HEADACHE IN TEENS WITH BIPOLAR DISORDER - PowerPoint PPT Presentation

Loading...

PPT – HEADACHE IN TEENS WITH BIPOLAR DISORDER PowerPoint presentation | free to download - id: 66d02f-ZjcwN



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

HEADACHE IN TEENS WITH BIPOLAR DISORDER

Description:

HEADACHE IN TEENS WITH BIPOLAR DISORDER - Palmetto ... – PowerPoint PPT presentation

Number of Views:68
Avg rating:3.0/5.0
Slides: 74
Provided by: Ricardo157
Learn more at: http://www.palmettobehavioralhealth.com
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: HEADACHE IN TEENS WITH BIPOLAR DISORDER


1
  • Ricardo J. Fermo, MD
  • Diplomate of the American Board of Psychiatry and
    Neurology            
  • Diplomate of American Board of Child and
    Adolescent Psychiatry
  • East Cooper Psychiatric Solutions, LLC
  • 887 Johnnie Dodds Blvd. , Suite 100
  • Mount Pleasant, South Carolina 29464
  • ECPSLLC.COM
  • O (843) 856 6998
  • F (843) 856 6997

2
Disclosures
  • Abbott Laboratories
  • AstraZeneca
  • Bristol Myer-Squibb
  • Cephalon
  • Eli Lilly Co.
  • Forest Laboratories, Inc.
  • GalaxoSmithKline
  • Janssen Research
  • Jazz Pharmaceuticals
  • Lundbeck
  • Mallinckrodt
  • Merck
  • Novartis
  • Otsuka America Pharmaceuticals Inc.
  • Palmlabs
  • Pfizer, Inc.
  • Sanofi Aventis
  • Sepacor Inc.
  • Shire Pharmaceuticals

3
  • EPIDEMIOLOGY

4
  • Affects 5.7 million American adults -NIMH
  • 2.6 of the U.S. pop. age 18 and older in a
    given year
  • Mean age of onset 25 y/o (correct dx gt10 yr.)
  • Equal Distribution between men and women
  • 5th leading cause of disability

5
  • Total cost estimated to exceed 45 Billion per
    year
  • 1st-degree relatives of individuals with Bipolar
    Disorder has an increased risk ranging from 4 to
    24.
  • Long term illness that must be managed throughout
    a persons life (90 relapse rate)

6
(No Transcript)
7
(No Transcript)
8

9
HERITABILITY (GENETICS) RELATIVE WITH BIPOLAR
DISORDER AND CHILD ODDS
  • One parent 25
  • Two parents 50-75
  • One MZ twin 30-90
  • One DZ twin 5-25
  • American Journal of Medical Genetics Part C
    (Semin. Med. Genet.) 123C4858 (2003)

10
  • ETIOLOGY

11
  • No single cause
  • Hereditary factors
  • The most prominent theory centers around changes
    in monoamine neurotransmitters within the CNS
    i.e. excessive NE and DA in mania and deficits in
    NE, 5-HT, and DA
  • Psychodynamic A defense against depression.
  • Stress Diathesis Theory

12
  • DIAGNOSIS

13
DSM V CHANGES TO BIPOLAR DISORDER
  • Criteria for mania/hypomania includes emphasis
    on changes in activity and energy not just mood
  • Mixed episode now is a new specifier with
    mixed features
  • Anxious distress specifier
  • No more Bipolar NOS - Other Specified Bipolar
    and Related Disorder diagnosis

14
Diagnostic Problems
  • Time-consuming and difficult to differentiate
  • Subtle Symptoms
  • Moody ADHD/Disruptive Disorders
  • Non-Bipolar Depression
  • Pervasive Developmental Disorders (High
    Functioning autistic Spectrum
  • Substance Use Disorders

15
Cues that Unipolar Depression may be Bipolar
Disorder
  • Early onset of depression
  • Highly recurrent depression (4 or more episodes)
  • Psychotic Depression
  • Postpartum onset of depression
  • History of mixed mood states
  • Family History of Bipolar Disorder
  • gt3 failed antidepressant trials
  • Marked agitation with an antidepressant
  • Manning JS Family Practice 300 2 Supp S 6-9

16
Qualities that differ between Bipolar D/O vs.
Unipolar D/O
  • Total Sleep Time BPgtUP
  • Hypersomnia BPgtUP
  • Psychomotor Retardation BPgtUP
  • Postpartum Depression BPgtUP
  • Weight Loss UPgtBP

