that symptoms
are developmentally appropriate
-CD/ODD
-Depression

2
Q

Definition

A

Manic Episode

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

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:
-inflated self-esteem or grandiosity
-decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
-more talkative than usual or pressure to keep talking
-flight of ideas or subjective experience that thoughts are racing
-distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
-increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
-Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., sexual behavior, shopping, gambling)

3
Q

Hypomanic Episode

A

Same as manic episode except:

  • Lasting at least four consecutive days
  • Represents a change in functioning for the person
  • But no marked impairment in social or occupational functioning
4
Q

Depressive Episode

A

Meets criteria for a major depressive episode

5
Q

Bipolar 1

A

Manic episode
-May or may not show depression (note that textbook is mistaken)
-Specifier – with mixed features
-Person is experiencing episodes that include symptoms of both mania and
depression (e.g., a manic episode in which some symptoms of depression are
present)

6
Q

Bipolar 2

A

Major depressive episodes and hypomanic episodes

  • Has not ever had a full manic episode
  • Specifier – with mixed features
7
Q

Cyclothymia

A

Period lasting at least 1 year (in children and adolescents, 2 years for adults) when there numerous hypomanic and depressive symptoms that do not meet full criteria for either a hypomanic, manic, or major depressive episode

8
Q

Bipolar Disorder in Children

A

Between 1990 and 2000 diagnoses of bipolar disorder in children quadrupled

1999 saw the publication of a book entitled the Bipolar Child by a New York psychiatrist

Argued that bipolar disorder in children was overlooked

Provided a vague and general list of behaviors

  • Poor handwriting
  • Complains of being bored
  • Is very intuitive or very creative
  • Excessively distressed when separated from family
  • Has difficulty arising in the A.M
  • Elated or silly, giddy mood states
  • Curses viciously in anger
  • Intolerant of delays

NOT SPECIFIC
Could be normal or another condition

9
Q

Bipolar Definition

A

2001 field decided that bipolar disorder could be diagnosed in children

Noted that there can be differences in presentation of bipolar in children and adults

Adults typically have discrete episodes

In children, may see changes in mood even within the same day

Tend to have long episodes like this (1 to 4 years)

10
Q

Narrow/broad

A

Narrow phenotype
“Classic” adult symptoms
-Mania, grandiosity

Some children/adolescents meet the full diagnostic criteria meant for adults

Broader phenotype
-Irritability, mood lability

Irritability is much more common than mania

However, irritability is not a specific symptom for bipolar

Occurs in other disorders as well

  • Depression
  • ODD

Is this actually bipolar disorder?

11
Q

Diagnostic Challenges

A

Irritability, rather than euphoria, can be the predominant mood
state

Differential diagnosis

Depression, ODD, CD, ADHD

Due to this overlap, some authors have argued that to be diagnosed with bipolar disorder, children must show core features of
mania, which has higher specificity

Grandiosity, elevated mood

These features do occur in a significant number of youth who have been identified as having bipolar disorder

Children may not show discrete episodes:

Children often show rapid mood changes (between depression and
mania on the same day)

Also see youth with chronic mania

12
Q

Practice Parameters of the American Academy of Child and Adolescent Psychiatry

A

DSM criteria for adults should be applied to children and
adolescents

Mania, which may include irritability, present as a marked change in the individual’s state

Illness represents a departure from baseline functioning

Note that many children do not meet the duration criteria for a full manic episode, which is required for bipolar I, so bipolar 2
and cyclothymia are more common diagnoses

Diagnostic validity of bipolar disorder in preschool children has yet to be established

AS OF NOW YOU MUST USE DSM-5 ADULT CRITERIA

13
Q

DSM-5 DMDD BS

A

Inclusion of new disorder

Disruptive Mood Dysregulation Disorder (DMDD)

Very controversial

No published data using these criteria

14
Q

DMDD

A

A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward
people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.

B. The temper outbursts are inconsistent with developmental level.

C. The temper outbursts occur, on average, three or more times per week.

D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers)

E. Symptoms are present for 12 months or more

F. Not diagnosed before age 6 or after age 18

G. Age at onset of the outbursts and irritable mood is before age 10

H. Child has never met criteria (except duration) for a manic or a hypomanic episode (even lasting one day)

Is not diagnosed concurrently with:
ODD
DMDD is more severe
Bipolar disorder

15
Q

Research on DMDD

A

Research on this disorder is very limited

More research has focused on related on construct – severe mood dysregulation (SMD)

Also includes symptoms of hyperarousal (e.g., flight of ideas, agitation, insomnia)

Work has been done primarily on one sample

16
Q

SMD vs Bipolar

A

Children diagnosed with bipolar disorder (using adult criteria) much more likely to have future manic episodes than children with SMD

Children who meet criteria for SMD more likely to go on to develop major depression

Suggests that SMD and bipolar disorder are distinct

17
Q

DMDD Research

A

Research teams worked retrospectively by applying new criteria
to data already collected

Axelson et al. 2013

  • Examined DMDD in a large sample of 6 to 12 year olds seeking psychiatric services
  • Found that DMDD was not well-differentiated from CD or ODD
  • 58% of youth with ODD and 62% of youth with CD met criteria for DMDD

No difference between youth with and without DMDD diagnosis in symptom severity or functional impairment

DMDD diagnosis showed poor stability (Later didn’t meet criteria)

Youth with CD/ODD did not look different to youth with DMDD

18
Q

Drequency and duration in DMDD

A

Copeland et al. 2013 examined the DMDD criteria in three large
community samples

Found that the frequency and duration criteria are very
important

In these samples, 80% of preschoolers and 50% of older youth were reported to have severe temper outbursts

When frequency criteria (3 x week) applied, number drops to 17% in preschoolers, and 6% to 7%

Irritability present in 8-13% of children and 21% of preschoolers

When duration criteria (1 year) applied drops to 1.5-2.8% in older children and 6% in preschoolers

All criteria yields a prevalence of about 1% in older children and
3.3% in preschoolers

Again, was not clear that this disorder was distinct from ODD

Apply the duration criteria STRICTLY

19
Q

DMDD validity

A

Validity of this diagnosis not firmly established

Risk of over-diagnosis

Irritability is an important construct in child psychopathology

Key dimension on many types of child psychopathology

20
Q

Summary

A

Bipolar disorder occurs in children

Currently, adult diagnostic criteria is applied to pediatric cases

Children may present with extreme irritability and tantrums

DSM-5 introduced a new diagnosis – DMDD – to describe this presentation

Not clear that this disorder is distinct from ODD

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