Chapter 14 (copy)

Pediatric Bipolar Disorders

• Pediatric Bipolar Disorders in Children and Adolescents



 Mania – discrete period of elevated, expansive, or irritable mood and increased level of energy and activity

 DSM-5

 Pediatric Bipolar I Disorder

 Pediatric Bipolar II Disorder

 Cyclothymic Disorder

Pediatric Bipolar I Disorder

• Pediatric Bipolar I Disorder in Children and Adolescents

 Experience at least one manic episode preceded or followed by a major depressive or hypomanic episode(s)

 Last at least 1 week and symptoms are present most of the day; nearly every day

 1 week waived if hospitalization is required

 3 or more of the following (4 or more if irritable mood):



 Decreased need for sleep

 More talkative

 Fight of ideas or feel thoughts are racing



 Increased in goal-behavior

 Excessive involvement in activities with possible harmful consequences

 Marked impairment in social or occupational functioning or need for hospitalization, or there are psychotic features

• Pediatric Bipolar I Disorder in Children and Adolescents

 Manic Episodes and Children

 Report expansive mood, elevation, and increased energy

 Elevated mood and increased energy: cardinal symptoms



 90% experienced increased energy

 Many report irritable mood during manic episodes

 Mood: touchy, angry, oppositional, or reactive

 81% show irritable mood

• Pediatric Bipolar I Disorder in Children and Adolescents

 Manic Episodes and Children

 Three manic symptoms regularity observed:



 About 80%

 Decreased need for sleep

 About 70%



 Relatively specific sign of Pediatric Bipolar disorder

Pediatric Bipolar II Disorder

• Pediatric Bipolar II Disorder in Children and Adolescents



 Last at least 4 days and symptoms are present most of the day; nearly every day

 3 or more of the following (4 or more if irritable mood):

 Inflated self-esteem or grandiosity

 Decreased need for sleep

 More talkative

 Fight of ideas or feel thoughts are racing

 Distractibility

 Increased in goal-behavior

 Excessive involvement in activities with possible harmful consequences

 Unequivocal change in functioning and observed by others

 Not severe enough to impair social or occupational functioning or necessitate hospitalization.

• Pediatric Bipolar II Disorder in Children and Adolescents

 Hypomania is somewhat difficult to assess in children

 Does not lead to marked distress or impairment in functioning

 Major depressive episode



 Pediatric Bipolar II = major depressive episode + hypomanic episode

 Pediatric Bipolar I = major depressive episode + manic episode

Cyclothymic Disorder

• Cyclothymic Disorder in Children and Adolescents

 Rarely diagnosed in children and adolescents

 Defined by periods of hypomanic symptoms that do not meet full criteria and periods of depressive symptoms that do not meet full criteria

 Experience symptoms for at least 1 year, and must not be symptom free for more than 2 months

 Clinically significant distress or impairment

Pediatric Bipolar Disorders: Problems and Differentiation

• Problems associated with PBD

 Psychotic Features

 Hallucinations or Delusions



 DSM-5 Specification: presence of psychotic symptoms

 Tend to have worse outcomes



 Tend to show mixed signs and symptoms during a single mood episode

 Mixed mood: meet criteria for either a manic or hypomanic episode and simultaneously show subthreshold symptoms of depression or vise versa

• Differentiation PBD from Other Conditions

 Externalizing Behavior Problems

 Comorbid with:



 ODD



 Substance Use

 May have some overlap in some symptoms, but are manifesting the symptoms for different reasons

 Disruptive Mood Dysregulation Disorder

 Children with DMDD and Pediatric Bipolar disorders can show irritability and angry outbursts

Pediatric Bipolar Disorders: Prevalence, Course, and Outcomes

• Prevalence, Course, and Outcomes

 Prevalence

 Lifetime sample rate: 1.9%

 Clinic sample rate: 6%-7%

 Psychiatric hospital rate: 26%-34%

 Gender

 Bipolar I disorder: no gender, but symptom differences



 Comorbid Differences:

 Girls: greater risk for anxiety disorders

 Boys: greater risk for ADHD



 Ethnicity

 No ethnicity differences, but symptom presentation may vary across ethnicities

• Prevalence, Course, and Outcomes



 Youth usually begin showing prodromal, subthreshold mood problems, months or years before their first mood episode.

