Tulburari Afective La Copii Si Adolescenti

8/12/2019 Tulburari Afective La Copii Si Adolescenti

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REVISTAROMNDEPEDIATRIE VOLUMULLXI, NR. 2, AN2012130

Adresa de coresponden:Asist. Univ. Dr. Anamaria Burlea, Universitatea de Medicini Farmacie Gr. T. Popa, Str. Universitii Nr. 16, Iaie-mail: [email protected]

PARTICULARITI CLINICO-EVOLUTIVE ITERAPEUTICE ALE TULBURRILOR AFECTIVE

BIPOLARE LA COPII I ADOLESCENIAsist. Univ. Dr. Alexandra Bolo, Asist. Univ. Dr. Anamaria Burlea,

Prof. Dr. Roxana ChiriUniversitatea de Medicini Farmacie Gr. T. Popa, Iai

REZUMAT

Tulburrile afective bipolare reprezint o condiie medical ncsubdiagnosticatsau nediagnosticat la

copii i adolesceni. Trsturile clinice specifice, cum ar

ficiclarea rapidi episoadele mixte, complic, deobicei, posibilitile de diagnostic clinic. n plus, comorbiditile asociate sau supraadugate pot avea impact

asupra diagnosticului diferenial. Astfel, vor finecesare studii specifice diferitelor grupe de vrstcare vorgenera criterii de diagnostic particulare fiecrei vrste. Acest lucru este necesar pentru tinerii pacienideoarece un diagnostic adecvat ct mai precoce va determina i un management terapeutic adecvat.

Cuvinte cheie: tulburare afectiv, diagnostic, adolesceni, terapie

REFERATE GENERALE

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Tulburrile psihice ale copiilor sunt mult maidificil de caracterizat dect cele ale adulilor. Dei

s-au realizat progrese n ceea ce privete diagnosticultulburrilor psihice la copii, multe tratamente suntadministrate pentru o simptomatologie vag, cumar fiagresivitate, depresie sau manifestri discom-portamentale (1). O serie de factori contribuie laaceastsituaie, cum ar fi:

mult timp copiii au fost neglijai de serviciilemedicale psihiatrice;conceptul de anormalitate la copii este influ-enat de procesul de dezvoltare a acestora,ceea ce face mult mai dificil interpretarea

unor indicatori ai disfuncionaliti cerebrale;diagnosticul diferenial este mult mai dificilde realizat la copii comparativ cu adulii, dincauza lipsei expresivitii modificrilor com-portamentale din psihopatologia copiilor;copiii prezint multe dificulti n ceea ceprivete descrierea simptomatologiei psihia-trice.

Debutul simptomatologiei tulburrilor afectivebipolare se realizeaz la vrste foarte diferite, nspecial ntre 18 i 24 de ani, dar 59% dintre adulii

bipolari au prezentat un prim episod afectiv nainteavrstei de 18 ani. Simptomatologia specific

tulburrilor afective bipolare este variabilla copiii adolesceni i prezinto serie de simptome supra-adugate i comorbiditi, cum ar fiabuzul de dro-guri sau ADHD. Astfel, se constatcla un numrimportant de copii tulburarea afectivbipolarestegreit diagnosticat; de aceea, se ncearcgsireaunei soluii n ceea ce privete diagnosticarea pre-coce a acestei tulburri psihice pentru a asigura untratament adecvat. Diagnosticarea ct mai precocea tulburrii afective bipolare reprezintun obiectivclinic important, avndu-se n vedere urmtoarele

motive (4):tulburarea afectivbipolarreprezinto sursimportantde disfuncionalitate psihosocialpentru copii i adolesceni, cu importanteconsecine asupra vieii acestora;existevidene clinice care aratfaptul cunsindrom psihiatric, cu ct este mai prelungit,cu att acesta este mai refractar la tratament.

