![Goals of Today’s Presentation ,[object Object],[object Object],[object Object]](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
Recomendados
Recomendados
Más contenido relacionado
La actualidad más candente
La actualidad más candente (20)
Destacado
Similar a Barclay Gr 11 19 08 Pediatric Bipolar Disorder Revised111708
Similar a Barclay Gr 11 19 08 Pediatric Bipolar Disorder Revised111708 (20)
Barclay Gr 11 19 08 Pediatric Bipolar Disorder Revised111708
- 1. Help for the Primary Care Physician Gregory P. Barclay, M.D. November 19, 2008 Pediatric and Adolescent Bipolar Disorder
- 21. ADHD and PBD - Key Differences Not seen Present Flight of Ideas/Racing Thoughts ADHD/ADD Bipolar/Depression Common Family History Rare Common Aggressive or suicidal behavior Less prominent Very prominent Irritable mood Not seen Common Psychotic Symptoms Not seen Common Hypersexuality Much less common Common Elevated Mood ADHD PBD Symptom
Notas del editor
- Medline search: 5 publications relating to PBD before 1980 27 from 1980-1989 50 from 1990-1999 227 from 2000-2005
- Most recent epidemiologic data suggest that PBD may not be rare at all, but that it is difficult to diagnose and rather than identify bipolar disorder clinicians instead diagnose one of its multiple comorbidities Direct to consumer advertising has been shown to have profound influences on physician prescribing patterns that promote overuse. Biederman (Harvard) has received $15 million from pharmaceutical companies Melissa Del Bello (Cincinnati) received $180K in fees from Seroquel’s manufacturer, not including her research funding. “ Just as a child with a hammer discovers new things that “need” to be hammered, when psychiatry finds new drugs it discovers new people who “need” to be treated with them.
- DSM IV - “A hypomanic episode requires a distinct period of persistently elevated, expansive, or irritable mood lasting throughout at least 4 days” However, the vast majority (>70%) of PBD patients have mood/energy shifts several times per day. Reports of very early onset bipolar disorder raise questions about the appropriateness of applying adult criteria to toddlers The validity of diagnosing bipolar disorder in preschool children has NOT been established and therefore caution should be taken before making the diagnosis. One must ascertain the context of emotional and behavioral dysregulation.
- Trinucleotide Repeat Amplification (Adenine, Cytosine, Guanine)
- 35-40% of parents whose children took stimulants said their child “gets wild” when the medication wears off Stimulant rebound doesn’t appear to portend mania or even bipolar spectrum disorder (but it needs to be ruled out before a diagnosis is made) 61% of treatment emergent mania cases were related to SSRI use. 9% were triggered by atypical antidepressants and 6% tricyclics. -TEM much more common in girls vs........ boys Treatment with mood elevating agents in children diagnosed with BPD led to new manic, often psychotic or aggressive behavioral changes in half of cases exposed and almost half of those given antidepressants. Risk of such responses was nearly as high in girls as in boys and was predicted by exposure to a mood elevating agent and by early onset anxiety symptoms. “Megamania” (per Geller, 2007) Agitation and manic symptoms affect 1:10 children treated with SSRI’s. TEM is recognized in DSM IV as a substance-induced mood disorder distinct from PBD.
- More than 60% of Adult Bipolar Patients retrospectively report the onset of symptoms before age 20, 30% noted the onset before age 13 While longitudinal studies show that 75-80% eventually recover from their first episode, recovery takes many months and >70% relapse. Life time mortality for Bipolar Disorder = 18%
- Continuous, rapid cycling was the most prevalent pattern 60% prevalence of psychosis 55% had mixed mania 50% grandiose delusions Chronic picture of long current episode duration (mean = 309.8 days to 4 years) and daily (ultradian) cycling
- High rates of “mania” are described in clinical samples of ADHD Follow-up studies did not show increase bipolar disorder as adults “Burgeoning administration of stimulants and antidepressants to the general pediatric population - the potential for adverse effects in children are high” Geller+DelBello, 2006 Conduct Disorder is highly comorbid. The main differentiating feature is the lengthy prodrome in conduct disorder manifested by progressively more severe rule breaking, whereas mania mostly presents with an abrupt onset of impulsive behavior (Singh, 2006)
- Manic grandiosity and irritability present as marked changes in the individual’s mental and emotional state rather than reactions to situations, temperamental traits, negotiation strategies, or anger outbursts. Adolescents with BD are reported to have a high rate of suicide attempts and clearly are at risk for completed suicide Less than 1% of the hypersexual group had a history of sexual abuse.
- Pathological Elation = elated mood is out of context and impairing Grandiosity = out of context and impairing Children developmentally cannot present with many of the manifestations of mania observed in late teenage & adult onset mania.
