pediatric bipolar disorder - illinois alliance of ... · treatment of pediatric bipolar disorder 2....

8/9/2012

Washburn ABBHH 2011Washburn,ABBHH 2009 (c) 1

Pediatric Bipolar Disorder

Jason J. Washburn, Ph.D., ABPP

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Bipolar Disorder Understanding Differences between Adults & Children

Overview of Talk

Diagnosis of Pediatric Bipolar Disorder

Treatment of Pediatric Bipolar Disorder

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Special Thanks

Eric Youngstrom, Ph.D.g ,

Department of Psychology University of North Carolina at Chapel Hill,

Psychology, Davie Hall, CB3270Chapel Hill, NC 27599-3270

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Bipolar Disorder In Adults

A Brief Review

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Peace-Wirt, Indiana, by Gage @ bipolar.about.com

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Epidemiology & Impact

Prevalence: BD I: 1.21-1.6% prevalence (3.3-4.0 million)

BD t 2 6 6 5% l BD spectrum: 2.6-6.5% prevalenceImpact $24-45 billion/year 2-3 times more likely to divorce Increased substance abuse, incarceration 6th leading cause of disability

S i id

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Suicide Nearly 30% make a suicide attempt; 18% complete Risk of completed suicide is over 20 times the risk in

the general population

Angst, 1998; Judd et al., 2002; Klienman, et al., 2003; Kessler et al, 1994; Stimmel, 2004; Chen & Dilsaver, 1996

DSM-IV Manic episode• Persistent elevated, expansive, or irritable mood for at least one

week and:

• Inflated self-esteem; decreased need for sleep; talkativeness; racing thoughts; distractibility; increased activity; and daring

Diagnostic Criteria

racing thoughts; distractibility; increased activity; and daring behaviors

• Impairment in psychosocial functioning

• Not only due to other psychiatric and medical conditions

DSM-IV Hypomanic episode: less intensity than mania, at least 4 days

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DSM-IV-TR, 2000

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Signs & Symptoms of Mania

• Increased energy, activity, and restlessness • Excessively "high," overly good, euphoric mood • Extreme irritability • Racing thoughts and talking very fast, jumping from one idea to

another • Distractibility, can't concentrate well • Little sleep needed • Unrealistic beliefs in one's abilities and powers • Poor judgment • Spending sprees

A l i i d f b h i h i diff f l

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• A lasting period of behavior that is different from usual • Increased sexual drive • Abuse of drugs, particularly cocaine, alcohol, and sleeping

medications • Provocative, intrusive, or aggressive behavior • Denial that anything is wrong NIH Publication No. 3679

GRAPES

G randiosity

R acing Thoughts

A ctivity is goal directed, hypersexual

P ressured Speech

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E lation/ elevated or expansive mood

S leep need is decreased

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DSM-IV Major depression episodeP i t t d d d i it bilit

Diagnostic Criteria

• Persistent depressed mood or irritability for at least 2 weeks and:• Motivation, sleep, appetite, concentration,

and energy disturbances

• Guilt, suicidal thoughts or behaviors

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• Impairment in psychosocial functioning

• Not only due to other psychiatric and medical conditions

DSM-IV-TR, 2000

Signs & Symptoms of Depression

• Lasting sad, anxious, or empty mood • Feelings of hopelessness or pessimism g p p• Feelings of guilt, worthlessness, or helplessness

Loss of interest or pleasure in activities once enjoyed, including sex • Decreased energy, a feeling of fatigue or of being "slowed down" • Difficulty concentrating, remembering, making decisions • Restlessness or irritability • Sleeping too much, or can't sleep

10NIH Publication No. 3679

• Change in appetite and/or unintended weight loss or gain • Chronic pain or other persistent bodily symptoms that are not caused

by physical illness or injury • Thoughts of death or suicide, or suicide attempts

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SPACE DRAGS

S leep disturbance D epressed mood

P leasure/interest (lack of)

