Bipolar Spectrum in Children and Youth

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Bipolar Spectrum in Children and Youth

• Division of Child Psychiatry Half-Day
• Hôpitalier Pierre Janet, Jan 19, 2007
• Michael Cheng, www.drcheng.ca

2
Disclosures

• Janssen Ortho (Risperdal / Risperidone)
• Lundbeck (Celexa / Citalopram)
• Abbott (Depakote, Synthroid)

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Goals

• By the end of this session, participants will be
  familiar with
• What the Research Bring to Clinicians
• a) Current research and practice guidelines for
  bipolar
• 2. What Clinicians Bring to the Research
• b) Broad versus narrow and other current
  controversies
• c) Not all that rages is bipolar one
  clinicians views on differential diagnosis of
  affect dysregulation

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Case 1 Bipolar Benoit

• 9-yo boy referred for intractable bipolar
  disorder
• Comorbid diagnosis of ADHD
• Rapid cycling and rages triggered by
  everything ? touch, sound, smells
• Mother I have bipolar too.
• Medications have included everything
• What do you think?

5
Case 2 Selfish Sam

• 11-yo boy, diagnosis of ADHD, longstanding anger
  problems, with low frustration tolerance and
  inflexibility to change/transitions
• Rages/frustration triggered by How are you
  feeling today?
• Selfish, self-centred, and has no friends
• What do you think?

6
Case 3 Oppositional Ophelia

• 11-yo girl, previously well, now problems over
  past few months
• ADHD, on stimulant medication
• Defies authority at school, Why should I have to
  listen to those teachers?
• Stays up late, wakes up early, and appears
  revved up
• What do you think?

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Epidemiology
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In the good old days...

• Kids didnt get bipolar
• BUT in studies of adults with bipolar
• Up to 30 of cases of bipolar occur before age
  20, usually after puberty

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Everyone seems to have bipolar why?

• ? Pharmaco-centric approach
• ? Direct marketing of medications
• ? (American) Psychiatrists spending less time
• ? Media awareness of bipolar
• ? High rate of psychotropic use in American youth
  including
• Prescription, e.g. SSRIs, stimulants
• Non-prescription, e.g. marijuana, stimulants,
  etc.

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Everyone seems to have bipolar why?

• Overstimulation
• Video games, televisions, disrupting sleep/wake
  cycles
• Lack of omega 3
• Caffeine
• Soft drinks and coffee
• Average teen male has 3 soft drinks daily

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Problems with Overdiagnosis

• Hinders correct diagnosis and correct treatments
• Tendency to medicate the chemical imbalance
• Side effects from (polypharmacy) medications
  (such as atypical antipsychotics)
• Diluting the bipolar concept means a
  trivialisation of the disorder
• Baldessarini, Plea for Integrity of the Bipolar
  Concept, 2000

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Would you prescribe this?

• Dr. So and So
• Rx
• Caffeine 150 mg daily
• Increase to 300 mg daily on weekends
• Mitte TEN year supply

Health Canada daily limit is 85 mg daily for
teens
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Epidemiology varies widely

• Prevalence ranges between 0.6-15 in different
  studies
• Strober et al., 1995
• Biederman et al., 1995
• Lifetime prevalence of 0.99 in aged 14-18,
  Lewinsohn et al., 1995
• British epidemiologic study finding no case of
  mania amongst pre-adolescent children (Meltzer et
  al., 2000)
• Prevalence lt0.1 in aged 9-13 in Costello, Great
  Smoky Mountain Study of Youth, 1996

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Prevalence of Bipolar Disorder
Lewinsohn, JACAAP, 1995
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Diagnosis
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Terms

• Bipolar
• Condition with mood/affect lability in addition
  to other symptoms as per DSM-IV
• Mood/Affect regulation
• Ability to control/regulate your mood/affect
• Mood/Affect dysregulation/lability
• Inability to control/regulate mood/affect and is
  a symptom seen in many different conditions

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The Explosive Child

• Ross Greenes phenotype to describe child with
  explosive tempers, tantrums, rages, meltdowns,
  easily triggered by anything
• Heterogenous, final common pathway for youth with
  
• Low frustration tolerance
• Inflexibility to changes, transitions, demands
• PLUS an inflexible environment

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DDx Bipolar All Causes of Mood Lability / Rage

• Medical includes
• Including Sleep Disorders / Seizure Disorders /
  Tourettes / Endocrine / etc...
• Psychiatric includes
• Mood disorders
• Substance use disorders
• Autism spectrum
• Learning disorders (e.g. NVLD)
• ADHD / ADD
• Developmental Disorders
• Regulatory-Sensory Processing Disorder (not yet
  an official DSM-IV term)
• Intermittent Explosive Disorder
• Personality Disorders

