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Pediatric Bipolar Disorder. Mani N Pavuluri, MD, PhD Berger Colbeth Chair in Child Psychiatry Pediatric Brain Research and Intervention Center University of Illinois at Chicago @ copy righted. Overview of the presentation. How does it look? Measurement - PowerPoint PPT Presentation
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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
Pavuluri, 2012
Specific to PBD
Irritability77-98%
Mixed Mania20-84%
Chronicity4229 months;
84%
Rapid Cycling46-87%
ComorbidADHD75-98%
Pavuluri, 2012
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
Major Depressive Disorder
Mania
Pavuluri, 2012
Mood Spectrum:
Time
Depressed Mood
Elevated Mood
Normal
Major Depressive Disorder
Mania
Dysthymia
Pavuluri, 2012
Mood Spectrum:
Time
Depressed Mood
Elevated Mood
Normal
Major Depressive Disorder
Mania
Dysthymia
Hypomania
Pavuluri, 2012
Mood Spectrum:
Time
Depressed Mood
Elevated Mood
Normal
Major Depressive Disorder
Mania
Hypomania
Bipolar Disorder
Dysthymia
Pavuluri, 2012
Mood Spectrum:
Time
Depressed Mood
Elevated Mood
Pediatric Bipolar Disorder
Pavuluri, 2012
Mood Spectrum
Time
Depressed Mood
Elevated Mood
Normal
Major Depressive Disorder
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
Pavuluri, 2012
BP-II at Intake – Convert to BP-I
Mania
Hypomania
BP-NOS
Euthymia
Dep-NOS
Major Depression
Birmaher et al, AACAP, 2003
Pavuluri, 2012
“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.
Pavuluri, 2012
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
Pavuluri, 2005
Reliability
Internal Consistency: 0.96 Test Re-test Reliability: 0.96
Pavuluri, 2012
0
5
10
15
20
25
30
35
40
HCADHDBD OnlyBD+ADHD
CMRS-P Total Score
Pavuluri, 2012
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
Pavuluri, 2012
Mania vs. ADHD ADHD
Primarily a disorder of attention, not mood
Onset before age 7 Persistent, not episodic
Problem of Comorbidity
Pavuluri, 2012
Pavuluri, 2012
Pavuluri, 2012
Pavuluri, 2012
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
Pediatric Bipolar Disorder
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
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