A gitation

C oncentration problems

R etardation movement

A ppetite disturbance

G uilt worthless useless

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C oncentration problems

E nergy (lack of) or fatigue

G uilt, worthless, useless

S uicidal thought

Bipolar Mood States

Mood States: D iDepressionEuthymiaHypomaniaMania

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ManiaMixed States

Youngstrom et al, 2007

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Classic Bipolar I

Distinct episodes of marked

Mania mania and depression (variable interepisode interval –may be shorter in children)

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Days

Depression


Rapid Episoding (4 episodes/year) with Mixed States

Mania Mania Mania Mania

14Days

Depression

Days

Depression

Days

Depression

Days

Depression


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Subtypes of Bipolar DisorderBipolar I disorder

• Manic• DepressedDepressed• Mixed• Rapid cycling • Psychotic

Bipolar II disorder (hypomania and MDD episodes)Cyclothymic disorder (hypomania and mild depression)

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Cyclothymic disorder (hypomania and mild depression)Bipolar Not Otherwise Specified (NOS)

DSM-IV-TR, 2000

Genetic “Iceberg”

Recognized (Bipolar I II)Recognized (Bipolar I, II)

Spectrum (missed bipolar I & II;Cyclothymia, NOS)

U i i d

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Unimpaired(low loading,high functioning familymembers, “hyperthymic”)

Youngstrom, 2007

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Bipolar Disorder In Children

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The latest “fad” Diagnosis?Popular Press Coverage

Oprah 20/20

Ti i N k Time magazine, Newseek The Evening News with Dan Rather The Early Show NPR

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Visits with a diagnosis of PBD as a % of total office-based visits by youth and adults

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Copyright restrictions may apply.

Moreno, C. et al. Arch Gen Psychiatry 2007;64:1032-1039.

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Diagnosis of Bipolar Disorder in Children & Adolescents

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Challenges in Diagnosis

Symptom Overlap

High Rates of ComorbidityHigh Rates of Comorbidity

Variability in Symptom Presentation

Cycling

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No Clear Pediatric-Specific Diagnostic Criteria

Lack of Standardized Assessments


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Overlap of Symptoms

Sadness, adhedonia, irritable mood

ADHD, ODD, CD

Rages, aggressive ADHD, ODD, CDg ggbehavior, defiance

Poor judgment ADHD, ODD, CD

Grandiosity CD, psychopathy, substance abuse

Increased energy ADHD

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Distractibility ADHD

Pressured speech ADHD

Racing thoughts Expressive language disorder, substance abuse

Comorbidity of PBD

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ADHD: 40-90% ODD: 30-90% CD: 30-90%

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Variability in Symptom Presentation

He’s got Conduct disorder!

Mania He’s got Conduct disorder! Or wicked ADHD... or both!

Seems “within normal limits” to me.

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Days

Depression A textbook case of major depression


Nonpathological Extremes

Mania Birthday Party -- Too much cake & presents

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Days

Depression Death of pet


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No Pediatric-Specific Criteria

• “Rages” & aggression?• Rages & aggression?

• Irritability?

• Cycling or “episoding” Chronic irritability?

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Severe Mood DysregulationDisorder?


Cycling (Episoding)

Rapid Cycling: 4 Episodes per YearYear

Ultra-rapid Cycling: Extremely brief and frequent manic episodes lasting less than 4 days

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daysUltradian Cycling: Daily cycling,

lasting minutes to hours

Geller & Cook, 2000; Brotman et al., 2006

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Ultra-rapid, Ultradian, or Mixed?

ManiaMania

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Days or Hours

Depression

Models of “Mixed”

Distinct State Ultradian Cycling

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Youngstrom et al, 2007, 2008

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Different Episode Types at Different Ages?

90100

ManicManic MixedMixed “Melancholic”“Melancholic”

2030405060708090

Per

cent

age

Per

cent

age

Mix

ed

KraepelinKraepelin. Manic Depressive Insanity and Paranoia. . Manic Depressive Insanity and Paranoia. Edinburgh: E&S Livingstone; 1921:169.Edinburgh: E&S Livingstone; 1921:169.

