Download Bipolar Disorder - American Academy of Child and Adolescent Psychiatry

Pediatric Bipolar
Disorder
Mani N Pavuluri, MD, PhD
Berger Colbeth Chair in Child Psychiatry
Pediatric Brain Research and Intervention Center
University of Illinois at Chicago
@ copy righted
Overview of the presentation
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How does it look?
Measurement
How to differentiate from ADHD
Prevalence
Onset
Follow up
Assessment: Big picture
Pavuluri, 2012
Pavuluri, 2012
What is a Pediatric
Bipolar Disorder?
Central feature:
Elevated, expansive mood or
Irritable mood
Pavuluri, 2012
Equivalent description in a child
Mood
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Excited
Giggly
Silly
Giddy
constantly on the go
laughing fits
joking and feels
invincible
“ overwhelming”
“ like wanting to jump
on the bed”
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Constantly irritable
Aggressive
throwing pot plants
slamming doors
hard to transition
Acidic
Abrasive
hostile in words
Kicking
screaming
intense & inconsolable
out of proportion to the
psychosocial stresses around
them
Pavuluri, 2012
Feeling good
about myself
1) Generous gave money to the
school’s mission collection
2) Friendly to everyone
3) Share my lunch with my friends
getting up every morning at the
regular time not tired
I eat breakfast, lunch and dinner
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Pavuluri, 2012
Timeline
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Ultra Rapid Cycling: Complex Cycling
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“Mini cycles within a big cycle”
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Frequency: most days in a week
Intensity: severe enough to cause extreme
disturbance in one domain or moderate
disturbance in two or more domains
Number: three or four times a day
Duration: four or more hours a day
Pavuluri, 2012
Specific to PBD
Comorbid
ADHD
Irritability
77-98%
75-98%
Chronicity
4229 months;
84%
Rapid
Cycling
46-87%
Mixed
Mania
20-84%
Pavuluri, 2012
Mood Spectrum: Normal
Elevated
Mood
Depressed
Mood
Time
Pavuluri, 2012
Mood Spectrum: Major
Depressive
Disorder
Elevated
Mood
Normal
Depressed
Mood
Time
Pavuluri, 2012
Mood Spectrum: Mania
Elevated
Mood
Normal
Major Depressive
Disorder
Depressed
Mood
Time
Pavuluri, 2012
Mood Spectrum: Dysthymia
Elevated
Mood
Mania
Normal
Major Depressive
Disorder
Depressed
Mood
Time
Pavuluri, 2012
Mood Spectrum: Hypomania
Elevated
Mood
Mania
Normal
Depressed
Mood
Major Depressive
Disorder
Dysthymia
Time
Pavuluri, 2012
Bipolar
Mood Spectrum:
Disorder
Elevated
Mood
Mania
Hypomania
Depressed
Mood
Normal
Major Depressive
Disorder
Dysthymia
Time
Pavuluri, 2012
Pediatric
Mood Spectrum: Bipolar
Elevated
Disorder
Mood
Depressed
Mood
Time
Pavuluri, 2012
Mood Spectrum
Mania
Elevated
Mood
PBD
Hypomania
Normal
Depressed
Mood
Dysthymia
Bipolar
Major Depressive
Disorder
Time
Pavuluri, 2012
Distribution of Bipolar
Subjects
2%
10%
4%
BP I
BP II
Cyclothymia
BP NOS
84%
Pavuluri, 2005
BP-NOS at Intake – Convert to BP-I
Mania
Hypomania
BP-NOS
Euthymia
Dep-NOS
Major Depression
Birmaher et al, AACAP, 2003
Pavuluri, 2012
BP-II at Intake – Convert to BP-I
Mania
Hypomania
BP-NOS
Euthymia
Dep-NOS
Major
Depression
Birmaher et al, AACAP, 2003
Pavuluri, 2012
“Diagnostic fashion
runs in cycles!”
Pavuluri, 2012
Pavuluri, 2012
Child Mania Rating Scale, Parent Version
The following questions concern your child’s mood and behavior in the past month. Please place a check mark or an ‘x’ in a box
for each item. Please consider it a problem if it is causing trouble and is beyond what is normal for your child's age. For example,
check ‘never' if the behavior is not causing trouble.
Never Sometimes Often Very Often
/Rarely
1. Have periods of feeling super happy for hours or days
at a time, extremely wound up and excited, such as
feeling "on top of the world"
0
1
2
3
0
1
2
3
3. Think that he or she can be anything or do anything
(e.g., leader, best basketball player, rap singer,
millionaire, princess) beyond what is usual for that age
0
1
2
3
4. Believe that he or she has unrealistic abilities or powers that
are unusual, and may try to act upon them, which causes trouble
0
1
2
3
2. Feel irritable, cranky, or mad for hours or days at a time
Pavuluri et al, aacap 2004
Pavuluri, 2012
How to use it?
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Have the parent focus on the child’s
behavior in the past month.
