1 / 63

Juvenile Onset Bipolar Disorder: Identification & Treatment

Juvenile Onset Bipolar Disorder: Identification & Treatment. ©Carrie Cadwell PsyD HSPP Cadwell Psychological Services, LLC www.cpsllc.info. Why discuss the Bipolar Spectrum in Youth?. Issue of myths versus realities STEP-BD study “what age did you first become bipolar?”

sona
Download Presentation

Juvenile Onset Bipolar Disorder: Identification & Treatment

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Juvenile Onset Bipolar Disorder: Identification & Treatment ©Carrie Cadwell PsyD HSPP Cadwell Psychological Services, LLC www.cpsllc.info

  2. Why discuss the Bipolar Spectrum in Youth? • Issue of myths versus realities • STEP-BD study “what age did you first become bipolar?” • 28% said before age 13 • 37% said between 13 and 17 • 35% said 18yo and above

  3. Why discuss the Bipolar Spectrum in Youth? • Issue of reasonable diagnostic clarity • COBPD: mixed states common with significant anxiety overlap; restlessness/impulsivity/decreased concentration present; dysphoria/irritability present; behavioral dyscontrol • Is it ADHD and depression? • Is it depression and anxiety? • Is it ADHD and ODD? • Is it ADHD, depression, and anxiety? • Is it PTSD? Complex Trauma? Develop Trauma? • Or is it COBPD? (get the picture)

  4. What is the controversy? • Are these youth best characterized as early onset Bipolar disorder or multiply disordered? • Is early onset BPD the same disorder as classic adult BPD • We do not know this yet

  5. Bipolar Disorder • Wolf and Wagner (2003): • 1% prevalence in American adolescents • Soutullo et al (2005): • 11% prevalence in young adults (Switzerland) • Holland 6 mo prevalence= 1.9% mania, .9% hypomania (adol.) • Denmark= 1.2% prevalence in 15 yo or younger whom were hospitalized • Finland= 1.7% adol. • University of Navarra data—4% prevalence of 5-8 yo

  6. Bipolar Disorder • Research Diagnostic Criteria (Papolos, 2002) • Marked variations in mood and energy level that are characterized by abrupt, rapidly alternating levels of arousal, excitability, motor activity and mood (ie mirthful, angry, depressed, anxious) • Diurnal cycles—low energy in am and boost in afternoon ..buzzing by evening • Seasonal affective impact

  7. Bipolar Disorder • RDC (Papolos, 2002) • Poor modulation of drives (anger, anxiety, SIB, sexual, appetite, acquiring things) • Sleep-wake cycle disturbance including dysomnias and parasomnias; nightmares • Low threshold for frustration---rage followed with withdrawal and remorse • Poor self esteem regulation (abrupt fluctuations in rejection sensitivity, LSE and grandiosity/bravado)

  8. Bipolar Disorder • RDC (Papolos, 2002) • Habituation deficit to situations---extreme, sustained overreaction to repetitive stimuli/triggers • Possible mood/energy induction with caffein. Corticosteroids, antidepressants, stimulants • Executive function deficits (unrealistic planning and others)

  9. Bipolar Disorder • RDC (Papolos, 2002) • Motor overflow/fine motor problems • Common comorbids: enuresis, night terrors, separation anxiety, panic/phobic dx, ADHD, OCD, conduct disorder, Tourette’s, Asperger’s, NVLD • Positive family history

  10. Bipolar Disorder • Fergus, 1999—American Psychiatric Assoc meeting • Look at • Grandiosity • Suicidal gestures • Irritability • Decreased attn span • Racing thoughts • If all 5- 91% prediction • If 3- 80% prediction

  11. Bipolar Disorder • Consensus Guidelines: • (Kowatch et al, 2005) • July 2003; 20 clinicians and CABF members developed guidelines over 2 days • Three sections: diagnosis, comorbities, treatment • We will cover diagnosis only

  12. Bipolar Disorder • Kowatch, 2005 • 1% prevalence in adolescents (BPD I, BPD II, cyclothymic)—Lewinsohn 1995 study • 5.7% BPD nos (some core sx but not full threshold for dx)—Lewinsohn 1995 study • In practice BP NOS and BPD II more likely to be seen, BP I more likely in inpatient settings • BPD II 5x more common than BPD I in teens • Rule of thirds—onset before 13, 13-18, 19+ (STEP-BD study)