17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
Comorbidity of Psychiatric Disorders in
Pediatric Bipolar Disorder
Bipolar Disorder
ADHD
ODD/CD
Tic Disorders
Learning Disorders
Depression/Anxiety Disorders
  • The rule more than the exception
  • Approximately 50-90
  • Disruptive Disorders
  • Anxiety Disorders
  • Substance Abuse (adolescents)

ADHD attention deficit hyperactivity
disorder CD conduct disorders ODD
oppositional defiant disorder
Pliszka SR. Pediatr Drugs. 20035741-750.
21
Clinical Presentation of Pediatric Bipolar I
Disorder
  • Adolescent patients with Bipolar I Disorder are
    diagnosed using the same DSM-IV-TR criteria as
    adults
  • Pediatric patients with Bipolar Disorder are more
    likely to present with
  • Predominantly mixed episode
  • Rapid Cycling
  • Prominent irritability that may lead to violence
    and explosiveness
  • Frequently associated with psychotic symptoms and
    markedly labile mood
  • Often suffer from a more chronic form of the
    illness characterized by longer symptomatic
    episodes that are often refractor to treatment

APA DSM IV AACAP Pavuluri MN et al. J Am Acad
Chld and Adolecnet Psychiatry 1005 44849-871
22
Characteristics Common to Pediatric Mania
  • Severe, prolonged irritability
  • Affective storms
  • Prolonged and aggressive temper outbursts
  • Mixed mania or rapid cycling (gt 70 of cases)
  • High comorbidity with ADHD
  • Chronic and unremitting course

Biederman J et al. Biol Psychiatry.
200048458-466. State RC et al. Am J Psychiatry.
2002159918-925.
23
DEFINITIONS
  • BIPOLAR DISORDER NOT OTHERWISE SPECIFIED (NOS) -
    recommended to describe the large number of
    youths who receive a diagnosis of bipolar
    disorder who do not have the classic adult
    presentation 1
  • Definitions currently used in the juvenile
    bipolar literature, but not provided in
    DSM-IV-TR, include the following
  • ULTRARAPID CYCLING refers to brief, frequent
    manic episodes lasting hours to days, but less
    than the 4-day prerequisite for hypomania. Having
    5 to 364 cycles per year 2
  • ULTRADIAN CYCLING refers to repeated brief
    (minutes to hours) cycles that occur daily.
    Having greater than 365 cycles per year 2
  1. NIMH, 2001
  2. Geller et al. (2000)

24
Clinical course of recurrent mood disorders
25
MEDICAL CONDITIONS THAT MAYMIMIC PEDIATRIC
BIPOLAR DISORDER
  • Hypothyroidism
  • Closed or open head injury
  • Temporal lobe epilepsy
  • Multiple Sclerosis
  • Systemic lupus erythematosus
  • Fetal alcohol spectrum disorder/ alcohol
  • related neurodevelopmental disorder
  • Wilson s disease
  • Kowatch et al. JCAAP. 2006 1573108

26
Factors Suggestive of Pediatric Bipolar Disorder
  • Depression
  • Family history of mood disorders
  • Disruptive behavior prominent mood symptoms
  • Psychosis
  • Attention-deficit / hyperactivity disorder
  • Poor stimulant response
  • History of medication-induced manic symptoms

27
PEARLS TO HELP WITH DIAGNOSIS
  • Family history (BP is highly heritable Identical
    twin concordance 70 vs. Fraternal 20) Best
    Predictor
  • Presence of elation/euphoria or grandiosity
  • Look at timeline of symptoms not just current
    mental status
  • Episodic worsening within chronic symptoms
  • MDD Psychosis, psychomotor retardation,
    childhood onset
  • History of medication-induced manic symptoms

28
PEDIATRIC BP VS. ADHD
Mania Item Bipolar ADHD
Irritable Mood 97 72
Grandiosity 85 7
Elated Mood 87 5
Dare devil Acts 70 13
Uninhibited People Seeking 68 21
Silliness/Laughing 65 21
Flight of Ideas 66 10
Accelerated Speech 97 78
Hypersexuality 45 8
Geller et al. J Affect Disord 1998
29
NON-SPECIFIC SYMPTOMS
  • Irritability (98 vs. 72)
  • Accelerated Speech (97 vs. 82)
  • Distractability (94 vs. 96)
  • Unusual Energy (100 vs. 95)

