pediatric bipolar disorder mani n pavuluri, md, phd berger colbeth chair in child psychiatry...

Pediatric Bipolar Disorder

Mani N Pavuluri, MD, PhDBerger Colbeth Chair in Child PsychiatryPediatric Brain Research and Intervention Center University of Illinois at Chicago

@ copy righted

Pavuluri, 2012

How does it look? Measurement How to differentiate from ADHD Prevalence Onset Follow up Assessment: Big picture

Overview of the presentation

Pavuluri, 2012

Pavuluri, 2012

What is a Pediatric Bipolar Disorder?

Central feature:Elevated, expansive mood or Irritable mood

Pavuluri, 2012

Equivalent description in a child

Excited Giggly Silly Giddy constantly on the go laughing fits joking and feels

invincible “ overwhelming” “ like wanting to jump

on the bed”

Constantly irritable Aggressive throwing pot plants slamming doors hard to transition Acidic Abrasive hostile in words Kicking screaming intense & inconsolable out of proportion to the

psychosocial stresses around them

Mood

Pavuluri, 2012

Feeling good

about myself

1) Generous gave money to the school’s mission collection

2) Friendly to everyone

3) Share my lunch with my friends

getting up every morning at the regular time not tired

I eat breakfast, lunch and dinner

Pavuluri, 2012

Pavuluri, 2012

Timeline Ultra Rapid Cycling: Complex Cycling

“Mini cycles within a big cycle”

Frequency: most days in a week Intensity: severe enough to cause extreme disturbance

in one domain or moderate disturbance in two or more domains

Number: three or four times a day Duration: four or more hours a day

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Specific to PBD

Irritability77-98%

Mixed Mania20-84%

Chronicity4229 months;

84%

Rapid Cycling46-87%

ComorbidADHD75-98%

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Mood Spectrum:

Time

Depressed Mood

Elevated Mood

Normal

Pavuluri, 2012

Mood Spectrum:

Time

Depressed Mood

Elevated Mood

Major Depressive Disorder

Normal

Pavuluri, 2012

Mood Spectrum:

Time

Depressed Mood

Elevated Mood

Normal


Mania

Pavuluri, 2012

Mood Spectrum:

Time

Depressed Mood

Elevated Mood

Normal


Mania

Dysthymia

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Mood Spectrum:

Time

Depressed Mood

Elevated Mood

Normal


Mania

Dysthymia

Hypomania

Pavuluri, 2012

Mood Spectrum:

Time

Depressed Mood

Elevated Mood

Normal


Mania

Hypomania

Bipolar Disorder

Dysthymia

Pavuluri, 2012

Mood Spectrum:

Time

Depressed Mood

Elevated Mood


Pavuluri, 2012

Mood Spectrum

Time

Depressed Mood

Elevated Mood

Normal


Mania

Hypomania

Dysthymia Bipolar

PBD

Pavuluri, 2005

Distribution of Bipolar Subjects

Pavuluri, 2012

BP-NOS at Intake – Convert to BP-I

Birmaher et al, AACAP, 2003

Major Depression

Dep-NOS

Euthymia

BP-NOS

Hypomania

Mania

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BP-II at Intake – Convert to BP-I

Mania

Hypomania

BP-NOS

Euthymia

Dep-NOS

Major Depression

Birmaher et al, AACAP, 2003

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“Diagnostic fashion runs in cycles!”

Pavuluri, 2012

Pavuluri, 2012

Child Mania Rating Scale, Parent Version

The following questions concern your child’s mood and behavior in the past month. Please place a check mark or an ‘x’ in a box for each item. Please consider it a problem if it is causing trouble and is beyond what is normal for your child's age. For example,

check ‘never' if the behavior is not causing trouble.

1. Have periods of feeling super happy for hours or days at a time, extremely wound up and excited, such as feeling "on top of the world"

2. Feel irritable, cranky, or mad for hours or days at a time

3. Think that he or she can be anything or do anything (e.g., leader, best basketball player, rap singer, millionaire, princess) beyond what is usual for that age 4. Believe that he or she has unrealistic abilities or powers that are unusual, and may try to act upon them, which causes trouble

0 1 2 3

Never Sometimes Often Very Often /Rarely

0 1 2 3

0 1 2 3

0 1 2 3

Pavuluri et al, aacap 2004

Pavuluri, 2012

How to use it?

Have the parent focus on the child’s behavior in the past month.

“Never/Rarely” and “Sometimes” = behavior that is causing minimal or no difficulty

“Often” and “Very Often” = behavior that is causing trouble.

The child’s score is the sum of all item scores.

