PEDIATRIC BIPOLAR DISORDER

Transcription

1 PEDIATRIC BIPOLAR DISORDER Swapna Deshpande, MD Clinical Assistant Professor Associate Training Director, Child/Adolescent Fellowship Program Department of Psychiatry & Behavioral Sciences University of Oklahoma Health Sciences Center

2 INCIDENCE OF BPD RISING A cohort or year-of-birth effect where there is an earlier age of onset and an increased incidence of both unipolar and bipolar disorder has been observed in every birth cohort since World War I.

3 EARLIER ONSET IN NIMH COHORTS

4 MORE IS USA VS NETHERLAND AND GERMANY

5 POSSIBLE HYPOTHESIS Was this an artifact? Was there another reason?

6 RATES IN US WERE DOUBLE Higher genetic loading (a higher percentage of positive family histories for bipolar and unipolar disorder) Higher incidence of childhood psychosocial adversity in the form of either physical or sexual abuse than those in Europe. In both instances, the rates in the United States were double those seen in the European cohorts.

7 POSSIBLE EXPLANATIONS: UNIQUE COHORT Possibilities include greater migration from Europe and other countries of those who were more adventuresome and risk taking Potentially a greater loading for bipolar disorder; increased risk of assortative mating Series of generations with more rapid rates of birth in younger individuals possessing more vulnerability markers or an increased vulnerability to gene/environment interactions.

8 POSSIBLE EXPLANATIONS Higher divorce rates Lesser presence of the extended family Greater stressors in parents including decreased vacation time in the United States versus Europe Lesser presence of the extended family Higher rates of alcohol and substance abuse Alterations in dietary habits and the possibility of increased environmental toxins

9 PHYSICIAN VISITS Recent data have suggested a 40-fold increase in the diagnosis of bipolar disorder in children and adolescents in a very short timeframe. Child Physician Visits , ,000 Not including children who werent seeking treatment.

10 CONTROVERSY Diagnostic controversy about childhood presentation. Most of the diagnostic controversy surrounds the irritable subtype of bipolar I and bipolar II disorder and the nature of the precise diagnostic thresholds for bipolar disorder NOS.

11 CASE PRESENTATION Courtesy Dr Courtney Nixon, MD Child and Adolescent Psychiatry Fellow, Department of Psychiatry and Behavioral Sciences

12 CASE PRESENTATION 17 year old WF with no prior psychiatric history presents to outpatient clinic for initial evaluation. Concerned she may have bipolar disorder because her biological father has been diagnosed with bipolar disorder

13 HPI Mood swings Irritability Periods of mildly depressed mood Poor sleep with low energy Weight gain of 50 lbs in 6 mo No periods of increased energy, impulsivity, etc

14 STRESSORS Mother with suicide attempt Frequent conflict with mother Multiple moves Bullied in middle school ISR for being disrespectful in middle school

15 PAST PSYCHIATRIC HISTORY Never hospitalized No suicide attempts 1 therapy session in the past Never on psychiatric meds Drinks ETOH ~1/mo, drinks 1-2 beers on these occasions, has never drank to intoxication

16 FAMILY PSYCHIATRIC HISTORY Biological father has been diagnosed with bipolar disorder, however, neither the patient nor her mother have ever known him to be sober from drugs and alcohol for any significant period of time Mother- intentional overdose on Ambien 3 yrs ago

17 SOCIAL HISTORY No real contact with bio father Mother was a flight attendant while pt was growing up and was not around much Mostly raised by both maternal grandma and paternal grandparents Has an older brother but has minimal contact with him Has a group of good friends in school, good grades, plays on the school golf team

18 MENTAL STATUS EXAM Affect slightly anxious, otherwise, within normal limits

19 Bipolar? Mood swings Irritability Periods of mildly depressed mood Poor sleep with low energy Weight gain of 50 lbs in 6 mo No periods of increased energy, impulsivity, etc Frequent conflict with mom Multiple moves Past Psych History Never hospitalized No suicide attempts 1 therapy session in the past Never on psychiatric meds Drinks ETOH ~1/mo, drinks 1-2 beers on these occasions, has never drank to intoxication Medical/Developmental Overweight Mother has full legal custody No other legal issues Social History Lives with mother and maternal grandmother Single, heterosexual Red Flags Mother with suicide attempt Bullied in middle school ISR for being disrespectful in middle school Family Psych History Biological father -bipolar disorder, As well as drugs and alcohol. Mother- intentional overdose on Ambien 3 yrs. ago depression? Mental Status Examination Affect slightly anxious, otherwise, within normal limits Relationships No real contact with bio father Mother was a flight attendant Mostly raised by grandmother Has 1 older brother but has minimal contact with him School/Work History Has a group of good friends in school, good grades, plays on the school golf team Works at Sonic part-time DSM IV Diagnosis I: Depression NOS, Anxiety NOS, r/o eating disorder II: Deferred III: overweight IV: family V: GAF 65