Un diagnostic precoce al tulburrii afective bi-polare la copii i adolesceni este asigurat de o seriede factori, i anume (5):


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REVISTAROMNDEPEDIATRIE VOLUMULLXI, NR. 2, AN2012 131

Identificarea simptomelor sugestive pentruepisodul maniacal;Cnd nu exist simptome psihotice, se vaasigura un diagnostic diferenial adecvat ntremanie i ADHD;Cnd existsimptome psihotice, diagnosticul

diferenial se va realiza ntre manie i schi-zofrenie.Estimarea prevalenei tulburrilor afective la

copii i adolesceni este foarte dificil deoareceexistfoarte puine studii pe acest tip de populaie.n trecut, se considera c tulburrile afective bi-polare ar firar ntlnite la copii i adolesceni, darn prezent se tie faptul caceasttulburare psihiceste frecvent, prevalena sa fiind ncnecunoscut(6). Rata prevalenei depinde de criteriile dediagnostic utilizate. DSM IV prezint aceleai

criterii de diagnostic pentru toate tipurile de pacienicu tulburare afectivbipolar, indiferent de vrst(7). Cu toate acestea, clinicienii trebuie sia n con-siderare toate aspectele referitoare la dezvoltareacorespunztoare a copiilor i adolescenilor, atuncicnd acetia sunt evaluai din punct de vedere psi-hiatric. De aceea, este important s nelegemaceast tulburare psihic din punct de vedere aldezvoltrii i creterii adecvate a acestora. Deexemplu, unii tineri care prezintciclare rapid aepisoadelor sau episoade hipomaniacale nu nde-plinesc criteriile de diagnostic pentru tulburareaafectivbipolara adultului, dar un diagnostic ctmai precoce pentru o astfel de categorie de pacienii un tratament adecvat determin o mbuntiremai rapida simptomatologiei. Pe de altparte, nsituaia n care debutul simptomatologiei este subvrsta de 13 ani, apar forme atipice i subclinice aletulburrii afective bipolare (8). n cazul prezeneiunei ciclri rapide, simptomatologia include epi-soade mixte, evoluie cronic, labilitate emoional

i episoade maniacale sau depresive cu manifestridiscrete. Copiii pot prezenta manifestri explozive,iar modificrile comportamentale sunt mai degrabcontinue, dect episodice. n timpul unui episodmaniacal, copiii manifestn general iritabilitate imai rar dispoziie euforic. Adolescenii diagnos-ticai cu tulburare afectivbipolarprezinto simp-tomatologie similarcu cea a adulilor i episoadeafective distincte, cu un debut rapid al simptoma-tologiei. n cazul episoadelor afective, simptoma-tologia este clasici diagnosticul este mai uor de

identificat. Tabelul 1 prezintdifereniat tulburareaafectivbipolarn funcie de vrst(dupAcademyof Child and Adolescent Psychiatry) (9).

Toate aceste simptome ale tulburrii afective bi-polare pot fiinfluenate de contextul cultural. Astfel,

un studiu efectuat pe pacienii din populaia Amisha descoperit ctinerii pacieni diagnosticai cu unepisod maniacal prezinto serie de simptome, cumar fiideaia de grandoare, reduse n intensitate, dincauza limitelor de naturreligioas. De asemenea,

studiile au artat faptul cacei copii provenii dinminoritile etnice cu un nivel socioeconomic redusau un risc mai mare de diagnosticare greita uneischizofrenii comparativ cu ali pacieni cu tulburareafectiv bipolar, deoarece episoadele maniacaleprezint frecvent i simptome psihotice. n plus,diferenele rasiale pot influena i managementulterapeutic (10). Un studiu asupra particularitilorterapeutice a descoperit faptul c adolesceniiafroamericani cu tulburare afectivbipolarprimescde dou ori mai multe antipsihotice dect cei de

