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Pediatric Bipolar Disorder

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“Bipolar Disorder in Youth: Does it Exist?” Halifax, Nova Scotia, Canada; March 22, 2006, Community presentation at IWK Health Centre
*Learn clinical presentation of pediatric bipolar disorder
*Differentiate pediatric bipolar disorder from other psychiatric disorders
*Learn genetics of bipolar disorder
*Learn treatment of pediatric bipolar disorder

Publicado en: Salud y medicina
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Pediatric Bipolar Disorder

  1. 1. Pediatric Bipolar Disorder Carlo G. Carandang, MD IWK Health Centre Dalhousie University Psychiatry
  2. 2. Objectives • Learn clinical presentation of pediatric bipolar disorder • Differentiate pediatric bipolar disorder from other psychiatric disorders • Learn genetics of bipolar disorder • Learn treatment of pediatric bipolar disorder
  3. 3. Detailed Objectives • What is bipolar disorder? – How is it different in children and teens? • Diagnostic criteria and controversy – What is not bipolar disorder? • Comorbid disorders • Treatment options – Medical – Psychological – Lifestyle • Issues for children, teens and families – School – Social and family life • Information sources
  4. 4. Sadness vs. Depression • Sad is what we feel when we lose something we love, or hope to attain. • Depression is something more: – Sadness that is there every day for more than two weeks – Interferes with life: friends, fun, family & school
  5. 5. Depression SIGECAPSSIGECAPS for 2+ weeks (5 of 9 criteria) Dysthymia: 1 year (3 of 9 criteria) In addition to low moods, the following: • Sleep Disturbance • Irritability (core symptom in youth, not adults) • Guilt • Energy • Concentration • Appetite • Psychomotor Agitation or Retardation • Suicidality
  6. 6. *suspect trauma or abuse in this age group if depressed 6 Rates of depression in children General population: – Pre-schoolers 0.3-0.9%* – Latency 1.5-3% (boys > girls) – Adolescence 1-6% (girls > boys) • Up to 10% for all syndromes • 10-24% by late adolescence comparable to adult: – Men (12%) – Women (21-24%)
  7. 7. Happiness vs. Mania • Happiness is what we feel when close to people we love, or our goals are met. • Mania is something different: – Euphoric or irritable mood that persists out of context – High energy, grandiose, low need for sleep – Interferes with life – Lasts 4-7 days
  8. 8. Mania • DIGFASTDIGFAST 3 of 7 criteria (4 if mood only irritable and not euphoric or expansive) • Distractibility • Insomnia (decreased need for sleep) • Grandiosity • Flight of ideas • Activity (increase in goal-directed) • Speech (pressured) • Thoughtlessness (reckless behaviors)
  9. 9. Why do we care about mood disorders? • Duration and Course of Pediatric Unipolar Depression: – Duration: 3-9 months – 10% last more than 2 years – 60-70% risk of recurrence in adulthood (Weller and Weller 2000) – 20-32% develop bipolar disorder within 5 years (Geller et al., 1994; Strober and Carlson 1982; Strober et al., 1993)
  10. 10. Risks of bipolar disorder • Suicide: – 50% attempt – 15% will die • Disrupted friendships, high divorce rates • Family conflicts • Lower educational attainment • Higher unemployment or lower paid work
  11. 11. Pediatric Bipolar Disorder • Minimal research regarding phenomenology and course • DSM-IV Bipolar criteria not validated for prepubertal and early-adolescent populations • Late-adolescent-onset bipolar disorder is viewed as having similar phenomenology to adult-onset bipolar disorder
  12. 12. Diagnostic Controversy • 2 views regarding appearance of bipolar in children – Conservative DSM-IV • Strict criteria • Higher threshold for diagnosis – Broadly-defined Bipolar NOS • Irritability: often misinterpreted • Lower threshold for diagnosis
  13. 13. Clinical Manifestations of Pediatric Bipolar Disorder • Teen-Adult presentation: – Distinct episodes of mania and depression lasting >1 week – Expansiveness, elation, grandiosity present • Pediatric presentation: – Brief, adult-like episodes (hours-2 days) – Chronic course, no clear episodes • Mixed depressive and manic symptoms • Continuous/rapid cycling • Irritability, mood lability, explosiveness
  14. 14. Diagnosis of Pediatric Bipolar Disorder: Symptom Thresholds • FIND (frequency, intensity, number, duration) – Frequency • Sxs occur most days of the week – Intensity • Sxs cause disturbance in functioning – Number • Sxs occur at least 3-4 times per day – Duration • Sxs occur at least 4 hours per day (total)
