distinct period of elevated, expansive, or irritable mood, clearly different from normal for person
duration at least four days
unequivocal change in functioning obserable by others
not severe enough to cause marked impairment (no hospitalization, no psychosis)
bipolar mixed state
unrelenting dysphoria or irritability
severe agitation
unendurable sexual excitment
intractible insomnia
suicidal obsessions or impulses
“histrionic” demeanor, yet with genuine expressions of intense suffering
Bipolar I Disorder: mania
Bipolar II Disorder: major depression episodes and only hypomania episodes
Cyclothymia: only hypomanic episodes
Bipolar Disorder Not Otherwise Specified (NOS): “bipolar features” but do not meet criteria for specific diagnosis
possibly most heritable major mental disorder
prevalence rate in males and female adults approximately equal (in contrast to unipolar depression which shows higher female prevalence)
presentation may be somewhat different in males and females
untreated episodes may become progressively more severe, more frequent, and more treatment resistant
“kindling” hypothesis
Bipolar Disorder in Children, Pediatric Bipolar Disorder
not a new idea: “mania in childhood” (Weinberg & Brumback, 1976)
“The clinical presentation of this disorder in the preadolescent and early adolescent age groups is greatly debated, although mid- to late-adolescent onset BD is considered similar to that of adult BD.” (Pavuluri, Birmaher, & Naylor, 2005, p. 846)
the National Institute of Mental Health Research Roundtable on prebubertal bipolar disorder (2001) suggested that pediatric BD can present as “narrow” or “broad” phenotypes
children and adolescents with the “narrow” phenotype show recurrent periods of major depression and mania or hypomania consistent with DSM-IV criteria
most of these youth experience multiple episodes and rapid cycling
most fail to meet duration criteria of DSM-IV and are usually diagnosed as NOS
severe affective instability
children and adolescents with the “broad” phenotype consistitute the majority of referrals to clinicians
“present with severe irritabilty, ‘affective storms’, mood lability, severe temper outbursts, symptoms of depression, anxiety, hyperactivity, poor concentration, and impulsivity with or without clear episodicity” (Pavuluri et al., 2005, p. 847)
if youths never experience major depression the validity of this diagnosis is called into question
less common: .4 to 1.2% prevalence for any bipolar; BP II, BP NOS, & cyclothymia more common
“most comorbid” disorder: 99% of the time there is a second diagnosis
Modal Child Presentation: ultra-rapid cycling and comorbid ADHD
irritability more common symptom (96.7%) and is also seen in ADHD groups (71.7%)
Geller and colleagues have suggest that grandiosity, elated mood, hypersexuality, fight of ideas, and decreased need for sleep best differentiate pediatric BD (7 to 16 year olds) from ADHD children and from helathy controls
rapid mood fluctuations
untrarapid cycling (5-364 cycles per year)
ultradian cycling (>365 cycles per year)
labile, unstable, changeable mood prominant in children younger than 20 years of age (Carlson, 1983)
rage
“One of the earliest manifestations may be frequent and extreme temper tantrums, sometimes lasting hours and triggered by minor admonishments.” (Post, et al., 2004, p. 899)
several features are consistently agreed on as typical of pediatric BD (Pavuluri et al., 2005, p. 848):
chronicity with long episodes
predominantly mixed episodes (20% – 84%)
prominent irritabilty (77% – 98%)
high rate of comorbid ADHD (75% – 98%) and anxiety disorders (5% – 50%)
family history of bipolar disorder
controversaries remain regarding bipolar disorders in children:
is it the same as bipolar disorder in adults?
should children be treated with neuroleptic medications?