Dramatic Increase cause?
Increase may reflect earlier under-diagnosis, current over-diagnosis, possibly a true increase in prevalence, or some combination of these factors
This increase emphasizes the need for research that validates the diagnosis of bipolar disorder in children and the importance of developing treatments that are safe and effective
Symptoms / Characteristicsand Key Terms
An episode or cycle is the period of a mood
Mania: abnormally elevated mood causing impairment
Hypomania: shorter in duration than mania and does not cause marked impairment in functioning
Elevated mood: being inappropriately happy
Labile: fast changing, easily altered mood
Mixed states: symptoms of mania & major depression during same episode
Irritable mood: temper tantrums & rages not proportionate to the event
Symptom Presentation in Children/Adolescents
Irritable mood (vs. sad/euphoria in adults) present in almost all
cases Rapid shifts in mood and energy
Elated mood during manic episode
Mixed episodes (simultaneous manic & depressive symptoms) at same time / same day
Short durations (several hours; several days, consecutive days)
Increased verbalizations
Distractibility
Inflated self-esteem
Decreased need for sleep
More likely to experience mixed states
Manic Episodes
Distinct period of abnormally elevated (irritable) mood and abnormally and persistently increased goal directed activity or energy clearly different from usual mood; duration: most of day nearly every day for at least 1 week
Sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self of others, or there are psychotic features
Hypomanic Episode
Distinct period of abnormally elevated (irritable) mood and abnormally and persistently increased goal directed activity or energy clearly different from usual mood; duration: most of day nearly every day for at least 4 days
Episode is not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization. No psychotic features.
Criteria of Mania/Hypomania
For either Manic Episode of Hypomanic episode, three of the following must be present (four if mood is only irritable) to a significant degree
- Inflated Self-Esteem of Grandiosity
- Decreased need for sleep
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility (attention too easily drawn to unimportant stimuli)
- Increase in goal directed activity or psychomotor agitation
- Excessive involvement in activities that have high potential for painful consequences
Major Depressive EPISODE (not DISORDER)
5 or more of the following symptoms present during the same 2 week period and represent change from previous functioning. One symptom has to be depressed mood or loss of pleasure
- Depressed most of the day, nearly every day, as indicated by subjective report or by observations made by others (in children can be irritable mood)
- Anhedonia
- Significant weight change
- Sleep disturbance (insomnia/hypersomnia)
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness or inappropriate guilt
- Diminished ability to think or concentrate/indecisiveness
- Recurrent thoughts of death or suicide without a plan, or suicide attempt or a specific plan for attempting suicide
DSM-5 Criteria
Bipolar 1 and 2
Presence of at least 1 manic episode during a person’s life time
- Manic episode is a change from typical functioning & causes significant impairment
- No depression requirement, but manic episode is often preceded by or may be followed by a major depressive episode
Bipolar 2 Disorder
Must meet criteria for current or past hypomanic episode AND current or past major depressive episode
Bipolar 1 and 2 Specifiers
With anxious distress With mixed features With rapid cycling With mood-congruent psychotic features With mood-incongruent psychotic features With catatonia With peripartum onset With seasonal pattern
Bipolar 1 only
With melancholic features
With atypical features
Rapid Cycling/ Mixed Features Specifiers
Rapid Cycling Specifier:
-Presence of at least 4 mood episodes in previous 12 months that meet criteria for manic, hypomanic or major depressive episode
Mixed Features:
-During manic or hypomanic episode, at least three symptoms of depression are present
-During major depressive episode, at least three manic/hypomanic symptoms are present
Cyclothymic Disorder
- For at least 2 years (1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode
- During 2 year period (1 year for children/adolescents), the hypomanic and depressive symptoms have been present for at least half the time and the individual has not been without a symptom for more than 2 months at a time
- Criteria for major depressive, manic, or hypomanic episode has not been met.
Diagnostic Issues
- Developmental criteria
- Differential diagnosis
- Determining end of episodes
- Not due to substance-induced mania
- Misperceptions of the symptoms especially when there are comorbid conditions
- Bipolar I was often diagnosed as schizophrenia
Impairment
Domains of Impairment
- Family – family conflict
- Social- peer rejection
- Emotional
- Executive function & cognitive performance
- Education / vocational difficulties
- Poor educational attainment
- Adjustment – substance use, incarceration, suicide, hospitalizations
Prevalence Rates Overall
The 12-month prevalence in the United States is 0.6% for Bipolar I
- 12-month prevalence in United States is 0.8% for Bipolar II
- 12-month prevalence of Bipolar I across 11 countries ranged from 0% - 0.6%.
- 12-month prevalence of Bipolar II internationally is 0.3%
Prevalence Rates of Bipolar Disorder in Children and Adolescents
One community study showed a lifetime prevalence of bipolar disorder of 1% in youths aged 14 to 18 years, using the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) (Lewinsohn et al., 1995)
-Brotman and colleagues (2006) found the lifetime prevalence of severe mood dysregulation to be 3.3% in children aged 9 to 19 years from an epidemiological study sample
Ethnic/Racial Differences in Bipolar Disorder
Minimal research on prevalence rates and ethnicity
Often minority youth are misdiagnosed as having schizophrenia or conduct disorder
Bipolar I is more common in high-income than low-income countries (1.4 % vs 0.7%) (American Psychiatric Association, 2013)
A study by Perron and colleagues (2010) revealed the following:
- African Americans and Latinos expressed similar rates in presentation of 14 out of 16 manic symptoms compared with whites, with the exception of grandiosity/self-esteem, in which they were more likely to exhibit this symptom compared with whites.
- Higher rates of depressive episodes were observed among whites
- Overall, this data indicates that the expression and functional impairments of bipolar I disorder is very similar across racial ethnic groups using this community-based sample.
Development and Course: Bipolar I
The mean age of onset of first manic, hypomanic or major depressive episode in bipolar I: 18 years of age
- Onset occurs throughout the lifecycle, including in childhood and in the elderly
- More than 90% of those who experience a single manic episode go on to have recurrent mood episodes
- 60% of manic episodes occur immediately before a major depressive episode
Development and Course: Bipolar II
Average age of onset for bipolar II is 20 years of age
- Compared with adult onset of bipolar II, childhood or adolescent onset is associated with a more severe lifetime course
- Often begins with a depressive episode and is not recognized as bipolar II until hypomanic episode occurs
Etiology: Biopsychosocial
Genetics / Biological Basis
One of the most highly heritable psychological disorders
Family studies have high concordance rates
Bipolar & schizophrenia share same genetic susceptibility
Imperfect concordance rates demonstrate environmental contributions 80%
Involves multiple genes; neurochemicals
Course is exacerbated by environmental factors such as:
Family, peer, & teacher conflict
Academic stress
Disruption of the sleep-wake cycle
Expressed Emotion (EE): qualitative measure of the ‘amount’ of emotion displayed by a family or care takers.
High level of EE: Family members with high expressed emotion are hostile, very critical and not tolerant
High levels of EE in the home associated with worsened prognosis and relapse (Geller et al., 2004)
Etiology: Environmental
Separated, divorced or widowed individuals have higher rates of bipolar I disorder than do individuals who are married or have never been married
-The direction of this association is unclear