“Never/Rarely” and “Sometimes” =
behavior that is causing minimal or no
difficulty
“Often” and “Very Often” = behavior
that is causing trouble.
The child’s score is the sum of all item
scores.
Pavuluri, 2012
Interpreting the results
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A cut off score of 15 screens for the
manic spectrum
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A cut off score of 20 is highly specific
for mania
Pavuluri, 2012
Reliability
Internal Consistency: 0.96
 Test Re-test Reliability: 0.96
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Pavuluri, 2005
CMRS-P Total Score
40
35
30
25
20
15
HC
ADHD
BD Only
BD+ADHD
10
5
0
Pavuluri, 2012
Why should I choose it?
PROS
DSM IV basis
Singular item focus
Integrated functionality
Age specific items
Timing of symptoms
Language
Linked examples
Pavuluri, 2012
Formulation
Diagnosis
Precipitating Factor
Why now?
Outcome
Interpersonal
DD 1. (w/3 main symptoms)
2.
3.
Functioning
Other…
Background
Mother - Dev. Hx
Relationships
Maturity
Personality
Work
Psychopathology
Attachment/Goodness of Fit
Father
Personal
Resources
Parenting
Temperament and
Personality Style
Strengths
Capacity
Coping Mechanisms/Defenses
(knowledge, skills, attitude, motivation)
M-F (partnership)
Context
Child
Siblings
Family
- Support
- stresses
*Central Issue
*EMIC vs. ITIC
Structural (roles, relationships) C – C, M – C, F – C, etc.
Strategic (problem solving, family beliefs)
Systemic (theme)
*Find the Person/s
Family
Friends
Teacher
Home
School
Mania vs. ADHD
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ADHD
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Primarily a disorder of attention,
not mood
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Onset before age 7
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Persistent, not episodic
Problem of Comorbidity
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Comorbidity of ADHD In
Pediatric Bipolars
Study
n
Mean
Age
West et al., 1995
14
15.1
57%
Wozniack et al., 1995
43
7.9
98%
Faraone et al., 1997
68
6.1
93%
Geller et al., 2000
60
11
98% / 72%
Kafantaris et al., 1998
48
16
29%
Kowatch et al., 2000
42
11
71%
DelBello et al., 2001
34
15.7
ADHD
65%
Pavuluri, 2005
Distinguishing Between Bipolar
and ADHD
Bipolar
100
90
89
ADHD
86
80
71
Patients (%)
70
60
50
43
40
40
30
20
14
10
5
10
6
6
0
Elevated mood
Grandiosity
Flight of ideas
Decreased sleep
Geller & Zimerman 2002.
Hypersexuality
Pediatric Bipolar Disorder
 12 yr.
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Prepubertal & Early
Adolescent Onset
Bipolar Disorder (PEA
- BD)
Juvenile BD
Atypical BD
Childhood Onset BD
> 12 yr.
Adolescent Onset
Bipolar Disorder
(AO-BD)
Pavuluri, 2012
FEATURES
IRRITABLE MOOD
INTER EPISODE RECOVERY
PEA – BD
 12 YRS.
AOBD
> 12 YRS.
Prominent
(up to 98%)
Less Prominent
(up to 22%)
Low
(0 – 16%)
Moderate
(20 – 50%)
Chronic
Episodic
> Ultradian
> Rapid
Up to 20 – 85%
Up to 25%
ADHD, ODD
Substance Abuse,
Anxiety, PTSD
EPISODIC/ CHRONIC
CYCLING
MIXED
COMMON COMORBIDITY
DISORDERS
Pavuluri, 2012
Prevalence of BP in
Adolescents
Diagnostic interviews with 1709 high school
students, ages 14-18 years
Findings
1.0% prevalence of BP (primarily BP II
and cyclothymia)
5.7% prevalence of BP NOS
Lewinsohn 1995
Age of Symptom Onset
NDMDA Survey N=500
Lag to Diagnosis = 8 Years
30%
28%
20%
59%
10%
12%
16%
15%
14%
9%
5%
<5
5-9
10-14
15-19
20-24
25-29
30+
Years of Age
Lish 1994
Pavuluri, 2012
Recovery and Relapse
100
Subjects who recovered
80
87.2
77.9
Subjects who relapsed after recovery
% of Subjects
65.1
55.8
60
55.4
53.7
39.6
36.0
40
64.0
29.0
20
14.0
16.7
0
6
12
18
24
Follow-up, mo
36
48
Pavuluri, 2012
Developing the language
Symptom
List
Brain
Disorder
Invisible
Fist
FIND
Signature
Pavuluri, 2012
OUTINE
FFECT CONTROL
CAN DO IT
O NEGATIVE THOUGHTS; LIVE IN THE NOW
E A GOOD FRIEND: BALANCED LIFESTYLE
H! HOW CAN WE SOLVE IT?!
AYS TO GET SUPPORT
Pavuluri, 2012