Geller et al. J Child and Adol Psychophar m.2002
30
(No Transcript)
31
Clinical Pearls
  • Difficult to diagnosis/Be sure diagnosed is
    correct
  • Select a evidence based medication regiment
  • Use the right doses of medication/Ensure the
    medication trial continues for an adequate
    periods of time.
  • Be aware of any psychiatric comorbitities
  • Carfully Assess for adverse reactions/Remove
    agents that may be exacerbating situations
  • Combination interventions most often used

32
Predictors of Bipolar Disorder
  • MDD with
  • Psychosis
  • Psychomotor retardation
  • Pharmacological induced mania/hypomania
  • Family history of bipolar disorder

33
Mood Disorder Questionnaire
Has there ever been a period of time when you
were not your usual self and
you felt so good or so hyper that other people
thought you were not your normal self or you were
so hyper that you got into trouble? you were so
irritable that you shouted at people or started
fights or arguments? you felt much more
self-confident than usual? you got much less
sleep than usual and found you didnt really
miss it? you were much more talkative or spoke
much faster than usual? thoughts raced through
your head or you couldnt slowyour mind down?
Hirschfeld. Prim Care Companion J Clin
Psychiatry. 200249-11.
34
(No Transcript)
35
  • DISEASE STATE

36
(No Transcript)
37
Depression Is the PredominantMood in Bipolar I
Disorder
12.8-year prospective NIMH natural history study
(N 146)
  • Patients with bipolar I disorder spent nearly
    half of the time symptomatically ill
  • Time spent depressed was ? 3 times more than time
    spent manic
  • Time spent manic accounted for only 9.3 of the
    time
  • Depression (but not mania) predicted greater
    future illness burden

Judd LL et al. Arch Gen Psychiatry.
200259530537.
38
Maintenance Treatment to Help Maintain Stability
Against Depressive Episodes Is Particularly
Important
Depression A Dominant Next Episode Among
Patients Receiving Placebo
During Two 18-Month Maintenance Trials
Mood Polarity of Events in Bipolar I Disorder
Bowden C et al. Arch Gen Psychiatry.
200360392400. Data on file, GlaxoSmithKline.
39
  • TREATMENT

40
Treatment Objectives for Bipolar Disorder
  • Bipolar disorder is a lifelong illness
    therefore, maintenance treatment is the core of
    management1
  • Treatment choice should be made by collaborative
    effort between patient and physician2
  • The goal of acute therapy is to stabilize acute
    episodes with the goal of remission2
  • The goal of maintenance therapy is to optimize
    protection against recurrence of episodes2
  • Concurrently, attention needs to be devoted to
    maximizing patient functioning and minimizing
    subthreshold symptoms and adverse effects of
    treatment2

1. Calabrese et al. J Clin Psychiatry.
200263(suppl 10)18-22. 2. Hirschfeld et al. Am
J Psychiatry. 2002159(4 suppl)1-50.
41
SOMATIC TREATMENTS
  • Recommendation 6. For Mania in Well-Defined
    DSM-IV-TR Bipolar I Disorder, Pharmacotherapy Is
    the Primary Treatment

42
THE CHOICE OF MEDICATION(S) SHOULD BE MADE BASED
ON
  • (1) Evidence of efficacy
  • (2) Phase of illness
  • (3) Presence of confounding presentations (e.g.,
    rapid cycling mood swings, psychotic symptoms)
  • (4) Agents side effect spectrum and safety
  • (5) Patients history of medication response
  • (6) Preferences of the patient and his or her
    family. A history of treatment response in
    parents may predict response in offspring
  • Duffy et al., 2002

43
(No Transcript)
44
  • Psychosocial Treatments as an adjunct to
  • Medications
  • Parent/Family Psychoeducation
  • Relapse Prevention
  • CBT or IPT for Depression
  • Interpersonal and Social Rhythm Therapy
  • Family Focused Therapy
  • Community Support Programs

45
AACAP Treatment goals for pedicatric Patients
with Bipolar Disorder
  • The general goals of treatment are
  • Manage Symptoms and maintain response
  • Provide education about the illness
  • Promote Adherence to treatment
  • AACAP Guidelines suggest using a comprehensive
    treatment plan, combining pharmacotherapy with
    behavioral/psychosocial interventions

AACAP 2007
46
FDA APPROVED MEDICATIONS FOR PED BPD I, MIXED OR
MANIC
  • Airpiprazole 10-17
  • Olanzapine 13-17
  • Quetiapine 10 - 17
  • Risperidone 10-17
  • Lithium 12-10