 Common mood problems: dysphoria, concentration difficulties, irritability, agitation



 Once a full-blown mood episode is experienced, symptoms usually persist for some time

 One study: 2.5 years after the first mood episode 81.5% of youth fully recovered

 Relapse is not uncommon

• Prevalence, Course, and Outcomes

 Outcomes



 Greater risk for:

 Frequency of manic symptoms

 Less remission of symptoms and relapse over time

 Greater number of psychiatric hospitalizations

 Education, employment, and substance use problems

 No medication used as intervention

 Greater risk for:

 Recurrent episodes of mania and depression

 Employment and relationship problems

 Legal problems

 Hospitalizations

 Substance use disorders

 Suicide

• Higher Socioeconomic Status and Less Parental Psychopathology Improve Prognosis in Youths with Bipolar Disorder (Diler et al., 2022)

 Method

 Participants:

 Diagnosis of BD-I, BD-II or BD-NOS

 Improving Group

 70 youth, Mage = 12.3 (BD-I/II = 40 and BD-NOS = 30)

 Ill Group

 82 youth, Mage = 11.7 (BD-I/II = 54 and BD-NOS = 28)

 Longitudinal and correlational

 Method of Observation:

 Youth and caregivers completed interviews and questionnaires at baseline follow-up (Myears = 12.8) to assess:

 Mood trajectories

 Functional assessment

 Demographic and other clinical assessments (e.g., anxiety, parental psychopathology)

 Results

 Since intake the Improving Group, compared to the Ill Group, showed:

 Lower subthreshold depression and hypo/mania

 ADHD

 Disruptive behavior disorders

 Parental SES

 Since intake parental SES remined unchanged for the Ill Group, but increased for the Improving Group

 Prediction of Improvement

 Higher SES + absence of parental BD and substance use disorder = better outcomes

 Parental substance use disorder predicted lower SES = poor outcomes

 Message



Pediatric Bipolar Disorders: Risk Factors

• Pediatric Bipolar Disorders: Risk Factors

 Genes

 Greatest risk: having a biologically related family member with a bipolar disorder

 MZ higher concordance rate than DZ



PBD: Risk Factors

• Pediatric Bipolar Disorders: Risk Factors

 Brain Structure and Functioning

 Smaller brains

 Impairment areas associated with emotion processing and emotion regulation

 Hyperactivation of the amygdala

 Hypoactivation in areas of the prefrontal cortex

 Implications:

 Misinterpret the emotional expressions of others in a hostile or threatening way, followed by personally more negative emotions

 Poor regulation of negative emotions may be associated with acting out

• Pediatric Bipolar Disorders: Risk Factors

 Emotion Regulation

 As shared:

 May have problems directing their attention aways from negative events and experience

 Once upset, they may also have difficulty regulating their emotions to deal effectively with problems

 Stressful Life Events

 Youth with bipolar report:





• Pediatric Bipolar Disorders: Risk Factors

 Family Functioning

 Three Patterns:

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 Negative thoughts, feelings, and actions can be elicited from parents

 Parents may have mood disorders

 Expressed Emotion (EE)

 Degree to which caregivers display criticism, hostility or emotional overinvolvement toward a family member with a mental health problem

Pediatric Bipolar Disorders: Assessment

• Pediatric Bipolar Disorders: Assessment

 Assessment Tools

 Self-report interviews and questionnaires



 Observations

 Medical exams

 Brain imaging

Pediatric Bipolar Disorders: Intervention

• Pediatric Bipolar Disorders: Risk Factors

 Medication

 Medication is the primary form of treatment



 Lithium is not considered as a first-line treatment for youth due to lack of efficacy and side effects