  15. 15. (Leibenluft et al., 2003) NIMH-Proposed Bipolar Phenotypes in Youth • Narrow Phenotype: Strict DSM-IV criteria • Intermediate Phenotype-Mania NOS: duration 1-3 days; otherwise meets full criteria • Intermediate Phenotype-Irritable Mania: mood irritable, not euphoric or expansive; otherwise meets full criteria • Broad Phenotype: chronic, non-episodic irritability; no other hallmark symptoms of mania
  16. 16. Pediatric Bipolar Disorder • Uncommon condition – 1% prevalence in adolescents • (Lewinsohn et al., 1995) – 0.5% prevalence in prepubertal youth (est.) • Duration and course: – 93 outpatients, 7 to 16 years of age (mean age = 11 years) with bipolar I or II – Mean age onset: 7 years of age – Mean episode duration: 3.5 years of age • (Geller et al., 2000)
  17. 17. (presented by Axelson 2003) Pediatric Bipolar Disorder: Comorbidity (Referred Samples) • ADHD: 60-90% • ODD/Conduct Disorder: 40-90% • Anxiety Disorders: 22-56% • Substance Abuse: 10-22%
  18. 18. (Geller et al., 1998) Differentiating Bipolar Disorder from ADHD • Findings – Bipolar disorder group > ADHD group • Elevated mood • Grandiosity • Hypersexuality • Decreased need for sleep • Racing thoughts
  19. 19. Over- and Under-Diagnosis of Pediatric Bipolar Disorder • Over-Diagnosis is the main problem – Some families and clinicians have interpreted irritability as a pathognomonic symptom of mania. – Irritability a very frequent symptom of numerous child psychiatric disorders (ADHD, ODD, Conduct, Autism, Major Depression, Schizophrenia)
  20. 20. Over- and Under-Diagnosis of Pediatric Bipolar Disorder • Under-diagnosis may occur if mania is not considered in the differential diagnosis of ADHD. • Knowledge of pediatric presentation of mania vs. adult presentation can help with the differential diagnosis of irritability and ADHD, and thus help avoid over- or under-diagnosis.
  21. 21. Clinical Pearls for Diagnosis of Pediatric Bipolar Disorder • Family History • Presence of elation/euphoria or grandiosity • Hypersexuality • Acute onset of depression • Psychotic depression • History of medication-induced mania
  22. 22. Kindling TheorySeverityofSymptoms Time Full Disorder Threshold
  23. 23. Molecular Genetic Studies • Strongest evidence of linkage to date for “Bipolar Genes:” 18p, 18q, 21q • Polygenic • Linkages have not been replicated • Mood Genes: Hunting for Origins of Mania and Depression by Samuel Barondes
  24. 24. Onset of Bipolar Disorder • Gene by environment interaction • Genetic vulnerability combined with environmental stressor produces phenotype • Risk if one affected first-degree relative : ranges from 6.5%-25% (compared to 1% in general population) • Depression most common in relatives
  25. 25. Unipolar and Bipolar Affective Disorder • Bipolar Affective Disorder – Greater genetic contribution – Treated with mood stabilizer first line – Psychotherapy alone not a reasonable treatment approach • Unipolar Affective Disorder – Genetic contribution, but greater environmental contribution – Psychotherapy alone first line for mild to moderate unipolar depression – Psychotherapy with antidepressants for moderate to severe unipolar depression
  26. 26. What might Bipolar Disorder look like? • Amy is 12 years old. For the past 3 months she has felt sad almost every day. She has been crying several a times week, at times for no reason at all. Her appetite has gone down and she has lost about 7 pounds. She also hasn’t been sleeping well and said that she takes about 2 hours to fall asleep and then wakes up several times at night. • During the day, Amy said that she is tired and has no energy. Although she said that she thinks that life is not worth living, she does not have a plan to end her life. As a result of her difficulties, Amy stopped calling friends and does not talk as much with her parents. She also stopped playing piano and guitar, which she used to enjoy.
  27. 27. What might Bipolar Disorder look like? • Over the next few days Amy seems to be feeling a bit better. She has started to call her friends again and seems to have more energy. She is also more talkative when around others. She has started to play piano and guitar again and her parents noticed that she seemed to giggle a lot, which was unusual for Amy. • On Friday night she called about 10 of her friends to come over and “hang out.” Most of them came over to the house and they began playing a game. Throughout the game Amy giggled uncontrollably and began telling jokes, most of which her friends didn’t find funny. Amy laughed at all of the jokes, however. She also put socks on her ears and began dancing around. Her friends did not laugh at this, so Amy kicked them out of the house.