47
SCREENING
  • Recommendation 1. Psychiatric Assessments for
    Children and Adolescents Should Include Screening
    Questions for Bipolar Disorder
  • Distinct mood changes associate sleep
    distrubances and psychomotor activation
  • Family history of mood disorders
  • Symptoms of irritability, reckless behaviors or
    increased energy
  • Perspective by family, school, peer, and other
    psychosocial factors rather than simply using
    checklist

48
ASSESSMENT
  • Recommendation 2. The DSM-IV-TR Criteria,
    Including the Duration Criteria, Should Be
    Followed When Making a Diagnosis of Mania or
    Hypomania in Children and Adolescents
  • Recommendation 3. Bipolar Disorder NOS Should Be
    Used to Describe Youths With Manic Symptoms
    Lasting Hours to Less Than 4 Days or for Those
    With Chronic Manic-Like Symptoms Representing
    Their Baseline Level of Functioning

49
ASSESSMENT (CONTINUED)
  • Recommendation 4. Youths With Suspected Bipolar
    Disorder Must Also Be Carefully Evaluated for
    Other Associated Problems, Including Suicidality,
    Comorbid Disorders (Including Substance Abuse),
    Psychosocial Stressors, and Medical Problems
  • Recommendation 5. The Diagnostic Validity of
    Bipolar Disorder in Young Children Has Yet to Be
    Established. Caution Must Be Taken Before
    Applying This Diagnosis in Preschoolchildren
  • Exposes them to aggressive pharmacotherapy

50
Pharmacologic Treatment Goals in Bipolar Disorder
Achieve rapid control of manic symptoms
Acute phase
Achieve remission of depressive symptoms
Return to normal levels of psychosocial
functioning
Maintenancephase
Delay or prevent recurrence of manic or
depressive episodes
Minimize subthreshold symptoms
Hirschfeld RM et al. Am J Psychiatry.
2002159(Suppl)150.
51
THE GOAL OF THERAPY
  1. Ameliorate distressing symptoms
  2. Provide education about the illness
  3. Promote adherence to treatment - prevent relapse
  4. Improve functioning
  5. Reverse illness Course
  6. Prevent full expression of condition
  7. they just dont grow out of it
  8. Neuroprotection
  9. Multi-modal treatment is a must
  10. Reduce long-term morbidity, and promote normal
    growth and developmental pathways

52
RECOMMENDATIONS
  • Assure Safety
  • Stabilize mood, ADHD, and disruptive behavior
  • Labs/Physical
  • Clarification Diagnosis
  • Collateral information from Pediatrician, School,
    other caretakers, DSS/Legal involvement?
  • Psychological testing
  • Psychotherapy
  • Individual/Family/School diagnostic
    evaluation, intervention, education
  • Psychopharmacological intervention
  • Informed Consent

53
Comprehensive Treatment Approach for Children and
Adolescents with Bipolar Disorder
Medication Therapy
Educational Interventions
Psychotherapy
54
Kowatch R, et al. 2005.
55
Bipolar Disorder - Psychoeducation
  • Symptomatology
  • Etiology ( e.g., genetics)
  • Treatment
  • Prognosis
  • Prevention (early signs of relapse/recurrence)
  • Psychosocial Scars
  • Stigma
  • Mood Hygiene
  • Importance of compliance

56
PSYCHOSOCIAL INTERVENTIONS
  • Family Therapy
  • Psychoeducation (Diagnosis, Treatment)
  • Emphasize Compliance
  • Mood monitoring
  • Social skills training
  • Strategies aimed at increasing life style
    regularity (Adhering to regular schedule, normal
    sleep/wake cycle)
  • Parent training in behavioral interventions to
    deal with problematic behavior
  • Therapist helps family see family dynamics that
    may be contributing to patients illness.

57
Bipolar Disorder No Response to Treatment
  • Misdiagnosis
  • Compliance
  • Adequate treatment (type, doses, duration)
  • Comorbidity ( e.g., substance abuse)
  • Exposure to Stressful Life Events (e.g., abuse)
  • Psychosocial Factors

58
  • PROGNOSIS

59
RISK FACTORS
  • Strong genetic component in Adults four- to six
    fold increase risk of disorder in first degree
    relatives of affected individuals 1
  •  
  • Degree of familiality appears even higher in
    early onset, highly comorbid cases 2
  •  
  • Premorbid psychiatric problems are common in
    early-onset bipolar disorder, especially
    difficulties with disruptive behavior disorders,
    irritability, and behavioral dyscontrol 3
  • Most childhood cases are associated with
    Attention Deficit Hyperactivity Disorder 4
  •  
  • In those whose first mood episode is a depressive
    disorder. Approximately 20 of youths with major
    depression go on to experience manic episodes by
    adulthood 5
  • Nurnberg and Foroud, 2000
  • Faraone et al., 2003
  • Carlson, 1990 Fergus et al., 2003 Geller et
    al., 2002a McClellan et al., 2003 Werry et
    al., 1991 Wozniak et al., 1995)
  • 4. Findling et al. 2001 Geller et al.,
    2002a Wozniak et al., 1995).
  • 5. Geller et al., 1994, 2001 Kovacs, 1996
    Rao et al., 1995 Strober and Carlson, 1982).