 Used to treat seizures have been used to treat mania in adults

 Decreases neural activity

 May be effective in youth, but may have side effects



 Most frequently prescribed medications

 Shown effective in the reduction of manic or mixed symptoms

 Not all youth respond, recovery rates are low, and may have side effects

• Pediatric Bipolar Disorders: Risk Factors

 Psychotherapy

 Purpose of Psychotherapy



 Teach coping and family communication skills to prevent relapse

 Common Components

 Psychoeducation

 Family involvement

 Reducing blame

 Skill building

• Pediatric Bipolar Disorders: Risk Factors

 Psychotherapy

 Child- and Family-Focused Cognitive-Behavioral Therapy

 Children aged 7 to 13 and their caregivers

 Monitoring and regulating emotions

 Improving parent-child interactions

 Managing disruptive child behavior

 Psychoeducational Psychotherapy

 Children ages 8 to 12 and their caregivers, but younger and older youth also participate

 Teaches families about mood disorders, emotion regulation, and problem-solving skills



 Older children and adolescent their family members

 Works to improve parent-child communication and problem-solving – decrease expressed emotions

• Schizophrenia



 Bizarre delusions (false beliefs)

 Hallucinations (false perceptions)

 Thought disturbances

 Grossly disordered behavior or catatonic behavior

 Extremely inappropriate or flat affect

 Significant deterioration or impairment in functioning

• Childhood and Adolescent Onset Schizophrenia

 A progressive neurodevelopmental disorder that causes significant distress and disability



 Worse long-term outcomes

 COS is rare

• DSM-5: Schizophrenia

 Symptoms –two (or more) – 1-month presence

 Delusions, hallucinations, grossly disorganized speech and behavior, flat affect/motivation

 Persistence



 1 month+ of psychotic symptoms

 Functioning

 Significant impairment in one or more areas of functioning

 For children and adolescents – a failure to achieve expected levels of interpersonal, academic, or occupational achievement

•

 Involve excesses in typical functioning

 Children with COS may display psychotic symptoms

 Most common presenting symptom is auditory hallucinations

 Children can also experience visual hallucinations, delusions, and thought disturbances

 Developmental Considerations

 Early psychotic symptoms may be less complex or reflect childhood themes

 Children might not experience psychotic symptoms as distressing or disorganizing

•

 Absent or impoverished behavior with respect to typical functioning

 Blunted or flat affect

 Avolition

 Social withdraw

 Passivity or Apathy

 Lack of spontaneity

 Reflect a loss of motivation and can range from minor to severe

 Can be persistent and difficult to treat

 Developmental Consideration

 Can be difficult to recognize in younger individuals

• Differentiate: Positive and Negative Symptoms

 The symptoms have different underlying neurobiological causes



 Negative: underactivity in frontal brain regions

 Prevalence and severity of symptoms changes over time

 Predominately positive symptoms tend to precede the emergence of predominately negative symptoms

 Symptoms respond differently to intervention

 Antipsychotic medication: less effective for negative symptoms

• DSM-5: Schizophrenia

 Differential Diagnosis

 Do not diagnosis schizophrenia if psychotic symptoms are attributed to:



 Medical illness



 Drug use

 Autism Spectrum Disorder

 Schizophrenia can be diagnosed comorbid with ASD only when hallucinations and delusions are present

• DSM-5: Schizophrenia

 Comorbidity and Schizophrenia

 Cognitive Impairments

 Movement abnormalities

 Mental Health Disorders

 Anxiety Disorders

 Major Depression

 Bipolar Disorders

 ADHD

 Conduct problems (ODD, CD)

 ASD

Schizophrenia: Prevalence and Course

• Schizophrenia: Prevalence

 Adult-Onset Schizophrenia



 Lifetime rate: 1%

 Typical onset: men – ages 20-24; women – ages 25-29

 No gender difference

 Adolescent-Onset Schizophrenia

 Between ages 13 and 17; much less common

 Rate: 0.23%

 Boys more than girls

 Childhood-Onset Schizophrenia



 Rate: 0.0019%

 Boys more than girls

• Schizophrenia: Course

 Schizophrenia typically progresses through a series of stages over months or years