  13. Bipolar Disorder • Why difficult per DSM criteria (Kowatch et al, 2005) • Issue of childhood equivalents---mania and hypomania---does the DSM present constructs that generalize down? • No clear stop/start to mood episodes • Child presentation often more mixed states---which can create a confusing diagnostic picture

  14. Bipolar Disorder • Gellar et al 2004: • 4 yr prospective study of 86 children/teens with bipolar symptoms • Inclusion in bipolar sx group required presence of grandiosity and elated mood (ie to differentiate ADHD) • Results- • 10% ultrarapid cycling; 77% ultradian cycling • On average 3.5 (+/- 2) cycles per day • Average onset—7.4 y.o (+/-3.5) • Average episode length 3.5 yrs (+/- 2.5)

  15. Bipolar Disorder • Kowatch et al, 2005 • Euphoric/Expansive Mood • excessive silliness, giddiness, excitability—look at congruence to context/triggers • Irritable Mood • “irritability” as sx is common to childhood-onset---depression, dysthymia, ODD, ASD, anxiety, ADHD • Disruptive behavior dx often show limited irritability with limit setting • Medication wear off for ADHD and side effect of SSRIs can create “whiny” irritability • ASD and Anxiety may show situational irritability or transition irritability • Key to all above irritability---limited in severity, frequency, and duration

  16. Bipolar Disorder • Kowatch et al, 2005 • Irritability cont. • MANIC IRRITABILITY= “frequently have rages or meltdowns over trivial matters (e.g. a 1- to 2- hour tantrum after being asked to tie their shoes). Aggressive and/or self-injurious behavior often accopmanies..” (p216) • This is qualitatively different from an 10-15 minute screaming match and slamming of doors after a parents says “no”

  17. Bipolar Disorder • Kowatch et al, 2005 • Grandiosity • Look at whether child can differentiate pretend play from reality • If hearing “I know…; I am the best…; I can take anyone down; I have special powers like (superhero)”—make sure to ask how they know this • “because I know” may indicate impaired reality testing or of acts on belief---”because my dad/mom told me so” = env’t • Decreased need for sleep • “a child’s sleep should be decreased by two or more hours per night for his or her age without evidence of daytime fatigue” (p216) • 4-5 hours sleep but still like the Energizer Bunny---heightened energy in evening, waking up during the night and engaging in goal directed activities)

  18. Bipolar Disorder • Kowatch et al, 2005 • Pressured Speech • It is normal to speak fast for children in carious emotional states • ADHD= incessant talking at fast rate • BPD= rapid speech that is loud, intrusive, and often hard to interpret • Racing Thoughts • My mind is going a million miles a minute • Observer---how easy is it to follow topic(s); baseline fx

  19. Bipolar Disorder • Kowatch et al, 2005 • Distractibility • Ask caregiver to think of a time when child was “even mood” or “doing fairly well” and question ADHD sx during this period • To what extent does it worsen during mood episodes? Is it present only in the course of the mood episode? What functional impact does this have? (ie poorer school perf.) • Increased Goal-Directed Activity/Psychomotor Agitation • Psychomotor agitation is non-specific (ie equal opportunity disorder sx) • Mania-look at heightened goal directed activity---excessive drawing, writing, building, creating, etc

  20. Bipolar Disorder • Kowatch et al, 2005 • Goal-Directed Act cont • Agitation/activity exceeds ADHD • Nervous agitation or trauma related hypervigilance/disorganized tension/agitation different

  21. Bipolar Disorder • Kowatch et al, 2005 • Excessive pleasurable/risky activities • Hypersexuality • Traumatized youth often have anxious/compulsive qualities to hypersexuality • BPD---pleasure seeking; teens may engage in sexual behaviors several times in a day • Psychosis • Hallucinations/delusions often present in BPD • Differentiate these from alert perceptual distortions and sleep onset or awakening phenomena

  22. Bipolar Disorder • Kowatch et al, 2005 • ADHD issue—is it comorbid, is it a prodrome? • Co-morbid ADHD 70-90% of CO-BPD • Comorbid ADHD 30-40% of AO-BOD • (Chang, 2005)—comorbid—children (90-95%), teens 50-60%) • Family History—if a child has a parent diagnosed with BPD that child has 2-3x increased risk

