J. Indian Assoc. Child Adolesc. Ment. Health 2012; 8(1):1-5. Editorial

Transcription

1 1 J. Indian Assoc. Child Adolesc. Ment. Health 2012; 8(1):1-5 Editorial Controversies in Paediatric Bipolar Disorder Vivek Agarwal 1, Sivakumar T 2 1.Editor JIACAM & Associate Professor, Department of Psychiatry, CSM Medical University, Lucknow 2.Senior Resident, Department of Psychiatry, AIIMS, New Delhi About two thirds of adult bipolar disorder (BPD) patients report onset of bipolarity in childhood and adolescence [1]. The earlier the age of onset, the greater the risk of recurrence, functional impairment and chronicity of mood symptoms [2]. An influential paper in mid nineties suggested that juvenile mania had an insidious onset and ran a chronic course [3]. Mixed episode was most common presentation, dominated by severe irritability and affective storms. 70% of patients had an onset <5 years of age. Despite being chronically manic, it was reported that juvenile mania was frequently comorbid with attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD) and anxiety disorders [3]. Their school of thought emphasized the centrality of irritability in establishing the diagnosis and recommend diagnosing BPD if the child meets DSM-IV criteria with irritability as a core symptom, even in the absence of elation, grandiosity, and episodicity [3,4]. This was followed by an explosion in literature on paediatric BPD. Research groups differed in viewing paediatric BPD as an insidious onset chronic disorder characterized by irritability without elation or grandiosity and highly comorbid with disruptive behavioural disorder (DBD). Some researchers considered irritability to be a core criterion only if it co-occurs with elated mood or grandiosity [5-7]. Indian studies differed from western studies and reported classical episodic BPD with much lower rates of comorbid DBD [8,9]. National organizations also differed in their recommendations on diagnosing paediatric BPD. While American Association of Child and Adolescent Psychiatrists (AACAP) practice parameter considered irritability to be a key diagnostic criterion [10], NICE guidelines disagreed [11]. NICE guidelines did not support the everyday clinical use of BPD-II or BPD-NOS in children. In contrast, AACAP advised caution only in diagnosing preschool BPD. Operational modifications of BPD (prepubescent and early adolescent BPD (PEA-BPD) 5, BPD-NOS given by COBY study 6 and BPD-NOS given by AACAP) were given. Some researchers described ultra-rapid/ultradian cycling to be common in paediatric BPD [5]. As it is difficult to differentiate ultradian cycling from the affective/ temperamental instability that is part of ADHD, severe DBD were possibly being labelled manic. Doubts have been raised if different researchers conceptualize paediatric BPD in the same way. In a cross-national study with 5 case vignettes of prepubertal patients, UK psychiatrists

2 were more conservative in diagnosing BPD than their US colleagues [12]. UK clinicians were more likely to make a diagnosis on the basis of pattern recognition (as conceptualized in ICD-10 Clinical description and Diagnostic guidelines) rather than symptom counting. Although each research group uses one form or another of the K-SADS, they differ in their interpretation of DSM-IV TR criteria, source of information, interviewing methods, type of questions asked, and the kind of responses counted [13]. In many studies, assessments were carried out by trained raters and diagnosis was reviewed by a psychiatrist or psychologist [3-6]. In some studies, children were not interviewed at all. In some studies, different raters assessed the parent and child but their ratings were combined to arrive at a diagnosis. 5 Use of OR rule which accepts as positive any informant s symptom endorsement (parent OR child) results in more children being diagnosed with mania than if parent/child agreement is required [16]. Despite using same DSM-IV-TR diagnostic criteria, symptom complex of overactive, disinhibited behaviour was being interpreted differently. Increasingly, youth with emotional and behavioural symptoms without classic episodic adult BPD were diagnosed as paediatric BPD [13]. Children with chronic irritability and explosive anger outbursts are diagnostically homeless under current classification system [17]. But labelling them as BPD exposes them to medications of doubtful efficacy. To facilitate further research, clinical sub grouping of paediatric BPD into narrow (classical BPD), intermediate (episodic irritable mania/hypomania without elation or mania/hypomania with classical elevated mood and grandiosity but of only 1-3 days duration) and broad phenotype or severe mood dysregulation (SMD) (chronic irritability and hyperarousal) was suggested [7]. Research on SMD has been done by researchers from national institute of mental health (NIMH). In a post-hoc analysis of Great Smoky Mountains data set for SMD, the most common diagnosis were ADHD (26.9%), CD (25.9%) and ODD (24.5%) [18]. SMD predicted unipolar depressive disorders and not BPD, in early adulthood. In a prospective 2 year follow up study of SMD and narrow phenotype BPD patients, only 1/83 SMD patients experienced a (hypo)manic or mixed episode in contrast to 58/93 narrow phenotype BPD patients [19]. In a 6 week double blind placebo controlled trial, Lithium did not show efficacy vs placebo among SMD patients [20]. The NIMH group data differentiating SMD from narrow phenotype BPD in terms of longitudinal outcome [19] is reasonably strong while post-hoc analysis of epidemiological data [18] family history [21] cognitive [22] and neuroimaging [23] studies are suggestive. Carlson argues that current situation is due to the way DSM describes mania [16]. Apart from not defining concept of episodicity clearly, DSM does not require a distinct period different from one s usual self. Given the need to rectify the situation and foster further 2