origine caucazian, din cauza interpretrii greite aunor simptome. (11) Scopurile principale ale mana-gementului terapeutic din tulburarea afectivbipolarsunt reprezentate de mbuntirea simpto-matologiei i de prevenirea recderilor, avndu-sen vedere reducerea morbiditii pe termen lung iasigurarea unei dezvoltri ct mai normale a acestortineri. Trialurile clinice controlate, efectuate petineri, sunt limitate, dar s-a constatat c cele maiutilizate medicamente cu rol normostabilizator suntreprezentate de Litiu, Carbamazepin i Valproat.De obicei, strategiile terapeutice n cazul copiilor iadolescenilor sunt bazate pe experiena cliniccupacienii aduli. Dar, simptomatologia afectivprezent la tineri nu se suprapune ntotdeauna cucea a adulilor i ar fi necesare trialuri clinicespecifice fiecrei vrste pentru a putea identifica untratament adecvat. naintea iniierii oricrei terapiipsihofarmacologice este necesar s se obin unconsimmnt informat adecvat, s se evaluezecorect faza de evoluie a tulburrii afective i sse

estimeze, pe ct posibil, durata tratamentului. Ale-gerea terapiei adecvate se bazeazpe urmtoareleprincipii: (12)

evidenierea eficacitii medicaiei alese;faza de evoluie a tulburrii psihice;

TABELUL 1. Evoluia clinica tulburrii afective bipolarenfuncie de vrst

Perioada

prepubertali

adolescena precoce

Perioada de

adolescentardiv

i adult

Episod iniial Depresiv Maniacal

Tipul

episoadelor

Ciclare rapid,

episod mixt

Discret cu debut

brusc i sfrit distnctDurata Cronic, ciclare

contnu

Sptmni

Funcionalitate

episodic

Frepisoade Funcionalitate bun


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prezena altor tipuri de simptome cum ar ficiclarea rapid, simptomele psihotice saumodificrile dispoziionale;efectele adverse ale medicaiei;istoricul pacientului legat de rspunsul lamedicaia anterioar;

preferinele pacientului i ale familiei.Psihoterapia reprezintun alt element important,parte integranta managementului terapeutic. Se potdezvolta msuri educaionale adecvate n urma con-sultrii familiei i a educatorilor i astfel pacientul irudele sale vor nva s managerizeze aceast tul-burare psihic. Msurile psihoterapeutice trebuie sfie adaptate la necesitile pacientului i implicmo-daliti de nvare de ctre pacient a simptomelorprodromale ce vor prezice un viitor episod afectiv, ba-zndu-se pe o serie de factori predictori, cum ar fi

deprivarea de somn, modificrile situaionale, patternulsezonier, abuzul de droguri sau noncompliana la tra-tament (13). Psihiatrul trebuie s realizeze un planterapeutic folosind un algoritm asemntor celui dinfigura urmtoare (14):

Litiu sau valproat (nu este rspuns)

Litiu+valproat (nu este rspuns)

Carbamazepin(nu este rspuns)

Carbamazepin+ litiu (nu este rspuns)

Olanzapinsau risperidon(nu este rspuns)

Noile anticonvulsivante (nu este rspuns)

Terapia electroconvulsivant

Pentru psihiatri este foarte important sneleagcnd s iniieze i cnd sdiscontinue terapia cunormostabilizatori. Deoarece exist doar ctevastudii la copii i adolesceni cu tulburare afectivbipolarprivind evoluia acesteia, experiena cliniceste cea care furnizeaz cele mai utile informaii

legate de terapie. Astfel, experiena clinicienilor su-gereazfaptul cnivelul terapeutic al timostabili-zatorilor trebuie meninut pentru minimum 2 ani,dup ce s-a obinut remisia simptomatologiei.Uneori, n cazul adolescenilor este necesardiscon-tinuarea tratamentului. Aceastdiscontinuitate tre-buie efectuatfoarte lent, n timp, cu o reducere adozelor pe parcursul a minimum 6 luni. (15)

Diagnosticarea i tratarea tulburrilor afectivebipolare la copii i adolesceni rmne o problemdificil avndu-se n vedere complexitatea feno-

menologiei i evoluiei acestei tulburri. Terapiafarmacologic este necesar n scopul asigurriiunei remisiuni adecvate, dar acest tip de pacienisunt frecvent subdiagnosticai i tratai necores-punztor. Astfel, vor finecesare i n continuare nu-meroase cercetri pentru a evalua necesitatea mo-noterapiei sau a combinaiilor terapeutice la tineriipacieni, deoarece este absolut necesaro intervenieprecoce i chiar agresivn cazul acestora.


