OT is a 7 yo Caucasian male, who currently lives with his biological mother & step father. He attends 2nd grade in special educationC/C Per OT: “I choked my younger brother” Per Mother: “OT has been very unpredictable, impulsive , aggressive towards family members, and threatening to kill himself”
Went to doctor’s office for his scheduled appointment, argued, refused physical At his return home, he was upset , argued with mother, broke step father’s laptop Tried to choke his brother PT, when mother tried to interrupt him, threatened to kill mother, and then kill himself No behavioral issues during first 3 years, described as “a very good baby” Behavioral problems started around age 3, after father’s physical assault on mother Patient started exhibiting aggressive behaviors at home and school, that have continued to the present without any improvement Violent behavior at home, threatening to use knives/toys as his weapons Multiple episodes of suicidal threats in the past (most serious attempt : trying to grab a knife from the kitchen to kill himself)
History of making threats to hurt others w/wo any accessible weapon nearby Destruction of property : when angry would break anything in his vicinity At school, pushing everything off the teacher’s desk. Turning it upside down Mother describes no precipitating factors to his anger and his outbursts which are episodic. During a typical episode (3-4episodes/week), OT will scream, curse at others, throwing objects, often threatening to kill himself and others Mother says that he is usually remorseful and apologetic a few hours after such episodes, and promises to mend his behavior in future Mother also reports has had chronic difficulties falling asleep. OT ( if not medicated) would keep awake till 2 -3 am , and then usually gets up on his own about 7-7.30 am , and does not report feeling tired History of inappropriate sexual behaviors, starting 3 wks before current admission OT is irritable most of the time when he is awake, most days of the week
Per mother , it’s very difficult for OT to focus on a thing Usually would not listen to her , when she is talking to him It’s very difficult for him to sit still Usually talks “superfast”, and jumps from one topic to the other Mother denied any symptoms suggestive of grandiosity Mother describes occasional episodes , where OT will slow down, isolates himself, does not talk “that much”, shows reduced interest in paying video games, would prefer to watch TV. No explicit sadness or crying has been observed during these episodes. These episodes are few and far between ( 1-2 times every month) No problem reported with sleep or appetite. No suicidal ideations during these times
Multiple (>7) admissions PREVIOUS DIAGNOSES: between 07 and 09. Oppositional Defiant Disorder Past Medications: Abilify, Conduct disorder (childhood Adderall, Cogentin, onset) Concerta, Depakote, Elavil, PTSD Geodon, Lithium, Risperdal, Ritalin, Seroquel, Strattera, Munchausen by proxy Trileptal syndrome (MBPS) Medical: Seasonal asthma, Mood disorder NOS occasional use of Albuterol Adjustment disorder inhaler Reactive attachment disorder Surgical : Tonsillectomy and Intermittent Explosive Adenoidectomy 03/08 Disorder
None Patient has more knowledge about sexual activities than would be expected for his age Inappropriate sexual behaviors began about 3 wks prior to admission, exposing himself in the unit during current admission
Mother suspects that Father had BP per she has depression mother (never treated, no Father has had problems medications) with Alcohol Maternal Aunt has Father has been in Jail depression, being about 8 times ( domestic treated violence, destruction of property, beating up people) Questionable hx of BP in Paternal GF Maternal side Paternal side
OT was born via NSVD. No post-natal complications Developmental milestones were appropriate for age Described as a warm and cuddly infant Aware of Physical violence towards the mother by biological father No other physical/emotional/sexual abuse reported
Problems began during Head start at around age 4 Had to change school about twice Currently goes to a day program(Tu,Th,Fr) Face to face (M, W) Is in the 2nd grade (IEP*) Behind in reading and spelling per mother ( per testing done at Hawthorn Grade levels are: ) Reading = 1.2 Spelling = 1.0 Math = 1.2*= Individual Education Plan
OT is a 7 yo Caucasian, slightly obese male, appears stated age. Fair grooming and hygiene . Pleasant and co-operative to begin with the interview, soon gets distracted, infrequently answering the questions in the first time. Fidgety and restless throughout the interview. Keeps jumping out of the chair. Speech had an increased volume and flow, normal syntax and grammar. Mood anxious and elated, affect labile .Thought process was logical & goal directed, whenever he chose to answer, but illogical during most part of the interview frequently derailing from the topic. Switching topics often. Denied any abnormal perceptual experiences. No delusions. AA Ox3. Memory : on recent recall 2/3 words after 5 minutes, able to recall past events with reasonable accuracy. Appeared to have average intelligence. Poor attention & concentration. Poor impulse control, Judgment poor. No insight into his problem.