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010

1515YearsYears 2020 2525 3030 3535 4040 4545 5050 5555 6060 6565


Screening and Diagnosing Pediatric Bipolar Disorder

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ABBHH Protocol for PBD

1. Screen for Mania

2 Obtain Evidence of Episodes2. Obtain Evidence of Episodes

3. Evaluate Diagnostic Criteria

4. Extend the Window of Assessment

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#1: Screen for Mania

Child Mania Rating Scale Pavuluri et al 2006Pavuluri et al., 2006

General Behavior Inventory Youngstrom et al., 2001

Young Mania Rating Scale Gracious et al., 2002

Child Behavior Checklist A h b h 1991

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Achenbach, 1991

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#2. Obtain Evidence of Episodes

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#3. Evaluate Diagnostic CriteriaUse PBD-Specific “Handle” symptoms:

G randiosityG y

R acing Thoughts

A ctivity is goal directed, hypersexual

P d S h

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P ressured Speech

E lation/ elevated or expansive mood

S leep need is decreased

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Evaluate the Severity of GRAPESApply FInD Criteria: pp y

Frequency of the symptom

Intensity of the symptom

Duration of the symptom

Irritability, rage, and/or aggressive behavior is considered ONLY for severity

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considered ONLY for severity

What about Irritability?

Course and Outcome of Bipolar Youth study

Irritable Only

Elated Only

Both Irritable &Elated

L lik l t b d d

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• Less likely to become depressed

• Irritability was episodic, not chronic– Chronic = severe mood dysregulation

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Carlson, 2010

Disruptive Mood Dysregulation Disorder

1. Severe recurrent temper outburstsp

2. Three + times per week

3. Mood between outbursts is persistently negative

4. Present for at least 12 months

5. Present in at least 2 settings

6. At least 6, but younger than 10

7. Not bipolar

8. Nor psychotic, PDD, SUD, etc…

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Summary

1. Use screening measures to help referralg p

2. Determine if episodes are present

3. Focus on GRAPES

4. Extend the window of assessment -Diagnosis is ongoing

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Treating Children with Bipolar Disorder

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Treating Children with Bipolar Disorder

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Multi-Modal Treatment• Medication Stabilize mood & treat comorbid conditions

P h d ti• Psychoeducation

• Psychosocial Interventions Treat acute depression, reduce stress,

regulate emotion, prevent recurrence, improve functioning, increase medication adherence

Sleep and mood hygiene

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Sleep and mood hygiene

Family therapy to treat conflict, expressed emotion

LithiumAnticonvulsants

Divalproex (Depakote) Carbamazepine (Tegretol)

Medications

Carbamazepine (Tegretol) Lamotrigine (Lamictal) Topiramate (Topamax) Oxcarbazepine (Trileptal) Gabapentin (Neurontin)

Atypical/2nd Generation Antipsychotics: Clozapine (Clozaril)

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Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon) Aripiprazole (Abilify)

Bourin et al., 2005; Pavuluri et al., 2004; McClellan & Werry, 1997; Smarty & Findling, 2007

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RCTs: Pediatric Bipolar Disorder

• Lithium– 25 adolescents vs. placebo– Severe mood dysregulation = same as placebo

• Anticonvulsants– Toprimate (d/c)– Divalproex sodium (acute)

• Atypical Antipsychotics– Olanzapine

– Aripiprazole

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Aripiprazole

– Quetiapine (ineffective)

– Ziprasidone (unpublished)

– Riluzole

DelBello, et al.Bipolar Disorders.2009;11:483-493;

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Ongoing Studies

• Rilutek (Riluzole)( )• Amyotrophic lateral sclerosis

• Lamotrigine (Lamictal)

• Olanzapine / Fluoxetine (Symbyax)

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On-Line Survey (N = 854)Percentage on MedicationsTypical Antipsychotic

Atypicals

SSRI

Lithium

Stimulants

Anti-Anxiety

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0 20 40 60 80 100

Anti-Convulsants

Atypicals

Youngstrom et al, 2007; CABF, 2002

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Pharmacologic Patterns

Limited response to monotherapy is typical

Combination therapy is common

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Hellander et al., 2002; Smarty & Findling, 2007