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Interpreting the results

A cut off score of 15 screens for the manic spectrum

A cut off score of 20 is highly specific for mania

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Reliability

Internal Consistency: 0.96 Test Re-test Reliability: 0.96

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0

5

10

15

20

25

30

35

40

HCADHDBD OnlyBD+ADHD

CMRS-P Total Score

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Why should I choose it?

PROS

DSM IV basis

Singular item focus

Integrated functionality

Age specific items

Timing of symptoms

Language

Linked examples

FormulationDiagno

sisDD 1. (w/3 main symptoms) 2. 3.

Interpersonal

Relationships

Functioning

Other…

Family

Friends

Teacher

Home

School

Outcome

Precipitating FactorWhy now?

Temperament and Personality StyleStrengths

Coping Mechanisms/Defenses

- Support

- stresses

Attachment/Goodness of Fit

Parenting

Capacity

Context

BackgroundMother - Dev. Hx

Personality

Father Personal Resources (knowledge, skills, attitude, motivation)

M-F (partnership)

Child

Siblings

Family

Structural (roles, relationships) C – C, M – C, F – C, etc.

Strategic (problem solving, family beliefs)

Systemic (theme)

Maturity

Work

Psychopathology

*Central Issue

*EMIC vs. ITIC

*Find the Person/s

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Mania vs. ADHD ADHD

Primarily a disorder of attention, not mood

Onset before age 7 Persistent, not episodic

Problem of Comorbidity

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Pavuluri, 2005

98% / 72%1160Geller et al., 2000

93%6.168Faraone et al., 1997

29%1648Kafantaris et al., 1998

71%1142Kowatch et al., 2000

15.7

7.9

15.1

Mean Age

65%34DelBello et al., 2001

98%43Wozniack et al., 1995

57%14West et al., 1995

ADHDnStudy

Comorbidity of ADHD In Pediatric Bipolars

Distinguishing Between Bipolar and ADHD

8986

71

4043

14

510

6 6

0

10

20

30

40

50

60

70

80

90

100

Elevated mood Grandiosity Flight of ideas Decreased sleep Hypersexuality

Pat

ien

ts (%

)

Bipolar ADHD

Geller & Zimerman 2002.

Pavuluri, 2012


Prepubertal & Early Adolescent Onset Bipolar Disorder (PEA - BD)

Juvenile BD Atypical BD Childhood Onset BD

Adolescent Onset Bipolar Disorder

(AO-BD)

12 yr. > 12 yr.

Pavuluri, 2012

FEATURESPEA – BD 12 YRS.

AOBD> 12 YRS.

IRRITABLE MOOD Prominent(up to 98%)

Less Prominent(up to 22%)

INTER EPISODE RECOVERY Low(0 – 16%)

Moderate(20 – 50%)

EPISODIC/ CHRONICChronic Episodic

CYCLING > Ultradian > Rapid

MIXED Up to 20 – 85% Up to 25%

COMMON COMORBIDITY

DISORDERS ADHD, ODDSubstance Abuse,

Anxiety, PTSD

Prevalence of BP in Adolescents

Lewinsohn 1995

FindingsFindings1.0% prevalence of BP (primarily BP II 1.0% prevalence of BP (primarily BP II

and cyclothymia)and cyclothymia)

5.7% prevalence of BP NOS5.7% prevalence of BP NOS

Diagnostic interviews with 1709Diagnostic interviews with 1709 high school high school students, ages 14-18 yearsstudents, ages 14-18 years

Pavuluri, 2012

Age of Symptom OnsetNDMDA Survey N=500

Lag to Diagnosis = 8 Years

< 5 5-9 15-19 20-24

30%

20%

10%

10-14 25-29 30+

28%

14%12%

5%

15%

9%

16%

Years of AgeLish 1994

59%

Pavuluri, 2012

Recovery and Relapse

14.0

36.0

55.8

65.1

77.9

87.2

16.7

29.0

39.6

55.4 53.7

64.0

0

20

40

60

80

100

6 12 18 24 36 48Follow-up, mo

% o

f S

ub

jec

ts

Subjects who recovered

Subjects who relapsed after recovery

Pavuluri, 2012

Developing the language

SymptomList

FIND

Invisible Fist

Signature

BrainDisorder

Pavuluri, 2012

OUTINE

FFECT CONTROL

CAN DO IT

O NEGATIVE THOUGHTS; LIVE IN THE NOW

E A GOOD FRIEND: BALANCED LIFESTYLE

H! HOW CAN WE SOLVE IT?!

AYS TO GET SUPPORT

pediatric bipolar disorder mani n pavuluri, md, phd berger colbeth chair in child psychiatry...

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