  28. 28. What might Bipolar Disorder look like? • That weekend was difficult. Amy’s parents were awakened at 2AM on Saturday, as Amy was up playing piano and singing out loud. When they questioned Amy about playing music so late at night, she said she was practicing to be the best musician ever, and wanted to go on tour with her music. She said that these and other thoughts raced through her head. • Her parents tried to talk to her, but noted she was talking so fast and was giggling, so her parents had trouble following her. Her parents tried to discipline her but nothing seemed to work. Amy only became irritable or laughed at her parents. • On Monday her parents received a call from school saying that Amy was laughing uncontrollably in class and acting childish. She was sent home as a result. She was closely watched for one week by her parents and slowly began to unwind as she became more depressed and withdrawn, much like she was before.
  29. 29. So, what signs in Amy make us think bipolar disorder? • Symptoms of depression lasting over 2 weeks: – Sad mood (crying) – Sleep disturbance – Appetite change – Low energy – Withdrawn & little interest in activities – Suicidal thoughts • Symptoms of mania lasting 4 or more days – Euphoric mood – More talkative & pressured speech – Racing thoughts – No need for sleep – Grandiosity (singer) These symptoms also affected her relationships with friends, with her family and her functioning at school.
  30. 30. What do we do? • Comprehensive assessments • Treatment • Monitoring • Support • Case Management
  31. 31. Supports and their roles • Therapist • Family doctor • Psychiatrist • School professionals • Community supports: – Laing House – Phoenix Prevention Program • Family!
  32. 32. Family functioning • Acknowledge problems • Seek evaluation and treatment • “Take the illness out of it” • Be consistent about expectations and consequences • Review warning signs with your child – Card with signs and plans of action signed by both. Include support contacts.
  33. 33. What can youth and family do? Mood card: • A card that contains information on how to recognize and cope with mood episodes • Parents, youth and clinician together • Agree on “warning signs” of moods • List contact information of clinicians • Confidential relationships issue: right to inform? • Agree on plan of action • Can help adherence and acceptance
  34. 34. Mood Chart
  35. 35. What are the school challenges? • Inability to screen out environmental stimuli – Sounds, sights, smells – Decrease stimuli, find quiet study/work area, change seating arrangement • Inability to concentrate – Restless, short attention span, easily distracted, hard time following directions – Break large projects into smaller tasks, short frequent breaks, help with study skills, assignments one task at time or in writing, tape recorder or notetaker, photocopy notes, textbooks on tape
  36. 36. School challenges • Lack of stamina – Not enough energy for day or course load – Discuss part-time options, take tests or assignments in sections, beverages (juice, water) in class • Difficulty handling time pressures and multiple tasks – Trouble managing assignments, setting priorities, meeting deadlines, writing tests – Break larger tasks into smaller pieces, get syllabus, use calendar/day planner, extended time, change format, segmented tests
  37. 37. School challenges • Difficulty interacting with others – Difficult to talk to others, get notes, discuss assignments, participate in class, chat with others, make friends – Mentor/buddy • Difficulty handling negative feedback – Hard time understanding and interpreting criticisms – Ask teacher to talk with you about performance and specific ways to improve, alternative assignments/extra credits, problem solve together
  38. 38. School Challenges • Difficulty responding to change – Change may be stressful – Advanced warnings, social stories, guidance counsellor
  39. 39. Parent and Teacher Roles • Be aware of changes in performance and abilities at school (academics, social, affect) • Assist by: – Educating yourself – Listening – Problem solving – Communicating – Supporting (relaxation, coping, etc.) – Accommodating (identify and reduce stressors) – Being flexible
  40. 40. Can a healthy lifestyle help? Lifestyle changes can include: • Sleep • Diet • Exercise • Routines
  41. 41. Sleep • Lack of sleep or too much can impact moods • Needed sleep (16hrs for infants, 9hrs for teens, 7-8 for adults) • Keep regular sleep schedule – Go to bed and get up same time every day – Avoid naps through day – Adopt bedtime ritual to wind down (e.g. warm bath, reading, soft music, etc.) – Decrease distractions in room (no t.v., video games, computer, etc.) – Avoid caffeine
  42. 42. How do I get a healthy sleep? – Get regular exercise – Eat well balanced diet – Change time of day you take medication (Consult doctor) – Avoid late night shifts at work – If you wake up early in am and can’t get back to sleep get up and do quiet activity (e.g. reading) – Be aware of changes in routine
  43. 43. Diet • Nutrition can affect your health, energy, and sometimes your mood • If your body is nourished properly, your brain can function more effectively • Excessive amounts of sugar, caffeine, alcohol, or chocolate may be more likely to contribute to mood disturbances • Vegetables, fruit, oil-rich fish, and whole grains may be more likely to help with stability
  44. 44. What is a balanced diet? • Best advice is to limit the things you know can impact your mood and ensure you have a well balanced diet including foods from all the 4 major food groups and lots of water
  45. 45. Exercise • Exercise releases endorphins which are associated with good moods • Exercise can help reduce the stress hormone cortisol, often elevated in depressed people. • Exercise can help restore sleep and eating patterns
  46. 46. What if I hate to exercise? • Choose a method of physical activity you enjoy • Focus on making the experience as pleasant as possible • Start slowly and work up • A good goal to work towards is 30 minutes a day, 3 times a week
  47. 47. Routines • Keeping life structured may help with manageability • Could use – Day planners – Calendars – Sticky notes
  48. 48. Medical and Psychological Treatments • Medication management required to stabilize mood • Psychotherapy can address lifestyle changes, coping strategies, improve relationship skills and help with compliance with medication.