20 DOES THIS PATIENT MEET CRITERIA FOR BIPOLAR DISORDER? Why or why not?

21 OUR DIAGNOSIS Depression Not Otherwise Specified Anxiety Not Otherwise Specified Rule Out Eating disorder

22 IRRITABILITY Temporal lobe epilepsy PDD Disruptive Beh Disorders DEPRESSION ADHD Irritability : Low specificity for BPD GENERALIZED ANXIETY, PTSD

23 DSM IV CRITERIA FOR MANIC EPISODE

24 COMMON PRESENTATIONS IN CLINIC Irritability Conflict Aggression

25 AGGRESSION How long How frequent Worst episode Triggers Premeditated aggression Other settings Epilepsy Migraines Discipline or consequence Self harm

26 RESEARCH FINDINGS Among the early (before age 5) differentiators of children who would emerge with a confirmed childhood-onset bipolar diagnosis were symptoms including brief and extended periods of mood elevation and decreased need for sleep, each of which rarely occurred in those with ADHD.

27 ADHD VS. BIPOLAR Grandiosity, elated mood, daredevil acts, uninhibited people seeking, silliness/laughing, flight of ideas, racing thoughts, hyper sexuality, decreased need for sleep, increased goal-directed activity, increased productivity, irritable mood, and accelerated speech.

28 OVERLAP Irritability and Poor frustration tolerance ADHD 50% Bipolar more severe 80 90%

29 BIPOLAR DISORDER VS. DISRUPTIVE BEHAVIOR DISORDER If the behavior problems only occur while the child is in the midst of an episode of mania or depression, and the behavior problems disappear when the mood symptoms improve, the diagnoses of oppositional or conduct disorder should not be made.

30 BPD OR ODD If a child has off and on oppositional or conduct symptoms or these symptoms only appear when the child has mood problems, the diagnosis of BP (or other disorders such as recurrent unipolar depression or substance abuse) should be considered.

31 ODD If the child had oppositional behaviors before the onset of the mood disorders, both diagnoses may be given.

32 REFRACTORY CASES If a child has severe behavior problems that are not responding to treatment, consider the possibility of a mood disorder (bipolar and nonbipolar depressions), other psychiatric disorder (ADHD, substance abuse), and/or exposure to stressors. If a child has behavior problems and a family history of Bipolar disorder, consider the possibility that the child has a mood disorder (unipolar major depression or BP disorder).

33 FAMILY HISTORY OF BIPOLAR Difficult to evaluate esp. if Substance use is present. Decreased of sleep. Impulsivity or Poor judgment like spending a lot. Grandiosity High energy

34 SPECIFIC BIPOLAR CLUES If a child has behavior problems and is having hallucinations and delusions consider the possibility of BP disorder. Also consider the possibility of schizophrenia, use of illicit drugs/alcohol, or medical/neurological conditions.

35 TREATMENT Courtesy Dr Courtney Nixon, MD Child and Adolescent Psychiatry Fellow, Department of Psychiatry and Behavioral Sciences

36 SAFETY AND LEVEL OF FUNCTIONING Inpatient treatment may be necessary. NIH and AACAP- Acute presentations of mania in young people are managed in the hospital if the patient is at risk of suicide or if its first episode. Partial hospitalization, assertive outreach, and outpatient treatment are other options.

37 LITERATURE First line treatment- Second Generation Antipsychotics (SGA) Combination therapy with SGAs and mood stabilizers- no clear advantage No evidence supporting mood stabilizers as mono -therapy Various SGAs equally effective but vary in side effects Hazell, Jairam, Acute Treatment of Mania in Children and Adolescents, Current Opinions in Psychiatry, 2012; 25(4):

38 SGA Risperidone Abilify Geodon Zyprexa Seroquel

39 PHARMACOTHERAPY FOR MANIA Second generation antipsychotics (risperidone, aripiprazole, olanzapine, etc) most effective for acute manic/mixed episodes Combination therapy may be started with an SGA and mood stabilizer (lithium, valproate) with intent to use the mood stabilizer as maintenance treatment

40 PHARMACOTHERAPY FOR DEPRESSION Mood stabilizers (lithium, lamotrigine) May add on an SSRI for nonresponders

41 MAINTENANCE PHARMACOTHERAPY Mood stabilizers (lithium, valproate) Continuing meds used to achieve remission from manic or depressive episode

42 SIDE EFFECTS SGAs: Sedation, GI complaints, cold symptoms, headache, increased appetite, weight gain, EPS Mood stabilizers: N/V, increased appetite, weight gain, headaches, sedation, tremor, dizziness, rashes SSRIs/SNRIs: GI upset, headaches, increased or decreased appetite, insomnia/somnolence

43 PSYCHOSOCIAL TREATMENT Psychosocial Education Problem Solving Coping skills Reward Based CBT with interpersonal therapy with an emphasis on Empathic validation. Build resources to manage stress and lower expressed negative emotions in the family.

44 PSYCHOSOCIAL INTERVENTIONS No evidence for efficacy of psychosocial interventions alone without pharmacotherapy

45 QUESTIONS..? Thank You.