60
Depression is the Predominant Moodin Bipolar I
Disorder
Based on the 12.8-year NIMH natural history study
(n 146), of the 47 of time spent
symptomatically ill, patients experienced
depressive symptoms 3 times more than manic
symptoms1
67
Time spent symptomatically ill ()
Depressed
13
20
Cycling/ mixed
Manic
  • In another naturalistic study, patients treated
    for bipolar disorder experienced 121 days of
    depression, versus 40 of mania, in a single
    year2

76 of patient cohort were patients with bipolar
I disorder. 1. Judd LL et al. Arch Gen
Psychiatry. 200259530537. 2. Post RM et al.
Clin Neurosci Res. 20022142157.
61
PROGNOSITIC INDICATORS
  • Good
  • Short Duration of manic episodes
  • Advanced age of onset
  • Few suicidal thoughts
  • Few coexisting psychiatric disorder
  • Few medical problems
  •  
  • Poor
  • Poor premorbid occupational status
  • Alcohol Dependence
  • Psychotic features
  • Depressive features
  • Interepisode depressive features
  • Male gender
  • coexisting psychiatric disorder

62
Bipolar Disorder - Sequela
  • Poor academic functioning
  • Interpersonal and family difficulties
  • Increased risk for suicide
  • Increased use of tobacco, alcohol, and other
    substances
  • Behavior problems
  • Legal difficulties
  • Increased health services utilization (e.g.,
    hospitalizations)
  • Emslie GJ, Mayes TL. Biol Psychiatry.
    2001491082-1090.

63
(No Transcript)
64
(No Transcript)
65
(No Transcript)
66
Estimated Total Lifetime Cost per Case by
Prognosis Group
Thousands of dollars, 1998
Begley et al. Pharmacoeconomics. 200119(5 pt
1)483-495.
67
  • ARTICLE

68
HEADACHE IN TEENS WITH BIPOLAR DISORDER
  • Unpublished, presented at AACAP
  • Canadian teens, bipolar d/o
  • 55 outpts., 13 y/o-19 y/o BP I, II, NOS
  • 60 F, 60 with HA Sig. gt severity on
    depressive, manic and CGI
  • Teens with BP with HA Sig. rates of identity
    confusion, anger/depression, and disinhibition
    /persistence
  • Results BP teen w/ HA more prone to gt severity
    than BP teens w/o
  • Psy. Hosp. and psychosis gt BP teen without
    headaches-results counterintuitive

69
HEADACHE IN TEENS WITH BIPOLAR DISORDER (Cont.)
  • Rational
  • 1) BP teens with HA a different subtype? unique
    course, characterisics and perhaps treatment?
  • 2) under dx or tx in adult BP and headaches is
    well doc. Potential treating in youth is
    important.

70
  • SUMMARY

71
Summary
  • Difficult to diagnosis
  • Comorbidity
  • Comprehensive treatments
  • Goals and re-evaluation
  • Prognosis?

72
Unmet Needs in Pediatric Bipolar Disorder
  • Diagnostic Criteria
  • Faster improvement
  • Fewer side effects and better tolerability
  • Greater efficacy
  • Long term efficacy

Source Datamonitor, Stakeholder Insight MDD,
Q1.2 Adult population figures from
www.census.gov and MDD prevalence rates applied.
73
RESOURCES
  • WEBSITES
  • The Child and Adolescent Bipolar Foundation
  • www.bpkids.org
  • Depression and Bipolar Support Alliance
  • www.dbsalliance.org
  • The Bipolar Child
  • www.bipolarchild.com
  • Parents of Bipolar Children
  • www.bpparent.org
  • The Gray Center for Social Learning and
    Understanding
  • www.thegraycenter.org/Social_Stories.htm
  • National Institute of Mental Health (NIMH)
  • www.nimh.org

74
(No Transcript)
About PowerShow.com