Download Child and Adolescent Psychopathology

Part V: Other
Psychological
Disorders
Bipolar Disorder
Chapter 19
Joseph C. Blader and Gabrielle A. Carlson
HISTORICAL CONTEXT
 Emil Kraepelin (1921) coined manic-depressive insanity as
a cyclical disturbance of depression and manic excitement.
 1920s and 1930s concluded that Kraepelin' s conception of
manic-depression occurred among youth but was rare.
 1950s Lithium's efficacy for the treatment of acute mania
was established.
 Past 20 years recognition of frequent onset of BPD in mid-
to late-adolescence, with possible prodromal signs evident
even earlier.
DIAGNOSTIC CRITERIA AND
CLINICAL PRESENTATION
 In most formal definitions, BPD comprises:
 Episodes of depression; interspersed to greater or lesser
degree
 Episodes of manic (or mixed) symptoms
 Intervals between episodes during which mood state and
functioning may vary widely both across patients and for
the same person over time
 An overall course of illness that is chronic
(American Psychiatric Association, 2000; Goodwin & Jamison, 2007; World Health
Organization, 2010)
DIAGNOSTIC CRITERIA AND
CLINICAL PRESENTATION
 Bipolar I Disorder
 BPDI is the diagnosis applied to either:
• A person experiencing an episode of mania or a mixed episode.
• One who is experiencing an episode of major depressive disorder
or of hypomania but has had a manic or mixed episode in the past.
DIAGNOSTIC CRITERIA AND
CLINICAL PRESENTATION
 Other Forms of BPD: Bipolar II Disorder and
Cyclothymic Disorder
 BPDII and cyclothymia involve episodes of hypomania.
Hypomania differs from mania chiefly in terms of
severity and level of impairment.
 Cyclothymic disorder is a still milder form of BPD.
 BPDII is the diagnosis applied for an individual who is
experiencing either:
• An episode of hypomania.
• An episode of major depression but who also had a prior episode of
hypomania but never had a full manic episode.
PREVALENCE
 BPD among adults in the United States is generally
agreed to be about 1% to 1.5%, with lifetime
prevalence of disorders in the BPD spectrum
around 4.5% (Kessler et al., 2006; Merikangas et al., 2007).
 Lifetime prevalence among adolescents for bipolar
I or II disorder combined of 2.9%. Prevalence
increases with age during adolescence and 89.7%
of adolescents with these disorders were classified
as manifesting “severe” impairment.
DEVELOPMENTAL
PROGRESSION
 Adolescent-Onset BPD:
 High rates of serial hospitalizations
 Substance-abuse
 Suicide attempts or actual suicides
 Less robust response to lithium and divalproex
 Generally worse interepisode functioning than adult-onset
BPD
 Risk for adverse outcomes rises with earlier onset,
presence of psychotic features, mixed features,
and low socioeconomic resources (Birmaher, et al., 2006).
COURSE AND OUTCOMES OF BIPOLAR
DISORDER IN ADULTHOOD
 With age depressive episodes become more frequent and
longer.
 In the best of cases, functioning between episodes of mood
disturbance can be quite good and a stable, tolerant family
and a social milieu can act as a buffer.
 A less fortunate outcomes can lead to:
 A downward drift socially as interpersonal and occupational
functioning become increasingly erratic and inadequate
 Interepisode recovery is less successful
 Sources of social support may become alienated
 Legal entanglements
 Criminal activity
 Alcohol and drug abuse
CONCEPTUAL AND PRACTICAL ISSUES IN
THE DIAGNOSIS OF BIPOLAR DISORDER
AMONG YOUTH
 Symptom Differences and Confounding
Comorbidities
 An elevated or euphoric mood
 Extreme irritability
 Grandiosity
 Decreased need for sleep
 Increased talkativeness
 Distractibility
 Increases in goal-directed activity
 Psychomotor agitation
 Excessive involvement in pleasurable activities
 Psychotic symptoms
CONCEPTUAL AND PRACTICAL ISSUES IN
THE DIAGNOSIS OF BIPOLAR DISORDER
AMONG YOUTH
 Distinct Periods of Mood Symptoms or
Exacerbation
 Rapid cycling: Is defined by at least four episodes in a
year.
 Episodicity: Implies an onset with a significant change
from ordinary functioning.
 Periods of remission that occur spontaneously are very
uncommon among children, which is yet another
deviation from BPD’s episodic nature.
ALTERNATIVE APPROACHES TO
EMOTIONAL VOLATILITY IN YOUTH
 Persistence Versus Transience of Mood
Disturbance
 A number of children do show persistent negative mood
that changes only minimally with positive events.
 Children who manifest with significant irritability are, in
fact, highly overreactive to events.
 Ultradian cycling: Cycles appear many times within a
single day.
DISTINGUISHING NARROW,
INTERMEDIATE, AND BROAD
PHENOTYPES
 Narrow phenotype: Has a symptom presentation, course, and
episodicity fully aligned with current criteria for (adult) BPD, with the
additional requirement that the mood abnormality be euphoria or
signs of pathological grandiosity.
 One intermediate phenotype encompasses manic episodes that
last from 1 to 3 days. Current nomenclature would classify a
number of these situations as bipolar disorder not otherwise
specified (NOS).
 The other intermediate phenotype allows irritability to be the main
mood aberration, so long as there is also evidence of welldemarcated episodes.
 Broad phenotype: Denoted as severely disturbed behavior and
mood dysregulation, which essentially describes chronic negative
emotional reactivity and impulsivity.
RISK FACTORS AND
ETIOLOGICAL FORMULATIONS
 Depression
 Patients who develop BPD often experience depression as
their first episode
 Biological Susceptibility Factors
 Heritability and genetic markers
 Neurodevelopmental antecedents
 Disturbances of the sleep-wake cycle
 Cognitive Factors and Other Potential Markers
 Impaired response inhibitions and other executive functions
 Deficits related to attention and inhibitory controls
 Tendency to exaggerate and dwell on misfortunes
RISK FACTORS AND
ETIOLOGICAL FORMULATIONS
 Neuroanatomical and Neurophysiological Factors
 Reduced amygdala volumes
 Increased amygdala activity elicited by emotion relevant stimuli
 Reductions in volume of the anterior cingulate
 Experiential and Environmental Susceptibility Factors
 Childhood maltreatment
 Stress
 Childhood truama
 Psychotropic medications
COMORBIDITY, SEX DIFFERENCES &
CULTURAL FACTORS
 ADHD is the leading comorbidity among BPD children.
 Substance abuse is common among adolescents and
adults with BPD.
 Prevalence estimates of comorbid anxiety disorders vary
considerably in child BPD.
 Similar rates of BPD in adolescents but higher rates of
males in child samples.
 May be cultural differences in the use of diagnoses in
clinical settings.
THEORETICAL SYNTHESIS AND
FUTURE DIRECTIONS
 Forms of very early onset, chronic, and unremitting
affective and behavioral volatility have been postulated to
constitute a variant of BPD among youth.
 At this time, it remains uncertain whether these forms of
impairment are:
 Developmental versions of the same disease processes that underlie
later-onset BPD.
 Separate types of illness that might involve perturbations of the same
mechanisms of self-control and mood that are implicated in BPD.
 Fundamentally different problems, such as severe ADHD with ODD,
which demonstrate some phenotypic overlap with BPD.