  23. Bipolar Disorder • Does it work the other way around? NO • While youth diagnosed with COBPD have a high likelihood of additional ADHD diagnosis…..in youth diagnosed with ADHD there is only a 10-22% comorbidity rate (Faraone & Kunwar, 2007)

  24. Bipolar Disorder • Kowatch et al” • FIND criteria • Frequency—sx present most days in a week • Intensity--- severe impairment in 1 domain, moderate impairment in 2+ domains • Number--- sx occur 3-4x in a day • Duration---sx present 4+ hours in a day (does not have to be consecutive

  25. Risk Factors • AACAP guidelines (2007) • Family history (4-6x increased risk of BPD in first degree relatives of affected persons) • Hyperarousal, disruptive beh, irritability, behavioral dyscontrol, anxiety/dysphoria • 20% of youth with MDD go on to experience manic episodes • Predicting mania conversion in depression children (same as adults) • Rapid onset depression with psychomotor retardation/psychotic features • Family hx of affective dx • Antidepressant induced cycling

  26. Bipolar Disorder • Screening Measures: • Note: Parent report tend to be superior to teacher and self-report for identifying BPD in youth • Mood Disorder Questionnaire (MDQ) • 90% specific to BPD, 70% sensitive (adults) • MDQ-adol version (self report, parent report) (JCP, 2006) • Using a cut-off of 5 • Parent report 81% specific, 72% sensitive • Self report 73% specific, 38% sensitive

  27. Bipolar Disorder • MDQ cont.. • Best at screening BPD I not as sensitive to BPDII and BPDNOS (Hirschfeld et al 200, 2002, 2005; Miller et al 2004) • Outpatient mood disorder clinic • Sensitivity .73, specificity .90 • General population • Sensitivity .28, specificity .97 • Bipolar/Unipolar population • Sensitivity .58 (BPDI .58, BPDII/BPDNOS .30) • Specificity .67 • PCP tx for depression • Sensitivity .58, specificity .93

  28. Bipolar Disorder • Screening cont. • Parent Young Mania Rating Scale • General Behavior Inventory • Child Mania Rating Scale (Pavulari et al 2006) • Core characteristics: elevated mood, grandiosity, and irritability • 5-17yo • Cut off of 20 differentiated BPD from ADHD and no BPD (94% specific, 82% sensitive) • This translates into a youth having a score equal to or above 20 almost 14x more likely to have BPD than ADHD—scores for BPD+ADHD vs BPD alone pretty similar

  29. Bipolar Disorder • Screening cont. • Child Bipolar Questionnaire-2 (Papolos & Papolos) • 65 item parent rating scale • Ages 5-17yo • Scales: mania, depression, dysregulation of aggressive impulses, dysregulation of sexual impulses, sleep/wake cycle disturbance, low threshold for arousal, anergia, low frustration tolerance, attention deficits/executive functions, fear of harm to self or others • Promising measure in terms of psychometrics

  30. Bipolar Disorder • Other instruments: • JBRF: Diagnostic Assessment Package • Includes: • CBQ-2 • Jeannie/Jeffrey Questionnaire for Children (4-11yo) • Child Bipolar Screening Interview • Optional: • Overt Aggression Scale • Yale-Brown Obsessive-Compulsive Scale

  31. Bipolar Disorder • Jeannie and Jeffrey Interview (9-12 yo) • Basically it is the child bipolar questionnaire and adapted to use with children • Pictures that depict various symptoms and a statement about the picture • Client answers never, sometimes, often, always • Upwards of 40 items

  32. Bipolar Disorder • Cardinal Symptoms (Chang, 2005) • Look at • Grandiosity • Decreased need for sleep • Racing thoughts • hypersexuality

  33. Bipolar Disorder • Understanding Phenotype (Papolos et al, Pavulari et al 2002, Leibenluft et al 2003) • Narrow: cardinal features—grandiosity, elated mood etc= more specific to DSM criterion • Broad: explosive rages, aggression, hyperarousal, chronic mood disturbance • Intermediate: • Irritable hypomania • Shorter duration episodes • Core (Papolos)—adds the dimensions of anxiety sensitivity, fear of harm, and overt aggression (hence the OAS and YB-OCS)

  34. Bipolar Disorder • Other measures: • WASH-U-KSADS (Kiddie Schedule for Affective Disorders and Schizophrenia) • KSADS Mania Rating Scale • Behavioral Inhibition Scale/Behavioral Activation Scale (supplemental)