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Affect Dysregulation Seen in Many Situations
Normal
Bipolar
Affect Dysregulation
Learning Disabilities, ADHD
Regulatory-SensoryProcessing Disorders
Inspired by Bradley, 2000
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Overview of Pediatric Bipolar

• Narrow phenotype using DSM-IV criteria
• Bipolar I
• Mania (at least one episode)
• Bipolar II
• Hypomania Major Depression
• Cyclothymic Disorder
• Hypomania Dysthymia
• Broad phenotype
• Bipolar NOS
• Child does not meet full criteria, nor have
  clearly defined episodes
• CONTROVERSIAL

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Rapid Cycling

• DSM-IV rapid cycling
• More than four episodes of depression, or mania,
  or hypomania during one-year period
• Barbara Geller rapid cycling
• Mood dysregulation with rapid mood swings
• Such as ultraradian cycling (multiple episodes
  within single day)
• CONTROVERSIAL

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Bipolar NOS

• BP-NOS
• Elated or irritable moods that are disruptive to
  daily living, plus at least two other symptoms of
  bipolar disorder such as
• sleep
• appetite
• difficulty with concentration
• inappropriate social behavior
• Birmaher, Arch Gen Psychiatr Feb 2006

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The Bipolar Spectrum Tip of the Iceberg
Bipolar I, or II
Labelled bipolar but actually subsyndromal or
prodromal
High risk with cyclotaxia
High functioning restless, eager people (Jamison
Kessler, 2005)
Youngstrom, 2005
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Bipolar Criteria according Papolos

• Core phenotype with
• Episodic and abrupt transitions in mood
  accompanied by rapid alterations in levels of
  arousal, emotional excitability, sensory
  sensitivity and motor activity
• Poor modulation of drives (e.g. aggressive,
  sexual, appetite, acquisitive)

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Bipolar Criteria according Papolos

• Core phenotype with
• c) At least four of the following disturbances
• Excessive anger with oppositional/aggressive
  responses
• Poor self-esteem regulation
• Sleep/wake cycle disturbances
• Low threshold for anxiety
• Low threshold for arousal
• Executive function troubles (such as mental,
  emotional and motor activity inflexibility)

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YMRS (Young Mania Rating Scale)

• Uses narrow, DSM-IV criteria for Bipolar I/II
• Validated as useful and discriminating assay in
  children and adolescents
• Parent filled YMRS shown just as helpful as
  parent clinician YMRS
• Longitudinal studies have shown stability of
  Bipolar I, II over 4-years
• For the scale visit www.bpkids.org/learning/YMRSP
  arent.doc

Gracious, JAACAP, 2002
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My Clinical Interview

• Bipolar
• Affect dysregulation Circadian dysregulation
• Thus...
• Any troubles with mood swings?
• What do the moods swing between?
• Any high energy periods?
• How long do these high energy periods last?
• Any particular behaviors during the high energy
  periods? (e.g. increased activity, pressure of
  speech)
• Any changes (i.e. decreased need for sleep)
  during the high energy periods?

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Bipolar Child ? Bipolar Adult

• Children with bipolar do not necessarily become
  adults with bipolar (Lewinsohn, 2000)
• Age 12-18 ? 5 subsyndromal bipolar, i.e.
  bipolar NOS
• Age 24 ? Did NOT have elevated rate of bipolar I,
  II, cyclothymia (compared to others)

Lewinsohn et al., Bipolar Disorders, 2000
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On the other hand...

• Course and Outcome of Bipolar Illness in Youth
  (COBY)
• Multisite, prospective investigation of 263
  children aged 7-18 with bipolar I, II and NOS
• Bipolar NOS defined as mood change plus at least
  2 other manic symptoms lasting 4 hrs during at
  least 4 not-necessarily consecutive days
• 68 recovery with mean of 78 weeks bipolar NOS
  recovery at mean of 140 weeks
• About 20 of those with bipolar NOS or bipolar II
  converted to bipolar I
• Birmaher et al., Arch Gen Psychiatry, 2006

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DSM-IV Manic Episode

• ? mood with 3/7 or irritable mood with 4/7
  for 1-week of DIGFAST symptoms
• Distractibility
• Indiscretion (pleasure seeking but risky
  behavior)
• Grandiosity (increased self-esteem, special
  talents)
• Flight of ideas (increased rate of thoughts)
• Activity increase (e.g. more cleaning, a mission)
• Sleep deficit (lots of energy despite less need
  for sleep)
• Talkativeness (talking more than usual,
  interrupting others)

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(Adult) Bipolar Flags in Unipolar Depressive
Episodes

• Cycle induction at start or stop of
  antidepressant
• Change in type of depressive symptoms over time
  Early onset
• Psychotic symptoms
• Postpartum onset
• Treatment resistant unipolar
• Early response to antidepressant
• Zajecka, Medscape Psychiatry, 2007

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What counts as early?

