Mood swings in young people Bipolar I & II Disorders are uncommon before puberty; Mood Dysregulation (MD) is very common before puberty Are they the same problem? What are the beginnings of bipolar? What is emotional dysregulation? Should irritability (DMDD) be a separate condition? No competing financial interests [Funding from MRC, Wellcome; royalties from OUP] Acknowledgements to A.Stringaris, B.Birmaher, E. Heptinstall:
Bipolar disorder in young people Excessive and impairing mood changes are very common presentations Are they distinct in Course? Features? Causes? Treatment? Episodes of mania 4 days + 2-3 days+ Chronic lability of mood especially irritability Prevalence <0.1% 1%?? 3%? % w ADHD <10 15-40 90
Cycles and episodes Mood high 1 5 10 15 20 25 30 35 40 45 50 55 60 DAYS Mood low
Cycles and episodes Mood high 1 5 10 15 20 25 30 35 40 45 50 55 60 DAYS Mood low Bipolar I = 7 days Bipolar II = 4 days Bipolar S = less (or fewer symptoms)
Cycles and episodes Mood high 1 5 10 15 20 25 30 35 40 45 50 55 60 DAYS Mood low
Cycles and episodes Mood angry 1 5 10 15 20 25 30 35 40 45 50 55 60 DAYS Mood sad
Bipolar disorder in young people Excessive and impairing mood changes are very common presentations Episodes of mania +/- depression Chronic lability of mood especially irritability Comorbidity frequent, especially ADHD. Careful diagnosis is needed.
Bipolar Disorder in the Maudsley Clinical Database (ICD10) 3,641 referred cases under the age of 16 58 diagnosed mania or bipolar 22% <13; 23% prepubertal; similar presentations Best discriminators from age-matched: elevated mood; depression; depersonalisation; hallucinations; disinhibited; poor concentration; recent onset. (correctly classify 95%) Missed cases diagnosed as depression, hyperkinetic, autism or schizophrenia
What is the phenomenology of mania in children? Irritability Elated mood Grandiosity Hypersexuality Racing thoughts Insomnia Overtalkative, distractible, increased activity Are these symptoms reliable? specific? discriminating?
Cardinal features of mania Symptom Frequency Specificity Impairing Look for Euphoric ++ +++ ( +) - Substance use; medicn; epilepsy Irritable +++ (+) +++ Episodicity; mood context; -provocation Grandiose + ++ ++ Fluctuations; inappropriate - arrogance
Associated features of mania Symptom Frequency Specificity Impairing Look for Activity +++ - ( +) CHANGE of activity Hypersex uality + (+) +++ - Abuse Insomnia +++ + ++ Change; no daytime fatigue
What phenomenology is useful in diagnosing mania in children? Irritability Elated mood Grandiosity Hypersexuality Racing thoughts Insomnia Overtalkative, distractible, increased activity Episodicity
High-Risk Offspring: I 207 offspring from 105 families 32% major mood episode 89% first episodes depressive 17 ± 4 years at age of first episode; youngest 12 years Cycle length 31.0 ± 21 months 61% 5-year recurrence Duffy et al (2009) B J Psychiatry 195 457-8
High-Risk Offspring: II 388 offspring from 233 BP + 251 offspring from 143 control 21% (v 4%) mood disorder (25% ADHD, 26% anxiety, 19% DBD) 9% risk for depression, 12% for BP by age 12 Birmaher et al (2009) Arch Gen Psychiatry 66 287-96
High-Risk Offspring III: Review Expert assessment Affective psychopathology Adolescent/adult onset Structured interview Broad spectrum Child onset sometimes Good for early BP course Good for range of outcomes Duffy et al (2011) Early Intervention Psychiat 5 181-191
Clinical Implications Important to recognise bipolar disorder in childhood - predicts a poor outcome - delayed treatment worsens prognosis (?) - guide to therapy - caution with antidepressants - caution with stimulants Important not to over-recognise - require episodes of more than 1-2 days - avoid nonspecific use of neuroleptics Differential diagnosis required - consider alternative diagnoses - bipolar disorder may co-exist with other problems
Bipolar disorder in young people: II.Chronic mood dysregulation Excessive and impairing mood changes are very common presentations Comorbidity frequent, especially ADHD. Careful diagnosis is needed. Episodes of mania Chronic lability of mood +/- depression especially irritability