Number of Current Medications

3585% on 2+ meds

10

15

20

25

30

Per

cent

age

85% on 2+ meds

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0

5

1 2 3 4 5 6 to 10


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Lifetime Medication Exposure

40

10

15

20

25

30

35

Per

cent

age

85% exposed to 4+ meds

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0

5

10

1 to 3 4 to 5 6 to 10 11 to 15 16 to 20 21+


Pharmacologic Complexities

• Medications that may complicate treatment: Antidepressants

Psychostimulants

• Little research on treating depression

• Attention-deficit hyperactivity disorder must be re-evaluated after mood

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stabilized

Biederman et al., 1998; Smarty &

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Phenomenology and Course of Pediatric Bipolar Disorders

• 62.6% received any antimanic medication at any titime

• Non-antimanic medication: 77.4% for stimulants or other ADHD medication

64.3% antidepressants

• 67.8% two or more concurrent medication classes.

• Psychiatrists gave antimanics more than pediatricians

• Earlier recovery during eight-year follow-up was predicted by greater percent of weeks on lithium

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How do we know if Rx is working?• Provide feedback to parents and cliniciansp Be specific (who, what, how often, how much) Be behavioral Put it in writing

• Use a checklist or questionnaire Day-to-day 3-5 symptom target list

St d di d ti i

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Standardized questionnaires

• Report any side-effects to parent or clinician

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Psychosocial Treatment: Targets

• Medication Adherence

• Address symptoms not treated by medication

• Improve long-term functioning (social, occupational, relational)

• Monitor progress

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Psychosocial Approaches

• Parent/Family PsychoeducationC iti B h i l Th• Cognitive Behavioral Therapy

• Interpersonal Therapy• Interpersonal and Social Rhythm Therapy• Family Focused Therapy• Multi-Family Therapy

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• Community Support Programs• Dialectical Behavior Therapy

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Multifamily PsychoeducationalPsychotherapy

• Eight, 90-minute adjunctive treatment• Combines:

Pschoeducation Family Systems therapy Cognitive Behavioral Techniques

• Goals: Learn about bipolar and treatment

Gain support from other families & professionals

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Gain support from other families & professionals Develop skills in mood management, affect regulation,

problem solving, and communication.

• RCTs indicate promising efficacy

Fristad, et al. Impact of multifamily psychoeducational psychotherapy in treating children aged8 to 12 Years with mood disorders. Arch Gen Psychiatry. 2009;66(9):1013-1021

Family-Focused Treatment

Components: Psychoeducation

• Distinguish age appropriate moodiness• Distinguish age-appropriate moodiness

Relapse prevention Improve adherence to treatment

• Motivate adolescent to address disorder

Communication Skills Training Problem Solving Skills Training

B h i l M t T i i

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Behavioral Management Training Focus on Wake/Sleep schedule Address mood disturbances in the family

Miklowitz DJ et al. Family-focused treatment for adolescents with bipolar disorder. J Affect Disord. 2004;82(suppl 1):S113-S128.

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Child- and Family-Focused Cognitive Behavioral Therapy• Integrates psychoeducation, CBT, and

interpersonal techniques with pharmacotherapyinterpersonal techniques with pharmacotherapy• Targets: psychosocial and interpersonal stress

in children and families• Treatment Components: Routine Affect regulation

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Self-efficacy and coping Coping with depressive cognitions Social skill building Interpersonal problem solving Social support Pavuluri et al., 2004; West et al., 2006

RAINBOW

Routine

Affect regulation

I can do it

No negative thoughts and live in the now

Be a good friend/balanced lifestyle for parent

Oh – how can I solve this problem

Ways to get support

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RAINBOW Outcomes

Open trial (n=34)p ( ) Reduced inattention, aggression, mania, psychosis,

depression, and sleep disturbance

Continuation trial Booster sessions and psychopharm

Maintained gains up to 3 years

Group treatment (n=26)p ( ) Decreased mania, increased coping and well-being

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Future Therapeutic Approaches?• Transcranial Magnetic Stimulation

• Deep Brain Stimulationp

• Electroconvulsive Therapy

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Stein et al., 2006

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Thank you!

Jason J. [email protected]

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