• Taylor et al., Arch Gen Psych, Nov 2006
• Treatment with SSRIs is associated with
  symptomatic improvement in depression by the end
  of the first week of use, and the improvement
  continues at a decreasing rate for at least 6
  weeks.
• Early would be thus less than one week...

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What we learn from adults with bipolar

• In adults with bipolar disorder
• 50 report their first manic episode occurred
  before age 21
• 20 report it occurred in childhood (before age
  12)
• Thus, if 1-2 of adult population has bipolar I,
  then
• 0.5-1 of kids will have manic episode before age
  21
• 0.2-0.4 of kids will have manic episode (before
  age 12)

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DDx of Mood Lability Non-Verbal Learning
Disability
Harris, Psychiatr Services, May 2005, 56(5)
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Overview of NVLD

• Condition where child has problems with
  non-verbal skills
• Non-verbal communication skills
• VIsuospatial skills
• Often appears similar to Autistic Spectrum
  (particularly Aspergers)
• Usually want more human contact than Autistic
  spectrum youth

36
DDx of Mood Lability Regulatory-Sensory
Processing Disorder
Harris, Psychiatr Services, May 2005,
56(5) Cheng, CACAP Review, May 2006
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Regulatory-Sensory Processing Disorder

• Formerly known as sensory integration
• Not in DSM-IV, but is present in the DC0-3
  (Diagnostic Classification for age 0-3)
• Condition where a childs responses to normal
  sensory input is either under or over-reactive
• Increasing data for efficacy of specific sensory
  processing interventions, accommodations,
  modifications

38
Hyposensitivity

• Hypo, or under-reactivity with
• Touch
• Leading the child to crave more touch
• Movement
• Leading the child to crave more movement
• Smell
• Leading the child to seek out smells, e.g.
  smearing

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Hypersensitivity

• Touch
• Easily overwhelmed by light touch
• However often craves deep pressure touch
• Movement
• Easily overwhelmed by movement
• Smell
• Easily overwhelmed by smells

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Treatment

• Educating parents/child to understand sensory
  overload, so that they can learn better sensory
  and self-regulation
• E.g. for hypersensitive child
• Reduce sensory stimulation
• Use soothing stimulation
• As long as the nervous system is not overwehelmed
  all the time, the nervous system will be
  eventually able to tolerate what was initially
  intolerable...

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DDx of Mood Lability ADHD/ADD
Geller et al. J Affect Disord 1998
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Pediatric BP vs. ADHD

• Overlapping symptoms in DSM-IV criteria for ADHD
  / bipolar
• In patients with mania
• 60-90 will meet criteria for ADHD
• Clinical sense that antidepressant or stimulants
  will lead to activation and worsening symptoms
  in someone who has true bipolar

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Pediatric BP vs. ADHD
Geller et al. J Affect Disord 1998
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Kowatch in children, consider bipolarity if

• Acute dramatic worsening of apparent ADHD with
  severe mood swings, or activation with
  stimulants (or NE medications) with frequent mood
  swings, or
• Grandiosity and elated mood
• Inappropriate sexual behavior
• Severe mood swings (generally 3 or 4 times per
  day, lasting more than 3 or 4 hours in total)
• Increased (non-predatory) aggression
• Euphoria is less common.

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Kowatch in teens...

• Diagnosis is easier in teens because you can more
  or less use adult criteria
• Symptoms include
• Markedly labile moods with mixed features and
  extreme irritability
• Deterioration in behavior, including grades
  slipping and social relationships deteriorating.
• Comorbid substance abuse, usually including drugs
  and alcohol
• Worsening mania may result in (mood congruent)
  psychotic symptoms as well

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Treatment of Bipolar Disorder
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CANMAT 2007 (Adult) Treatment Guidelines

• Acute mania
• First-line lithium, valproate, atypical
  antipsycohtics
• Bipolar depression
• First-line
• Monotherapy with lithium, lamotrigine, or
• Olanzapine SSRI
• lithium or divalproex SSRI/bupropion plus
• Quetiapine monotherapy (NEW!)
• Maintenance
• First-line lithium, lamotrigine, valproate,
  olanzapine

Bipolar Disorders, Dec 2006
48
Pediatric Bipolar Treatment Non-Medication

• Developing self-regulation strategies
• Concepts used in
• Pavuluris CFF-CBT
• Maria Kovacs CERT
• Greenspans DIR / Floortime model
• ALERT Program for self-regulation

