bipolar disorder and kids

7/27/2019 Bipolar Disorder and Kids

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Bipolar Disorder and

Kids


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Early Onset ManiaAge 15-20


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Early onset Mania

Chronic, not episodic

Mixed states commonly occur with markeddysphoria and irritability

Severe oppositional behavior (rage after 18can be considered a personality disorder but notcorrect)

Ultrarapid Cycling

Explosive Outbursts or rage episodes


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Carlso, et al (2000) suggest:

Higher number of early onset are:

Male

Had a history of childhood behavior disorders

Display paranoia (can be mistaken with paranoid

schizophrenia with aggressive features)

Experienced less frequent remissions during a24 month follow up


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Symptom Similarties ADHD and

Childhood Onset Mania:

Irritability

Inattention

Hyperactivity

Impulsivity

High levels of energy

Pressured speech Chronic and non-episodic

Can be mispercieved as ADHD due to overlap.


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Differences Between ADHD and

BPD in Children and AdolescentsCommon in BPD but rare in ADHD:

Decreased need for sleep w/out daytime fatigue (In ADHD, theperson needs the sleep but cannot seem to get the sleep whenneeded BPD does not need to have the sleep)

Low morning arousal

Intense, prolonged rage attacks (lasting 2-4 hours)

Hypersexuality

Flight of ideas

Morbid nightmares (


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Differences Between ADHD and

BPD in Children and Adolescents,

cont. Psychotic symptoms

Family HX of obvious BPD or one of the

following in a blood relative:

1. Suicide

2.Severe AOD problems

3. Multiple marriages

4. Tendency to start numerous businesses


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BPD and ADHD: Comorbidity

BPD and ADHD represent distinctly different diseaseentities

In some children, ADHD may be a prodromalof BPD

BUT, most kids w/ADHD do NOT go on to develop BPDand most persons with BPD do NOT have early ADHDsymptoms. (but there can be symptom overlap).

So. There may be a subtype of BPD that presentsLIKEADHD


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Comorbidity, cont.

Childhood onset BPD may be related to

other BPD spectrum conditions but may

represent a subtype of mood disorders

Comorbid early onset BPD and ADHD

may constitute a distinct and particularly

serious syndrome


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BPD and Anxiety Disorders

Can co-exist in kids but the nature of the overlaphas not been determined.

The presence of either panic-disorder or bipolardisorder can increase the likelihood of the co-occurrence of the other.

Because of the risk of inducing mania,

hypomania, or cycle acceleration, care must begiven when treating both depression andanxiety.


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BPD and Other CoMorbidities

70% of early onset BPD first became

manifest as major depressive disorder

In older adolescents, the distinction

between BPD and Schizophrenia presents

a diagnostic challenge, especially if first

episode is psychotic mania. (psychotic

features overlap with schizophrenic

disorder)


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Psychopharmacology


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Caution:

The normal rate of hepatic (liver) metabolism is high in

children until the time of puberty.

So, most medications are aggressively metabolized inthe liver and rapidly excreted.

Thus, dosing for pre-pubertal children requires dosesthat may approach or equal adult dosing.

Then around 2-4 months surrounding entry to puberty,the rate of hepatic metabolism significantly SLOWS.

So young children whove tolerated higher doses well,may show side effects upon entry to puberty.


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Mood Stabilizers

see list of side effects, p. 258, HCP

Lithium

Divalproex (Depakote)

Carbamazepine (Tegretol)

Lamotrigene (Lamictal) (newer)


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Anti-Convulsants

Divalproex (Depakote) and Carbamazepine(Tegretol) are both anti-convulsants that have

some benefit in treating BPD.

A newer agent, lamotrigene (Lamictal) is less

widely prescribed as an anticonvulsant and a

mood stabilizer.

Mechanism of action: UNKNOWN


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FDA Approval for Kids? Divalproex (Depakote) is first-line agent for mania and

preferred RX for mixed episodes.

Divalproex is FDA approved for bipolar mania in adults.

Side effects include: drowsiness, weight gain, nausea,

vomiting,

Less common: liver damage, pancreatitis, hair loss,tremor, blood clotting problems, and polycystic ovariandisease.

Routine blood level screening is needed with this RX.

Toxic levels are can be life threatening


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Tegretol

Carbamazepine (Tegretol): 2nd line agent formania.

Side effects include: nausea, vomiting,

dizziness, drowsiness, and rash.

Less common: liver damage, cardiacabnormalities, decreases in both RBC an WBC

counts.

Toxic levels can be life threatening.


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Lamotrigene

First line agent for BPD in adults.

Side effects: rash, nausea, vomiting, constipation,ataxia.

Serious dermatological side effect:

Stevens-Johnson Syndrome (a more seriousrash) when lamotrigene is used along with

divalproex.

Report all side effects to physician.


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Guidelines

Treatment should be aimed at stabilization thepresenting symptoms, full resolution of the syndrome,then preventing relapse.

For Mania, Lithium and Depakote are first line agents

Olanzapine (Zyprexa) an atypical antipsychotic is FDAapproved for acute manic or mixed episode, but the APA

recommends using only in less severe episodes.

Caution about using anti-depressants because of risk ofcycle acceleration or manic switch.


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Dosage Guidelines

See p. 45 of CACP


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Disorders w/Evidence of

Progressive NeurobiologicalImpairment (According to Preston,

et al 2010)

Bipolar illness

ADHD

Schizophrenia Some cases of unipolar depression

Some cases of PTSD


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Outcomes Data

Little data about BPD and children.

In a 2 yr. follow up study, Geller, et al (2002)

reported that only 65 % of patients reached full

syndrome recovery.

Biederman, et al (2003) reported similar results.

Biederman, et al estimate that only 20% if youth with BPD

had achieved functional remission or euthymia (normal,

non-depressed mood) after 10 years.


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Psycho-education

Education for both patients and their families

should emphasize the necessity of long term

treatment.

Mood stabilizers are considered to be

maintenance therapy in BPD.

Use of anti-depressants and antipsychotics are

generally time limited.


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Conclusions:

BPD in children and adolescents is consideredto be more severe than in adults

Under-recognition and inappropriate TX leads toprolonged symptoms and suffering.

Meds used to TX BPD in kids are NOT

innocuous and polypharmacy is common, sorational and careful use of medications is veryimportant.

bipolar disorder and kids

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