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Clinical and therapeutical approaches of children and adolescent

bipolar disorders

Alexandra Bolos, Anamaria Burlea, Roxana Chirita

Universitatea de Medicini Farmacie Gr. T. Popa, Iasi

ABSTRACT

Bipolar disorder remains a condition which it is underdiagnosed and misdiagnosed among children andadolescents. The specific traits, like rapid cycling and mixed episodes often complicate the diagnosis. Inadditional, overlapping and comorbid conditions may influence the differential diagnosis. Thus, it is necessarythat age specific studies may produce diagnostic criteria specific for younger patients because an earlier andaccurate diagnosis will determine an adequate therapeutically management.

Key words: bipolar disorder, children, diagnosis, therapy

Child psychiatric disorders are more difficult tocharacterize than those of adults. Although thereare important advances in diagnosis of psychiatricdisorder at children, many treatments are prescribedfor vaguely defined disorder like aggressiveness,difficult behavior or depression. There are somefactors which contributed to this (1):

children have been neglected in psychiatricservices;abnormality in children is influenced bymaturation and development, that make moredifficult for doctors to interpret indicators ofbrain dysfunction;differential diagnosis is more difficult torealize compared with adult caused to lack ofrichness of behavioral expressions of psycho-pathology at children;children had a lot of difficulties to describepsychopathological symptoms.

Affective bipolar disorders had a variable age ofonset and it is especially diagnosed between agesof 18 and 24, but 59% of adults experienced theirfirst episode under the age of 18. The symptoms ofbipolar disorders are variable among children andadolescence and they had a lot of overlapping andcomorbid conditions like ADHD or substanceabuse. (2,3)

Thus, we want to point on fact that a goodnumber of children presented with bipolar disorderare misdiagnosed and this review offers a little

solution to the problem of an early diagnosis, whichit is critical for a good efficacy of treatment. Anearly diagnosis of bipolar disorder is a veryimportant clinical objective for psychiatrists forsome reasons (4):

This psychiatric disorder is a source of seriouspsychosocial dysfunction for children andadolescents with important consequences fortheir lives;There is evidence that a psychiatric syndromeis longer it will become more refractory totreatment.

There are three main diagnostic issues which arevery important to facilitate an early diagnostic ofbipolar disorder in children and adolescents (5):

to identify symptoms suggestive for mania;to differentiate between mania and ADHD,when there are not psychotic symptoms;to discriminate between mania and schi-zophrenia, when there are psychotic sym-ptoms.

To estimate the prevalence of bipolar disorderamong children and adolescent is very difficultbecause there are only a few studies on this type of

population. Even, in the past, it is believed thatbipolar disorder occurred rarely among childrenand adolescent, nowadays it is recognized that thisdisorder is frequently, but prevalence is stillunknown. The prevalence rates depend on diagnosticcriteria used. (6) The DSM IV presents the samecriteria of diagnosis for all types of patients withbipolar disorders regardless of age. However, theclinicians should consider developmental issueswhen it is necessary to evaluate children or adoles-cents. (7) Thus, it is important for all of us to

understand this disorder from a developmentalperspective. For example, some young persons whoexpress rapid cycle episodes and hypomania maydo not have criteria for an adult bipolar disorder,but an early diagnosis and treatment for such