Axis I : Bipolar disorderNOS(?) Hx ADHD (C)Axis II : NoneAxis III : Seasonal Asthma ObesityAxis IV : Problem with primary support group, Educational problemsAxis V : 20-25
Day 1 : OT has difficulty falling asleep. Day 4 : Behavioral issues continue, sent to the QR 3/4days. Fighting peers, provoking, not following directions Day 6 : Depakote level is 93mmol/liter Day 7 : Reports A/V hall. the “Grim Reaper” Day 8 : Geodon is increased to 40mg bid Day10: Sexually inappropriate behavior Day14: Lithium is added to the medication regime Day15: “My mind runs faster than the Mustang” Day 21: Geodon+ Lithium+ Depakote, ongoing Rx . No response to medications. Li+2 level awaited
The essential feature of Bipolar I Disorder is a clinical course that is characterized by the occurrence of one or more Manic Episodes or Mixed Episodes. Often individuals have also had one or more Major Depressive Episodes. Episodes of Substance-Induced Mood Disorder (due to the direct effects of a medication, or other somatic treatments for depression, a drug of abuse, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Bipolar I Disorder. In addition, the episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified
The essential feature of Bipolar II Disorder is a clinical course that is characterized by the occurrence of one or more Major Depressive Episodes accompanied by at least one Hypomanic Episode. Hypomanic Episodes should not be confused with the several days of euthymia that may follow remission of a Major Depressive Episode. Episodes of Substance- Induced Mood Disorder (due to the direct effects of a medication, or other somatic treatments for depression, a drug of abuse, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Bipolar I Disorder. In addition, the episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:1. inflated self-esteem or grandiosity2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)3. more talkative than usual or pressure to keep talking4. flight of ideas or subjective experience that thoughts are racing5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The symptoms do not meet criteria for a Mixed Episode. D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatments) or a general medical condition (e.g., hyperthyroidism). Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.
A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood. B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:1. inflated self-esteem or grandiosity2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)3. more talkative than usual or pressure to keep talking4. flight of ideas or subjective experience that thoughts are racing5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is NOT severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are NO psychotic features. F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder.
A. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1- week period. B. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
The Bipolar Disorder NOS category includes disorders with Bipolar feature that do not meet criteria for any specific Bipolar Disorder. Examples include1. Very rapid alternation (over days) between manic symptoms and depressive symptoms that meet symptom threshold criteria but not minimal duration criteria for Manic, Hypomanic, or Major Depressive Episodes2. Recurrent Hypomanic Episodes without intercurrent depressive symptoms3. A Manic or Mixed Episode superimposed on Delusional Disorder, residual Schizophrenia, or Psychotic Disorder NOS4. Hypomanic Episodes, along with chronic depressive symptoms, that are too infrequent to qualify for a diagnosis of Cyclothymic Disorder5. Situations in which the clinician has concluded that a Bipolar Disorder is present but is unable to determine whether it is primary, due to a GMC, or substance induced
Opinion 1 : Trying to use the course modifier “rapid cycling” , because children often do not have clearly demarcated episodes, but seem to be chronically cycling1-41. Pediatric bipolar disorder: emerging diagnostic and treatment approaches: Kowatch RA, DelBello MP.Child Adolesc Psychiatr Clin N Am. 2006 Jan;15(1):73-108. Review.2. Diagnostic characteristics of 93 cases of a prepubertal and early adolescent bipolar disorder phenotype by gender, puberty and comorbid attention deficit hyperactivity disorder :Geller B, Zimerman B, Williams M, Bolhofner K, Craney JL, Delbello MP, Soutullo CA. J Child Adolesc Psychopharmacol. 2000 Fall;10(3):157-64.3. Rapid, continuous cycling and psychiatric co-morbidity in pediatric bipolar I disorder: Findling RL, Gracious BL, McNamara NK, Youngstrom EA, Demeter CA, Branicky LA, Calabrese JR: Bipolar Disord. 2001 Aug;3(4):202-10.4. Childhood mania: insights into diagnostic and treatment issues: Wozniak J, Biederman J: J Assoc Acad Minor Phys. 1997;8(4):78-84. Review.