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Pediatric Bipolar Treatment Non-Medication

• Pavluris RAINBOW
• Routine
• Affect regulation
• I can do it
• No negative thoughts
• Be a good friend / balanced lifestyle
• Oh, how can we solve it?
• Ways to get help and support

Pavluri, JAACAP, 2004
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Pediatric Bipolar Treatment Non-Medication

• Regular routines to set biorhythms (as used
  significantly in Ellen Franks Interpersonal
  Social Rhythm Therapy)
• Regular bedtimes
• DARKNESS AT BEDTIME (Barbini, 2005)
• Mealtimes
• As much structure as possible
• Have parents draw out a time-table / schedule for
  their children

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Pediatric Bipolar Treatment Non-Medication

• ALERT Program
• Identify childs state of arousal / stimulation
• Under-aroused
• Just right
• Overaroused
• Preventing (sensory) overstimulation

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Pediatric Bipolar Treatment

• Reduce stimulation!
• Reduce non-medication stimulation
• E.g. Sensory stimulation
• E.g. High expressed emotion
• Stop stimulants
• Prescription
• Non-prescription
• Stop antidepressants

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Pediatric Bipolar Medication

• With BPD-I, manic, mixed, acute without psychosis
• First-line Monotherapy with
• Mood stabilizer (e.g. Li, DVPA or CBZ) OR
• Atypical (Olanzapine, Quetiapine or Risperidone)
• Second-line Monotherapy PLUS Augmentation with
• Mood stabilizer (e.g. Li, DVPA or CBZ) PLUS
• Atypical (Olanzapine, Quetiapine or Risperidone)
• (Treatment Guidelines for Children and
  Adolescents with Bipolar Disorder, JACAAP March
  2005)

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Lithium or not?

• If childs parents have lithium-responsive
  bipolar
• Choose lithium
• Tend to have psychopathology clustering in the
  affective spectrum, with episodic course)
• If childs parents have bipolar non-responsive
  with lithium
• Choose something else
• Tend to have broader psychopathology (i.e. more
  comorbidity) with chronic course.

Duffy, Grof, J. Clin Psychiatry, 2002 Dec
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Bipolar in Youth Treatment

• Comorbid ADHD symptoms?
• Low dose stimulant okay in combo with mood
  stabilizer

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Case 1 Bipolar Benoit

• 9-yo boy referred for intractable bipolar
  disorder
• Comorbid diagnosis of ADHD
• Rapid cycling and rages triggered by
  everything ? touch, sound, smells
• Mother I have bipolar too.
• Medications have included everything
• Dx ? Regulatory-Sensory Processing Disorder

58
Case 2 Selfish Sam

• 11-yo boy, diagnosis of ADHD, longstanding anger
  problems, with low frustration tolerance and
  inflexibility to change/transitions
• Rages/frustration triggered by How are you
  feeling today?
• Selfish, self-centred, and has no friends
• Dx ? Autism Spectrum Disorder

59
Case 3 Oppositional Ophelia

• 11-yo girl, previously well, now problems over
  past few months
• ADHD, on stimulant medication
• Defies authority at school, Why should I have to
  listen to those teachers?
• Stays up late, wakes up early, and appears
  revved up
• Dx ? Stimulant-induced manic episode or bipolar
  III

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Local Resources

• More materials on www.drcheng.ca including
• Family handout on bipolar
• Medication summary for physicians
• This presentation

61

• Michael Cheng
• Amy Martin
• Cherry Murray

Ottawas Online Directory of Mental Health
Services and Events
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Summary

• Child bipolar does exist
• Exact prevalence controversial
• If you are bipolar liberal, it is everwhere
• If you are bipolar conservative, it is rare
• Studies are NOT showing that bipolar NOS goes on
  to develop adult bipolar

63
Summary

• Rule out other causes of bipolar such as
• All the other usual suspects such as ADHD, etc.
• Autistic spectrum
• Non-verbal LD
• Sensory processing
• Freely use psychosocial strategies first for
  affect dysregulation
• In choosing medications, use lithium if family Hx
  
• Otherwise, use divalproex or antipsychotics

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Key References

• Kowatch et al., Treatment Guidelines for Children
  and Adolescents with Bipolar Disorder, Journal of
  the American Academy of Child and Adolescent
  psychiatry (JAACAP), 2005 44(3)213-235.
• Harris J The Increased Diagnosis of Juvenile
  Bipolar Disorder, Psychiatric Services, May
  2005, 56(5) 529-531.

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Acknowledgements

• Dr. Rob Milin
• Dr. Addo Boafo
• Dr. Hazen Gandy

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Insightful Questions