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patients it is important because early interventionmeans an improved outcome. On the other hand,often, patients with onset of the disorder youngerthan 13 years old had atypical and subthresholdforms of bipolar disorder. (8) For those with rapidcycling form, symptoms include mixte state,

chronic evolution, emotionally labile behavior andless discrete episode of mania or depression.Children can experience explosive outbursts andchanges in mood are continuous in course, ratherthan episodic. During a manic episode, childrenmanifest irritability more than euphoric mood.Adolescent patients with bipolar disorder hadsymptoms like adult patients and experience distinctepisode, unlike children with rapid onset of thesymptoms. Also, they present classical symptomsof mania and can be easily diagnosed with bipolar

disorder. Table 1 summarizes differences in bipolardisorder based on age of onset (from AmericanAcademy of Child and Adolescent Psychiatry).(9)

TABLE 1. Clinical course of bipolar disorder by age of

onset

Prepubertal and

young adolescent

Older adolescent and

adult

Inital episode Depressive Manic

Type of

episodes

Rapid-cycling,

mixed

Discrete with sudden

onsets and clear offsets

Duraton Chronic,

contnuous cycling

Weeks

Interepisodic

functoning

Nonepisodic Improved functoning

All these expression of bipolar symptoms and

behavior may be influenced by cultural context.Thus, a study on old order Amish patients foundthat among Amish youths manic symptoms, likegrandiosity were diminished by religious ties. Also,studies had shown that children from ethnic mi-norities with lower socioeconomic backgroundshad a greater risk of misdiagnosis of schizophreniathan other patients with bipolar disorder becausemanic episodes include frequently psychotic fea-tures. In addition, racial differences can influencetreatment patterns. (10) A study on treatment pat-terns found that African American adolescents withbipolar disorder were twice as likely as Caucasiansones to receive treatment with antipsychotic causeto misinterpretation of the symptoms. (11)

Therapeutic management of bipolar disorder

had two principals goals: to improve patientsymptoms and to prevent relapses in order to reducelong term morbidity and to have a normal growthfor these children. Controlled medication trials inyounger patients are limited, but the most common

drugs used are Lithium, Valproat, Carbamazepine.Therapeutically strategies for children and adoles-cents with bipolar disorder are based mostly onclinical experience with adult patients. But, mani-festation of bipolar disorder in youths doesnt mimeadult type of bipolar disorder and it is necessary

more controlled trial age specific to determinewhich therapy is most useful for youths. Beforeinitiating psychopharmacological treatment it isrecommended to obtain an appropriate informedconsent, to evaluate the phase of disorder and toestimate the length of treatment. The choice of me-dication is based on the following guidelines (12):

evidence of efficacy of the drug;phase of the disorder;the presence of other symptoms like rapidcycling, mood changes or psychotic features;

side effects of the drug;the history of the patient regarding theresponse to drug;preferences of patient and family.

Psychosocial treatment represents also a part ofan integrated approach of the therapeutically ma-nagement. It can be develop an appropriate learningenvironment by consultation with families andeducators, thus patients and family are taught tocope with this disorder. Psychotherapy should beflexible on the necessities of the patient and it involvesteaching the patient to predict future episode relapsesbased on some factors like sleep deprivation, situationalchanges, seasonal patterns, substance abuse and non-compliance to treatment. (13)

Psychiatrists should realize a plan of treatmentusing an algorithm like in the next figure. (14)

Lithium or valproat (if no response)

Lithium+valproat (if no response)

Carbamazepine (if no response)Carbamazepine+lithium (if no response)

Olanzapinum or Risperidonum (if no response)

Newer antiepileptic drugs (if no response)

Electroconvulsive therapyFor psychiatrists, it is also important to

understand when to initiate and when to discontinue

the therapy. Because there are only a few studiesperformed in children and adolescents with bipolardisorders regarding the course of the disorder,clinical experience provide us a lot of informationuseful for treatment. Thus, clinical experience


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suggests that therapeutic levels of mood stabilizersshould be maintained for at least 2 years after theresolution of the symptoms. Also, adolescent pa-tients may request discontinuation of the treatment.Discontinuation must occur very slowly and dosesshould be tapering over 6 month period. (15)

Diagnosis of bipolar disorder in children andadolescents is complicated by the complexity of the

phenomenology and course of the disorder. Thepharmacological treatment is necessary for a goodoutcome, but often this kind of patients are mis-diagnosed and undertreated. Thus, more research isrequired to evaluate monotherapy or combinationof therapies at youths because it is important to

have an early and even aggressive intervention atthese patients.