- Prepubertal Mania is non-classic: Dysphoric Mania Irritability Aggressiveness Absence of clear cut episodes that follow good premorbid adjustment Chronically impaired Ill for 3+ years w/multiple daily episodes Post-Pubertal mania follows a more classic pattern
- ADHD: Often talks Excessively PBD: Pressure to keep talking ADHD: Often runs about or climbs excessively Hypomania: Agitation GAD: Restlessness ADHD: Is often easily distracted by extraneous stimuli Hypomania: Distractibility GAD/Depression: Difficulty Concentrating Conduct Disorders, Substance Abuse, Cluster B Personality Disorders can be characterized by mood and behavioral problems similar to those seen in hypomania and mania. Pressured speech is rapid and difficult to interrupt. Racing thoughts correlate with pressured speech and discriminate PBD from ADHD There are no definitive studies outlining a developmentally valid method for assessing manic symptoms in very young children.
- NIMH Roundtable on prepubertal Bipolar Disorder in 2001 reached an agreement that the disorder could present in different phenotypes Broad phenotype represents the most referrals There is no evidence that intermediate and broad phenotypes go on to “adult” or classic bipolar disorder; however narrow phenotype shows most continuity with adult disorder.
- Subsyndromalcases of bipolar disorder showed increased psychopathology and an increase in adverse outcomes, but not an increase in classic bipolar I/II diagnoses Compared with a group of full syndrome bipolar youth, both groups had an increased risk of antisocial and borderline personality disorder at follow-up. Are the Broad Phenotypes more representative of a form of ADHD + the unexpected effects of stimulant medications? Relatively poor outcomes in those with phenotypic resemblance to severely ill adults with bipolar disorder + mixed mania, psychosis, rapid cycling, or treatment resistance. Recovered cases had ADHD (33%), ODD (24%), MDD (30%)
- No lab work or imaging tests are diagnostic Baseline labs for most meds include CBC, UA + Lytes, BUN, Creat., LFT’s, TFT’s, lead levels (if child under age 7). Child self-report includes the symptoms that best differentiate ADHD from Bipolar Disorder FIND: Frequency, Intensity, Number of symptoms, Duration of symptoms (Number = 3/4 per day, duration = 4 or more times per day)
- Randomized Controlled Trial without placebo As of 2005, only 5 placebo controlled studies; many open label Many needed “rescue” medications for aggression, psychosis, and sleep disturbance, which affects the validity of the studies Majority of patients received stimulants before the trial - no placebo used in this study Marginal efforts and poor compliance plague efforts to treat PBD with monotherapy. Need to try for 6-8 weeks @ therapeutic doses before trying another medication. Combinations, based on symptoms profile, seem to yield a much higher response rate. Lithium to date most used in PBD, but results are modest at best. Most recent studies suggest it is best utilized in combination with an atypical antipsychotic. There is no agreement on what “mood stabilizer” means - anticonvulsants have never been shown to stabilize moods; their use is based on an analogy to seizures - not science. Repackaging of drugs for newer more profitable indications. (flora et al) Quetiapine, Aripiprazole, Valproate, Olanzapine, risperidone & Ziprasidone approved for acute mania in adults Both Lamotrogine and Olanzapine are approved for maintenance therapy in adults with BPD Combination of Olanzapine and Fluoxetine approved for Bipolar Depression in adults, as is Quetiapine and Aripiprazole. The short and long term safety of mood stabilizers and atypical antipsychotics in young children has not been established.
- Controlled studies have found Gabapentin or Topiramate useful No evidence that tiagabine, oxcarbazepine, or zonisamide are effective for PBD Stimulants possibly useful once mood symptoms are controlled on mood stabilizers High relapse rates suggest that once remission occurs, should stick with initial regimen for 12-24 months If meds are tapered, need to monitor closely and restart meds if any signs of relapse evident. LiCO3 - cognitive problems Valproate - increased testosterone, PCOS Lamotrogine - Stevens Johnson Syndrome Risperidone - Hyperprolactinemia, pituitary tumors - “perhaps the best supported by evidence, given targeted symptoms of explosive outbursts, mood stabilization, and psychotic like symptoms” (McClellan) Olanzapine - weight gain Quetiapine - Sedataion, wide dose range Ziprasidone - EKG - prolonged QT Aripiprazole - Dyskinesias Olanzapine - one open trial (mean dose 9.8 mg./d) - effective in PBD Topiramate - inhibits glutamate activity, augments the effect of GABA Carbamazepine - best for acute mania and mixed states
- Maternal Warmth = “The quality of involvement, understanding, acceptance, and love that parents communicate on different levels and in ever-evolving ways as their children grow” (Levine) Youths with significant emotional and behavioral problems likely need intensive behavioral and parenting interventions in addition to medication therapy “Rainbow Program” (univ chicago) highly effective in pre/post studies. Parent therapy - addresses guilt, ineffective expectations, recognizing limits, not personalizing, & not using dx as an excuse. Depressed mothers express the most affectively charged negative statements which in turn are highly associated with low self worth and high child psychopathology rates Sibling therapy - help them understand issues relating to getting lost in the shuffle and feeling embarrassed. Group therapy programs are empirically supported but not yet validated - focus is on self management skills DBT - combination of compassion, warmth, and validation are critical to success
- Screen those with family history There is evidence that youths will often have depressive episodes before having their first hypomanic or manic episode Factors that predict development of mania noted in slide. “A child with symptoms of ADHD and mood lability who has a parent with bipolar disorder may actually be in the prodromal state of PBD. Treatment with stimulants has been reported to trigger manic episodes in children.