Opinion 2: Prepubertal BP I patients have multiple mood swings each day, have mixed episodes with short periods of euphoria mixed with longer periods of irritability.5,65. Mania-like symptoms suggestive of childhood-onset bipolar disorder in clinically referred children: Wozniak J, Biederman J, Kiely K, Ablon JS, Faraone SV, Mundy E, Mennin D: J Am Acad Child Adolesc Psychiatry. 1995 Jul;34(7):867-76.6. Four-year prospective outcome and natural history of mania in children with a prepubertal and early adolescent bipolar disorder phenotype: Geller B, Tillman R, Craney JL, Bolhofner K: Arch Gen Psychiatry. 2004 May;61(5):459-67.
Opinion 3: Geller in her classic paper of 2002 7 describes “Children are developmentally incapable of many manifestations of bipolar symptoms described in adults e.g., children do not “max” out on credit cards or have four marriages” and has discussed age equivalents of adult mania behaviors.7. Phenomenology of prepubertal and early adolescent bipolar disorder: examples of elated mood, grandiose behaviors, decreased need for sleep, racing thoughts and hypersexuality: Geller B, Zimerman B, Williams M, Delbello MP, Frazier J, Beringer L: J Child Adolesc Psychopharmacol. 2002 Spring;12(1):3-9.
Normal Child Child Mania Adult ManiaChild was super A 7-year-old boy was A 40-year-old manhappy on days family repeatedly taken to giggled infectiouslywent to Disneyland, the principal for while being placed inon Christmas clowning and giggling restraints in themorning, and during in class (when no one emergency room. Agrandparents’ visits. else was) and was 50-year-old man inChild’s joy was suspended from the emergency roomappropriate to school. He had to was infectiouslycontext. Child’s leave church with his amusing as hebehavior was not family for similar described multipleimpairing behaviors. A 9-year- hospitalizations, old girl continually losing jobs, and losing danced around at family ties. home stating, “I’m high, over the mountain high” after suspension from school.
Normal Child Child Mania Adult ManiaA 7-year-old boy played at being A 7-yo boy stole a go-cart An adult man kept hisa fire fighter, directing other because he just wanted to family in increasing debtfire fighters and rescuing have it, even though he knew due to multiple unrealisticvictims. The child was not stealing was wrong. He did business ventures. A 21 yocalling the fire station to tell not, however, believe it was man believed he couldthem what to do. Play was wrong for him to steal. When commit a homicide and notduring afterschool hours; it was the police arrived, the child be arrested because theage appropriate and not thought the officers were laws would not pertain toimpairing. there to play with him. An 8 him. An 18 yo woman rang yo girl opened a paper flower the mayor’s home doorbell store in her classroom and because she knew they was annoyed and refused to were engaged. When asked class work when asked by the if she had ever met the teacher. An 8 yo girl, failing mayor, she stated it did not at school, spent her evenings matter practicing for when she would be the first female president. She was also planning how to train her husband to be the First Gentleman. When asked how she could fail school and still be president, she said she just knew it
Normal Child Child Mania Adult ManiaNormal Children sleep An 8 yo boy A 25 yo womanapprox 8-10 hours a chronically stayed up worked both day andnight and are tired if until 2 a.m., evening full time jobs,they sleep fewer hours rearranging furniture seemingly withoutthan usual or playing games. fatigue. A father Then he awoke at 6 described his daughter a.m. for school & was as “she parties” for energetic during the days in a row, and day without evident then “sleeps” for days tiredness, or fatigue. in a row A 7 yo girl, daily, knocked on a friend’s door at 6 a.m. ready to play.