 The Premorbid Stage: Problems in Early Life

 The Prodromal Stage: Noticeable Changes

 The Acute State: Positive Symptoms and Impairment

 The Residual Stage: Chronic Problems

• The Premorbid Stage: Problems in Early Life

 Show no overt symptoms, but many who later develop schizophrenia demonstrate behavioral, social, and emotional problems

 Developmental Observations



 Learning problems

 Cognitive functioning delays



 Movement abnormalities (e.g., facial tics, grimaces)

 Social impairment (e.g., social withdrawal, social oddities)

 Unusual thought content

• The Prodromal Stage: Noticeable Changes

 Prodromal symptoms may emerge 2 to 6 years before the first psychotic episode

 Marked impairment in academic, behavioral, and social-emotional functioning

 May demonstrate:



 Restless and irritability



 Negligence of appearance and hygiene

• The Acute Stage: Positive Symptoms and Impairment

 Onset of positive symptoms





 Acute phase lasts about 1 to 6 months, depending on intervention

• The Residual Stage: Chronic Problems

 Can last for several months to years

 Variation in functioning:

 Some: improvement

 Most: experience negative symptoms and continued impairment

• Outcome

 Short-Term Prognosis

 Poor

 Psychotic symptoms typically persist for several months



 20% of patients: “good” outcomes

 Alleviation of positive symptoms, mild negative symptoms and a general return to functioning

 Long-Term Prognosis

 Childhood and adolescent onset tend of have poorer outcomes

Schizophrenia: Risk Factors

• Schizophrenia: Risk Factors

 Genetics



 Supported by family, twin, and adoption studies

 Transmission:

 Candidate genes

 Genetic abnormalities or mutations

• Schizophrenia: Risk Factors

 Brain Development

 Adulthood Onset

 Larger ventricles

 Reduced total volume and thickness of the prefrontal, temporal, and parietal cortices

 Reduced size of the hippocampus and thalamus

 Research on Childhood and Adolescence Onset



 Abnormalities tended to occur earlier in disorder course

 Show dramatic reductions in gray matter that predict the onset of psychosis

• Schizophrenia: Risk Factors

 Neural Pathways



 Dopamine-rich pathway

 Dopamine Hypothesis

 Excessive stimulation D2 receptors along the pathway contribute to the positive symptoms



 Dopamine-rich pathway

 Hypofrontality Hypothesis

 Underactivity of D1 receptors along the pathway contribute to negative symptoms

• Schizophrenia: Risk Factors

 Environmental Risks

 Prenatal maternal stress and exposure to disease



 Pre- or peri-natal complications

 Major life events

 Especially those perceived as “uncontrollable”

 Positive and negative

 Stressors associated with immigration and acculturation



 Cannabis use in adolescence

• Schizophrenia: Risk Factors

 Neurodevelopmental Model

 Development of Schizophrenia

 Early environment stressors, combined with biogenetic risk factors (from birth) lead to abnormalities in the organization and development of CNS

 Abnormalities of the CNS initially manifest as premorbid differences

 Abnormalities in the organization and development of the brain then manifest as prodromal signs and symptoms



Schizophrenia: Assessment

• Schizophrenia: Assessment

 Assessment Tools

 Self-report interviews and questionnaires

 Parent report interviews and questionnaires

 Observations

 Medical exams



Schizophrenia: Intervention

• Schizophrenia: Intervention

 Medication

 Conventional Antipsychotics

 Act as a dopamine antagonist by binding to D2 receptors, particularly in the mesolimbic pathway.

 Effective in reducing positive symptoms.

 Problems:

 Less effective in reducing negative symptoms.

 Can produce problematic side effects.

 Atypical psychotics

 Act as a dopamine antagonist (but weaker bind) and bind to serotonin.

 Effective in reducing positive and negative symptoms.

 Problems:

 Can produce problematic side effects.

• Schizophrenia: Intervention

 Psychotherapy

 Recommendation: mediation and psychotherapy.