  35. Bipolar Disorder • NPQ: Neuropsych Questionnaire (Gualtieri, 2007) • www.ncneuropsych.com • Online asst->start online asst-> administrator name: doctor, password:doctor • Ratings of various symptom areas—not diagnostic in and of itself but helpful in gathering information about patient status

  36. Bipolar Disorder • Kowatch, 2005 • % comorbids • CD/ODD—30-76% • Substance use 40% (also Chang, 2005) • Anxiety dx---36%

  37. Resources • Depression & Bipolar Support Alliance (www.dbsalliance.org) • Juvenile Bipolar Research Foundation (www.jbrf.org) • Child Adolescent Bipolar Foundation(www.bpkids.org) • The Bipolar Child (www.bipolarchild.com) • www.schoolpsychiatry.com • Bipolar Significant Others (www.bpso.org)

  38. Intervention • Medications • Child & Family Focused Cognitive Behavioral Treatment • Interpersonal Social Rhythm Therapy • Educational Interventions

  39. Issue of Medication • AACAP Practice Parameters (2007) • They note that the issue of medicating children with aggressive medication is a serious choice and there needs to be healthy caution about it • CABF survey found that of 854 caregiver respondents that 24% of affected children fell between 1 and 8yo

  40. Issue of Medication • AACAP Rec 6: “for mania in well defined DSM-IV TR Bipolar I Disorder pharmacotherapy is the primary treatment” • “Treatment should begin with an agent that is approved by the FDA for bipolar disorder in adults recognizing that the evidence of the efficacy for these agents in children & adolescents is sparse at best”

  41. Issue of Medication • Medication lifelong? • Comes back to answering the controversy of whether this is the same as adult BPD • AACAP recommends 12-24 mos continuation tx an some will need longer or lifelong maintenance tx • For adults we know that the relapse rate is high and that maintenance tx is typically needed

  42. Issue of Medication • CABF guidelines suggest stabilizing mood before addressing comorbidity (Correll 2008) • AACAP and CABF guidelines “advocate monotherapy with a mood stabilizer or atypical antipsychotic agent as a first line tx of BPD without psychotic features”

  43. Issue of Medication • Several available tx algorithms • Currently FDA approved for juvenile BPD: • Lithium down to age 12 • Risperdal and Aripiprazole • Range of meds get used though • Keep side effects in mind!

  44. Principles to live by… • Sleep: 7-8 hours restful sleep/developmentally appropriate • No drugs/alcohol • Medication adherence • 48 hour rule/pacing • Mood monitoring—what are my 3 warning signs • “EE” reduce negative expressed emotion • How do I solve the problem?

  45. Psychosocial Treatment • Should Address (AACAP, 2007) • Psychoeducation • Relapse Prevention • Individual Therapy • Social & Family Functioning • Academic & Occupational functioning

  46. Child & Family Focused CBT (Pavuluri et al 2004) • Derived for MultiFamily Psychoeducation Groups & Family Focused Tx BPD adults • Consider 3 things: • Characteristics of COBPD • Neurcircuitry dysfunction • Environmental stressors in family & school

  47. Child & Family Focused CBT (Pavuluri et al 2004) • Routine • Affect regulation • I can do it! • No negative thoughts & live in the Now • Be a good friend & Balanced lifestyle for parents • Oh how can we solve the problem • Ways to get support

  48. Child & Family Focused CBT (Pavuluri et al 2004) • Sessions 1 and 2---Parent & Child together • Psychoeducation • Develop common language—externalize the illness, give it a name • Mood charting/tracking for one month • Calling bipolar “wiring dysfunction” or “brain disorder” • Medications overview • RAINBOW overview • Discuss routine & relaxation

  49. Child & Family Focused CBT (Pavuluri et al 2004) • Sessions 3- Parents only • Discuss specifics of affective regulation • Encourage “I can do it” self statements and “no negative thoughts” • Train parents to coach their children to use the above • Discuss how to reorient grandiose, paranoid, devaluing thoughts in children

  50. Child & Family Focused CBT (Pavuluri et al 2004) • Sessions 4-7—child only • Introduce RAINBOW • Techniques of mood monitoring • Self talk for mood regulation • Identify “triggers” • Teach ABC model (antecedent-behavior-conseq) • “I can do it”, “No negative thoughts” • Write a “happy story” about self • Rewrite sad story to happy story

More Related