Normal Child Child Mania Adult ManiaA 7 yo child played doctor An 8 yo boy imitated a rock Numerous adults who hadwith the same aged friend. A star by gyrating his hips, and four or more marriages not12 yo boy looked at his rubbing his crotch during a due to death of spouses orfather’s pornographic research interview. A 9 yo who had multiplemagazines boy drew pictures of naked extramarital affairs. ladies in public, stating these were drawings of his future wife. A 14 yo girl passed notes to boys in class asking them to f *** her. A 7 yo girl touched the teacher’s breasts and propositioned the boys in the class. Another child called the “1-900” sex lines, which the parents discovered when the phone bill arrived at the end of the month.
Normal Child Child Mania Adult ManiaNormal subjects did not Unlike Manic adults, Adults conceptuallygive affirmative response children gave concrete understand “racing”to inquiries about racing answers to describe their thoughts and can describethoughts “racing thoughts.” them using the word Examples are: A girl racing pointed to the middle of her forehead and stated “I need a stoplight up there.” Other children noted the following: “It’s like an energizer bunny in my head.” “Too much stuff is flying around up there.” “I don’t know what to think first.” “My thoughts broke the speed limit.”
Opinion #4: Dr. Leibenluft’s NIH lab has given a demarcation between various phenotypic expressions of Mania/Hypomani a8: Defining clinical phenotypes of juvenile mania: Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS: Am J Psychiatry. 2003 Mar;160(3):430-7. Review.
The co-occurrence of additional disorders complicates both the accurate diagnosis of BPD and it’s treatment The presence of comorbidity compounds disability, complicates RX, and worsens the prognosis If comorbidity is not acknowledged, misattribution of impairing symptoms could lead to inappropriate therapeutic interventions, unnecessary exposure to neuroleptics, worsening of symptoms, and misuse of mental health resources9. Comorbidity in pediatric bipolar disorder: Joshi G, Wilens T: Child Adolesc Psychiatr Clin N Am. 2009 Apr;18(2):291-319, vii-viii. Review.
ADHD is comorbid with BPD : 60-90% ADHD comorbidity more often associated with early onset BPD Recognition of this comorbidity is very important because- Medications with Manicogenic potential- Atypical response- Less than expected antimanic response to thymoleptic agents- If the symptoms of inattentiveness, distractibility, talkativeness, and impulsivity are not recognized as comorbid ADHD, they may be inappropriately treated as residual symptoms of mania
Symptoms which are not mania specific : occur in both categories- Irritable mood- Accelerated speech- Distractibility- Increased energy Criteria which provide best discrimination- Elated mood- Grandiosity- Flight of ideas/Racing- Decreased need for sleep Of the poor judgment criteria (total poor judgment, hypersexuality, daredevil acts, silliness, uninhibited people seeking) only hypersexuality provides good discrimination between ADHD & PEA-BP* = Pediatiric and Early Adolescent10. DSM-IV mania symptoms in a prepubertal and early adolescent bipolar disorder phenotype compared to attention- deficit hyperactive and normal controls: Geller B, Zimerman B, Williams M, Delbello MP, Bolhofner K, Craney JL, Frazier J, Beringer L, Nickelsburg MJ: J Child Adolesc Psychopharmacol. 2002 Spring;12(1):11-25.
There are no FDA approved medications for children younger than 10 years Several antipsychotics are approved 10-17 Lithium is approved for 12 and above Contrast to 19 meds for ADHD
Need for NIMH or Private foundation to fund research Studies without a placebo arm are wanted by Parents, when considering entering their children in clinical trials12 Practical randomized, open comparative trials of two active agents could be performed at a single site or several sites, and not involve the expense of traditional Multi-site RCT’s1312. Parental attitudes towards early intervention in children at high risk for affective disorders: Post RM, Leverich GS, Fergus E, Miller R, Luckenbaugh D: J Affect Disord. 2002 Jul;70(2):117-24.13. Childhood-onset Bipolar Disorder: The Perfect Storm :Robert. M Post: Psychiatric Annals (Editorial): October 2009
AACAP Practice Parameters for BD Include screening questions for BD during psychiatric evaluation Use “unmodified” DSM-IV-TR criteria for diagnosis If + make sure you screen for all the comorbidities viz. substance, suicidality and medical problems Be cautious in diagnosing in pre-schoolers (refer/second opinion)
“If uncertainties make you anxious, don’t think about being a child psychiatrist”Dr. Elizabeth McCullough