 Components of most psychotherapies:

 Psychoeducation

 Medication adherence

 Cognitive-behavioral interventions

 Family-based interventions

 Integration back into the community

 Efficacy

 Limited research, but disappointing results for psychotherapy

 Promising: family therapy

Bipolar disorder 2: a DSM-5 disorder characterized by at least one hypomanic episode and one major depressive episode that results in a marked change in functioning but does not lead to impairment or require hospitalization.

Child-and family-focused cognitive-behavioral therapy ICFF-cB: Treatment for children (aged 7-13) with bipolar disorders and their caregivers; components include.(1) monitoring and regulating emotions, (2) improving parent-child interactions, and (3)managing disruptive child behavior.

Course and Outcome of Bipolar Youth (COBY) study: A large study of the course of bipolar disorders in children: results showed that most youths with bipolar disorders recovered from their symptoms, continued to experience mood problems, and experienced another mood episode.

Cyclothymic disorder: A DSM-5 disorder characterized by periods of hypomanic symptoms (but not a hypomanic episode) and depressive symptoms (but not a major depressive episode) lasting at least 1 year in children and adolescents.

Delusions: Erroneous, often bizarre, beliefs that usually involve a misinterpretation of perceptions or experiences.

Dopamine hypothesis: Posits that the positive symptoms of schizophrenia are caused by excessive stimulation of certain dopamine receptors (D2 receptors) along the mesolimbic pathway.

Expressed emotion (EE): Criticism, hostility, or emotional overinvolvement toward a family member with a psychiatric disorder.

Extrapyramidal Side effects: Side effects associated with the use of conventional antipsychotics; include problems Initiating movements, feelings of restlessness, and tardive dyskinesia.

Family-focused treatment for adolescents (FFT-A): A family systems therapy for adolescents with bipolar disorder and their caregivers; seeks to improve parent-child communication and problem-solving and avoid future mood episodes by decreasing expressed emotion.

Flight of ideas: Racing thoughts often experienced by people with mania or hypomania.

Goal-directed activity: A tendency to initiate a wide range of new behaviors

Grandiosity: Unusually high self-confidence, exaggerated self-esteem, and overrated self-importance.

Hallucinations: Erroneous, often bizarre, perceptions that do not correspond to reality.

Hypofrontality hypothesis: Posits that underactivity among certain dopamine receptors (D1 receptors) in the mesocortical pathway is responsible for the negative symptoms of schizophrenia.

Hypomanic episode: A distinct period of abnormally, persistently elevated, expansive, or irritable mood and increased activity and energy, lasting at least 4 days, but less than 1 week, and occurring most of the day nearly every day.

Insula: A centrally located region of the brain responsible for emotion regulation, self-awareness, and interpersonal functioning.

Lateral ventricles: Canals in the center of the brain that are filled with cerebrospinal fluid; sometimes enlarged in adults with schizophrenia.

Lithium (Eskatith): A mood-stabilizing medication used to treat bipolar disorders in adults; regulates norepinephrine and serotonin.

Mania: A discrete period of abnormally, persistently elevated, expansive, or irritable mood and increased level of energy and activity; an essential feature of all DSM-5 bipolar disorders.

Manic episode: A distinct period of abnormally, persistently elevated, expansive, or irritable mood and increased activity and energy, lasting at least 1 week and occurring most of the day nearly every day.

Mixed mood: The presence of either a manic or hypomanic episode and subthreshold symptoms of depression or, alternatively, the presence of a major depressive episode and subthreshold hypomanic symptoms.

Negative symptoms: Features of schizophrenia that reflect behavioral "underexpressions"; include flat affect, avolition, social withdrawal, passivity, apathy, and lack of spontaneity.

Negatively escalating cycle of communication: Parent-child interaction in which criticism from one family member elicits countercriticism from another family member, until it is difficult to resolve; usually involves a three-volley sequence.

Neurodevelopmental model for schizophrenia: Posits that early environmental stressors, combined with biogenetic risk factors, lead to abnormalities in the organization and development of the central nervous system; these abnormalities can be triggered to produce schizophrenia.

Neuroleptic malignant syndrome (NMS): A rare condition caused by an initial, high dose of conventional antipsychotic medication; characterized by severe muscle rigidity, loss of motor control, fever, and high blood pressure.