Emotional regulation Infancy Preschool School age caregivers and comfort repetitive behaviours self-stimulation attention away effortful self-control tantrum consequences covert resentment masking anger rule learning, culture problem-solving gender differentiation
Emotion Dysregulation ED: dimensional trait; it encompasses: emotional expressions and experiences that are excessive in relation to social norms. context inappropriate, and developmentally inappropriate e.g. rapid, poorly controlled shifts in emotion (lability) e.g. the anomalous allocation of attention to emotional stimuli e.g. irritability (inappropriate levels of reactivity), unpredictable mood changes, hot temper, temper tantrums, tearfulness, low frustration tolerance 19
Disruptive Mood Regulation Disorder Persistent dysphoria Angry outbursts Not validated (SMD included hyperarousal)
Irritability Differential Diagnosis ADHD (with emotional lability) Autism spectrum; organic brain syndromes DMDD/ Severe mood dysregulation Conduct/oppositional Adverse environment; PTSD Bipolar disorder
DSM 5 Diagnoses of conditions characterised by irritability Begin by establishing whether it comes in distinct episodes, and any affective features Maximum length of episode: > 48 hours Episode includes euphoria/grandiosity? bipolar Mood between episodes is sad/ angry? MDD criteria met? depression DMDD D MDD - major depressive disordermdd = major depressive disorder DMDD disruptive mood dysregulation disorder
DSM 5 Diagnoses of conditions characterised by irritability Maximum length of episode: > 48 hours Episode includes euphoria/grandiosity? bipolar Coexistent problems? Mood between episodes is sad/ angry? MDD criteria met? depression DMDD D MDD = major depressive disorder DMDD disruptive mood dysregulation disorder ODD = oppositional-defiant disorder ADHD=attention deficit/hyperactivity disorder PTSD=post-traumatic stress disorder
DSM 5 Diagnoses of conditions characterised by irritability Shorter episodes have a different implication advice Maximum length of episode: > 48 hours 6-48 hours <6 hours Inappropriate to context? Yes Coexistent problems? Mood between episodes is sad/ angry? Episode includes euphoria/grandiosity? MDD criteria met? bipolar depression DMDD D MDD = major depressive disorder DMDD disruptive mood dysregulation disorder ODD = oppositional-defiant disorder ADHD=attention deficit/hyperactivity disorder PTSD=post-traumatic stress disorder
DSM 5 Diagnoses of conditions characterised by irritability advice Maximum length of episode: > 48 hours 6-48 hours <6 hours ADHD Substance misuse Autism spectrum Organic brain disease ODD Secondary (drug, diet, PTSD, maltreatment) Inappropriate to context? Yes Coexistent problems? Mood between episodes is sad/ angry? Episode includes euphoria/grandiosity? MDD criteria met? DMDD D bipolar depression MDD = major depressive disorder DMDD disruptive mood dysregulation disorder ODD = oppositional-defiant disorder ADHD=attention deficit/hyperactivity disorder PTSD=post-traumatic stress disorder
DSM 5 Diagnoses of conditions characterised by irritability advice Maximum length of episode: > 48 hours 6-48 hours <6 hours ADHD Substance misuse Autism spectrum Organic brain disease ODD Secondary (drug, diet, PTSD, maltreatment) Inappropriate to context? Yes Coexistent problems? Mood between episodes is sad/ angry? Intermittent explosive disorder Episode includes euphoria/grandiosity? MDD criteria met? DMDD bipolar depression MDD = major depressive disorder DMDD disruptive mood dysregulation disorder ODD = oppositional-defiant disorder ADHD=attention deficit/hyperactivity disorder PTSD=post-traumatic stress disorder
What is bipolar disorder in young people? An important diagnosis in adolescents - sometimes missed in treating adolescence A similar symptomatology to adults - episodes may be short, eg 1-3 days A rare condition in prepubertal children - symptoms need developmental judgement - mood dysregulation a useful concept