Gagan Joshi, Carter Petty, Janet Wozniak, Stephen V. Faraone, et al.1.

A prospective open-label trial of quetiapine monotherapy in preschool

and school age children with bipolar spectrum disorder Journal of

Affective Disorders.Oct 2011

O. Bonnot, L. Holzer2. Utilisation des antipsychotiques chez lenfant etladolescent Neuropsychiatrie de lEnfance et de lAdolescence.Sep

2011

Howard Y. Liu, Mona P. Potter, K. Yvonne Woodworth, Dayna M.3.

Yorks, Carter R. Petty, et al. Pharmacologic Treatments for Pediatric

Bipolar Disorder: A Review and Meta-Analysis Journal of the American

Academy of Child & Adolescent Psychiatry.Aug 2011, Vol. 50, No. 8:

749-762.

Jonathan C. Pfeifer, Robert A. Kowatch, Melissa P. DelBello4.

Pharmacotherapy of Bipolar Disorder in Children and Adolescents CNS

Drugs. Jul 2010, Vol. 24, No. 7: 575-593

Eric Taylor5. Managing bipolar disorders in children and adolescents

Nature Reviews Neurology.Sep 2009, Vol. 5, No. 9: 484-491

N.C. Patel, D.M. Patrick, E.A. Youngstrom, S.M. Strakowski, M.P.6.

Delbello Response and Remission in Adolescent Mania Journal of the

American Academy of Child & Adolescent Psychiatry. May 2007, Vol. 46,No. 5: 628-635

Diagnostic and Statistical Manual of Mental Disorders,7. 4th Edition

(1994) American Psychiatric Association, Washington DC.

Edith M. Jolin, Elizabeth B. Weller, Ronald A. Weller8. The public

health aspects of bipolar disorder in children and adolescents Current

Psychiatry Reports.Apr 2007, Vol. 9, No. 2: 106-113

Michael Strober, Boris Birmaher, Neal Ryan, David Axelson, Sylvia9.

Valeri, Henrietta Leonard, et al. Pediatric bipolar disease: current and

future perspectives for study of its long-term course and treatment

Bipolar Disorders.Aug 2006, Vol. 8, No. 4: 311-321

Nick C. Patel, Melissa P. DelBello, Robert A. Kowatch, Stephen M.10. Strakowski Preliminary Study of Relationships Among Measures of

Depressive Symptoms in Adolescents with Bipolar Disorder Journal of

Child and Adolescent Psychopharmacology.Jun 2006, Vol. 16, No. 3:

327-335

Cassano G.B., McElroy S.L., Brady K., Nolen W.A., Placidi G.F.11.

Current issues in the identification and management of bipolar spectrum

disorders in special populations.J Affect Disord. 2000; 59 (suppl 1):

S69-79

Saunders and Goodwin12. The course of bipolar disorder Adv. Psychiatr.

Treat. 2010; 16:318-328.

Geller et al.13. Child Bipolar I Disorder: Prospective Continuity With Adult

Bipolar I Disorder; Characteristics of Second and Third Episodes;

Predictors of 8-Year OutcomeArch Gen Psychiatry2008; 65:1125-1133

Goldstein14. Recent Progress in Understanding Pediatric Bipolar

DisorderArch Pediatr AdolescMed 2012; 166:362-371.Rick T. Bowers, Christina G. Weston, Julia Jackson15. Child and

Adolescent Affective Disorders and their Treatment Journal of Affective

Disorders.Mar 2012: 189-214

REFERENCES

Documents

Tulburari Afective La Copii Si Adolescenti