3 research, DSM-V Childhood & Adolescent Disorders and the mood disorders Work Group have proposed Revising the wording of criteria for manic/hypomania to clearly operationalize episodicity [24] Introduction of a new diagnosis: temper dysregulation disorder with dysphoria (TDD)[25] TDD differs from SMD in not requiring hyper-arousal and ADHD-like symptoms. TDD can be conceptualized as most severely irritable patients with ODD. The new entity has been proposed to focus attention on severely impairing mood symptoms and to generate effective biological, psychological, and social treatments [25]. The proposal has been criticized as limited scientific evidence on SMD does not apply to TDD. It has been suggested to use a TDD like course specifier for other diagnosis (like ADHD, ODD, CD, mood disorders, anxiety disorders and autism spectrum disorders) or an analog of SMD as a separate diagnosis for study in the DSM-V appendix [26]. The entire debate has highlighted discrepant diagnostic practices and focused attention on diagnostically homeless youth with severe non episodic irritability. Let us hope that this signals the revival of phenomenology in diagnosing psychiatric disorders (an intended consequence of future classification systems!) rather than a symptom checklist approach. References 1. Perlis RH, Miyahara S, Marangell LB, et al. Long-term implications of early onset in bipolar disorder: data from the first 1000 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD). Biol. Psychiatry 2004, 55(9): Perlis RH, Dennehy EB, Miklowitz DJ, et al. Retrospective age at onset of bipolar disorder and outcome during two-year follow-up: results from the STEP-BD study. Bipolar Disord 2009, 11(4): Wozniak J, Biederman J, Kiely K, et al. Mania-like symptoms suggestive of childhood-onset bipolar disorder in clinically referred children. J Am Acad Child Adolesc Psychiatry 1995, 34(7): Biederman J, Mick E, Faraone SV, et al. A prospective follow-up study of pediatric bipolar disorder in boys with attention-deficit/hyperactivity disorder. J Affect Disord 2004,82 Suppl 1:S Geller B, Williams M, Zimerman B, et al. Prepubertal and early adolescent bipolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling. J Affect Disord 1998, 51(2): Birmaher B, Axelson D, Strober M, et al. Clinical course of children and adolescents with bipolar spectrum disorders. Arch. Gen. Psychiatry 2006,63(2): Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS. Defining Clinical Phenotypes of Juvenile Mania. Am J Psychiatry 2003, 160(3):

4 8. Srinath S, Janardhan Reddy YC, Girimaji SR, Seshadri SP, Subbakrishna DK. A prospective study of bipolar disorder in children and adolescents from India. Acta Psychiatr Scand 1998, 98(6): Jairam R, Srinath S, Girimaji SC, Seshadri SP. A prospective 4-5 year follow-up of juvenile onset bipolar disorder. Bipolar Disord 2004, 6(5): McClellan J, Kowatch R, Findling RL. Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry 2007, 46(1): NICE. Bipolar disorder. Available at: Accessed September 27, Dubicka B, Carlson GA, Vail A, Harrington R. Prepubertal mania: diagnostic differences between US and UK clinicians. Eur Child Adolesc Psychiatry 2007, 17: Carlson GA, Glovinsky I. The Concept of Bipolar Disorder in Children: A History of the Bipolar Controversy. Child Adolesc Psychiatr Clin N Am 2009, 18(2): Biederman J, Faraone S, Mick E, et al. Attention-deficit hyperactivity disorder and juvenile mania: an overlooked comorbidity? J Am Acad Child Adolesc Psychiatry 1996, 35(8): Geller B, Craney JL, Bolhofner K, et al. Two-year prospective follow-up of children with a prepubertal and early adolescent bipolar disorder phenotype. Am J Psychiatry 2002, 159(6): CARLSON GA. Broadening bipolar disorder by design or by accident? World Psychiatry 2011, 10(3): Parens E, Johnston J, Carlson GA. Pediatric mental health care dysfunction disorder? N Engl J Med 2010, 362(20): Brotman MA, Schmajuk M, Rich BA, et al. Prevalence, Clinical Correlates, and Longitudinal Course of Severe Mood Dysregulation in Children. Biol Psychiatry 2006, 60(9): Stringaris A, Baroni A, Haimm C, et al. Pediatric Bipolar Disorder Versus Severe Mood Dysregulation: Risk for Manic Episodes on Follow-Up. J Am Acad Child Adolesc Psychiatry 2010, 49(4): Dickstein DP, Towbin KE, Van Der Veen JW, et al. Randomized double-blind placebo-controlled trial of lithium in youths with severe mood dysregulation. J Child Adolesc Psychopharmacol 2009, 19(1): Brotman MA, Kassem L, Reising MM, et al. Parental Diagnoses in Youth With Narrow Phenotype Bipolar Disorder or Severe Mood Dysregulation. Am J Psychiatry 2007, 164(8): Rich BA, Schmajuk M, Perez-Edgar KE, et al. Different psychophysiological and behavioral responses elicited by frustration in pediatric bipolar disorder and severe mood dysregulation. Am J Psychiatry 2007, 164(2): Brotman MA, Rich BA, Guyer AE, et al. Amygdala Activation During Emotion Processing of Neutral Faces in Children With Severe Mood Dysregulation Versus ADHD or Bipolar Disorder. Am J Psychiatry 2010, 167(1):

5 24. DSM-V Childhood and Adolescent Disorders and the Mood Disorders Work Groups. Issues Pertinent to a Developmental Approach to Bipolar Disorder in DSM-5. Available at: %20Approaches%20to%20Bipolar%20Disorder.pdf. Accessed July 12, DSM-V Childhood and Adolescent Disorders Work Group. Justification for Temper dysregulation disorder with dysphoria. Available at: %20Revision%20Attachments/Justification%20for%20Temper%20Dysregulation %20Disorder%20with%20Dysphoria.pdf. Accessed February 26, Axelson DA, Birmaher B, Findling RL, et al. Concerns regarding the inclusion of temper dysregulation disorder with dysphoria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. J Clin Psychiatry 2011, 72(9):