  49. 49. Somatic Treatments • Lithium • Valproate • Carbamazepine • Atypical Antipsychotics • Third-Generation Anticonvulsants • ECT
  50. 50. (Pediatric Bipolar Disorder, JAACAP, 44:9, Sept. 2005) What do studies show regarding medications for pediatric bipolar disorder? • Combination of atypical antipsychotics and mood stabilizers appears effective for acute treatment and stabilization of pediatric bipolar disorder • Combination of mood stabilizer and stimulant appears promising for youth with ADHD and bipolar disorder • Antidepressants may worsen mania • Monotherapy with mood stabilizer alone may not maintain moods for longer than 4 months • Lamotrigine promising for bipolar depression
  51. 51. Treatment of Pediatric Manic Episode • Taper stimulant or antidepressant medications – Reevaluate mood & behavior • Still with mood symptoms? – Euphoric → lithium – Mixed → valproate – Psychosis/impulsive aggression → atypical • Non/partial response → lithium + valproate – Or mood stabilizer + atypical – Once stable - reevaluate ADHD • Still with ADHD symptoms? – Add low-dose stimulants
  52. 52. Treatment of Pediatric Bipolar Depression • Lithium monotherapy • If treatment refractory, consider adding lamotrigine (adjunctive or monotherapy) – Lithium + lamotrigine – LTG monotherapy • Adding SSRI to mood stabilizer needs close supervision, observing for rapid cycling
  53. 53. Psychosocial Treatments • Psychoeducation • Circadian Rhythm Hygiene (structured sleep/wake cycle) • Case management/wraparound services • CBT (especially for depression and anxiety) • Multifamily Psychoeducational Groups
  54. 54. Is adherence with treatment important? YES!
  55. 55. Adherence issues • Why take it? – Effective treatment can reduce number and severity of episodes and limit their effects. • Why do some not take it? – Stigma – Side-effects – Misunderstanding of its effects – Allure of mania – Cost – Poor relationship with therapist or doctor
  56. 56. Stigma • Overlap with denial of symptoms • Personal views of mental illness • Others’ experiences • Fear of criticism of others • Fear of misinterpretation of need for medication: “pathologized”
  57. 57. Allure of Mania • It can feel good…for a while. – Faster thinking – Creativity – Decreased need for sleep – Euphoria – Over-optimism • Decreased awareness of consequences • Over-confidence • Forget past depressions, negative effects.
  58. 58. Fear • “I won’t be me.” • “I will be controlled by medication. I need to deal with this myself.” • “It will damage my brain and my body.”
  59. 59. Side-effects • Sedation • Weight gain • Diabetes • Acne • Slower thinking • Loss of manic and hypomanic highs • Aim is to balance risks and benefits • Several options available!
  60. 60. Cost • Teens often acutely aware of family financial problems • First-line treatments are less expensive • Newer medications cost more but are covered by all plans. • Samples often available • Long-term costs of no treatment far greater
  61. 61. Why does a relationship matter? • Doctors’ and therapists’ role is to help with the problems that prevent adherence • Need to listen and actively address fears and side-effects • Informed consent requires good, clear information • Anger or frustration with treatment or clinician can show up as non-compliance.
  62. 62. How to tell if treatment is working? • Feeling better • Living better • Tolerating medication and side-effects: the balancing act
  63. 63. Pediatric Bipolar Summary • Difficult to manage • Currently overdiagnosed – KSADS-PL and/or WASH-U-KSADS often necessary • No “magic bullets” exist • Much more research is needed – Single agents – Combination pharmacotherapy – Pharmacotherapy + CBT – Multifamily Psychoeducation Groups
  64. 64. Internet Resources • Depression and Bipolar Support Alliance: – www.dbsalliance.org • Child and Adolescent Bipolar Foundation: – www.bpkids.org
  65. 65. Suggested Reading Parents and youth: • New Hope for Children and Teens with Bipolar Disorder, Boris Birmaher, MD. Three Rivers Press, NY, 2004. Clinicians: • Pediatric Bipolar Disorder: A Review of the Last 10 Years. Journal of the American Academy of Child and Adolescent Psychiatry 44(9): Sept. 2005.

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