Bipolar Disorder

Bipolar disorder in children and adolescents is characterized by recurrent episodes of elevated mood (mania or hypomania), which exceed what is expected for the child’s developmental stage and are not better explained by other psychiatric and general medical conditions. In addition, youth with bipolar disorder usually have recurrent episodes of major depression

Mania: Mania typically manifests as a cluster of symptoms denoting an increase in emotional, cognitive, and behavioral activity. During episodes of mania, youth can present with elation (euphoria) and/or irritability, increased energy, grandiose ideation or delusions, rapid to disorganized thinking, rapid (pressured) speech, distractibility, decreased need for sleep (eg, sleeping a few hours or awake all night and the next day without fatigue), and hypersexuality, as well as increased activity, agitation, impulsivity, and risky behaviors. 

Some investigators have argued that mania in children is mainly manifested with chronic symptoms of severe irritability, even if the irritability does not occur episodically. However, mania rarely occurs without elation; chronic (non-episodic) irritability is usually associated with other disorders (eg, oppositional defiant disorder and attention deficit hyperactivity disorder), rather than bipolar disorder 

Diagnosis:

Clinical Interview: Assessment of manic, hypomanic, and depressive symptoms in youth requires careful probing and multiple longitudinal assessments.

Diagnostic interviews: There are several structured and semi-structured interviews that can be used for diagnosing bipolar disorder, including the Kiddie Schedule for Affective Disorders and Schizophrenia for school age children – Present and Lifetime version (K-SADS-PL). However, these interviews are lengthy and time-consuming and are mainly used for research.

Clinician administered rating scales: like Young Mania Rating Scale (YMRS)and the KSADS Mania Rating Scale (KSADS – MRS). 

Youth and parent administered rating scales: It appears that parental reports are more effective in identifying mania than youth or teacher reports. The General Behavior Inventory, the parent version of the YMRS (P-YMRS), and the Child Mania Rating Scale for Parents about their children have been shown to be psychometrically sound and useful for the screening of bipolar disorder symptoms in youth, but further studies to evaluate the specificity of these instruments for bipolar disorder are warranted. The Child Behavior Checklist (CBCL) is a parent-report instrument that has been used to screen for bipolar disorder in youths by summing the Attention, Aggression, and Anxious/Depressed subscales (CBCL-PBD; pediatric bipolar disorder phenotype). However, the CBDL-PBD is not specific for assessing mania; rather, it seems to detect mood lability or severe psychopathology.

Treatment: 

Medications are a must and first line treatment. Psychotherapies is added onto pharmacotherapy. 

First Line Medications: Initial pharmacotherapy for pediatric mania is a second-generation antipsychotic, such as aripiprazole, asenapine, olanzapine, quetiapine, risperidone, or ziprasidone. The efficacy and tolerability of these drugs has been established in many studies, including 10 randomized trials. Based upon randomized trials, clinicians can expect that remission with second-generation antipsychotics will occur in approximately 25 to 70 percent of patients, and response (eg, reduction of baseline symptoms ≥50 percent) in 50 to 90 percent. 

No head-to-head randomized trials have compared different second-generation antipsychotics in children and adolescents with mania; across separate trials, the clinical effect of these drugs appears to be comparable. The specific choice thus depends on factors such as past response to medications, side effect profiles, comorbidities, potential drug-drug interactions, patient preference, and cost. As an example:

• Extrapyramidal symptoms may occur less often with quetiapine or olanzapine than other atypical antipsychotics, such as risperidone.
• Hyperprolactinemia may occur more often with risperidone than other second-generation antipsychotics.
• Metabolic side effects, such as weight gain and hyperlipidemia, appear to be more pronounced with olanzapine than other atypical antipsychotics, and least likely to occur in ziprasidone.
• Patients with risk factors for or a history of cardiac disease generally do not receive ziprasidone because the drug may prolong the QTc interval.

Treatment resistant patients — Pediatric mania often does not respond to multiple (eg, two to three) trials of second-generation antipsychotics. For these treatment resistant patients, we suggest lithium. For patients who responded partially to initial treatment with an antipsychotic, we add lithium to the antipsychotic. For patients who demonstrate little or no response to antipsychotics, we taper and discontinue the antipsychotic over one to two weeks, and at the same time start lithium and titrate the dose up.

Treatment refractory patients — Pediatric mania often does not respond to second-generation antipsychotics and lithium. For these refractory patients, we suggest medication combinations. For patients who are refractory to monotherapy trials with second-generation antipsychotics and lithium, we suggest combining a second-generation antipsychotic with lithium. The antipsychotic is selected from amongst those that were not previously prescribed during the initial monotherapy trials. For patients who received an antipsychotic plus lithium and did not respond sufficiently, we suggest tapering and discontinuing the antipsychotic, and simultaneously starting and titrating up a different second-generation antipsychotic. Other combinations that may be useful include second-generation antipsychotics plus an antiepileptic (eg, divalproex or lamotrigine), lithium plus an antiepileptic (eg, divalproex, lamotrigine, or carbamazepine), and first-generation antipsychotics plus lithium or an antiepileptic (eg, divalproex or lamotrigine).

Psychotherapy: 

Specific psychotherapies that can be added onto pharmacotherapy for pediatric bipolar patients include:

• Cognitive-behavior therapy
• Dialectical behavior therapy
• Family therapy
• Interpersonal and social rhythm therapy
• Motivational interviewing
• Psychoeducation

Disruptive mood dysregulation disorder

The diagnosis of disruptive mood dysregulation disorder requires each of the following criteria:

• Severe, recurrent verbal (eg, screaming) or behavioral (eg, physical aggression) angry outbursts that are grossly out of proportion to the provocation.
• The outbursts are not appropriate for the patient’s developmental level
• The outbursts occur, on average, at least three times per week.
• The outbursts occur in at least two settings from among home, school, or with peers.
• Persistently irritable or angry mood most of the day, nearly every day, between outbursts
• Symptoms have occurred for at least 12 months. Symptom free periods can occur, but may not exceed 3 months during the one-year timeframe.  
• Age at onset <10 years. The diagnosis cannot be given for the first time before age 6 years or after age 18 years.
• The patient has never had a period lasting more than one day during which the full symptom criteria for mania or hypomania, except duration, have been met  
• Symptoms do not occur solely during unipolar major depressive episodes, and are not better explained by other mental disorders (eg, autism)
• The symptoms are not attributable to the physiologic effects of a substance or medication, or to another medical disorder.

Disruptive mood dysregulation disorder may be comorbid with unipolar major depression, attention deficit hyperactivity disorder, conduct disorder, and substance use disorders. However, the diagnosis of disruptive mood dysregulation disorder, according to DSM-5, cannot be given simultaneously with the diagnoses of bipolar disorder, intermittent explosive disorder, and oppositional defiant disorder.

Disruptive mood dysregulation and intermittent explosive disorder are both characterized by recurrent, severe, angry outbursts. However, patients with disruptive mood dysregulation disorder are angry or irritable most of the day, nearly every day, in between the angry outbursts, whereas the diagnosis of intermittent explosive disorder does not require a mood disturbance between outbursts. In addition, angry outbursts in disruptive mood dysregulation disorder occur on average three times per week; in intermittent explosive disorder, verbal aggression occurs on average twice per week. Disruptive mood dysregulation disorder requires 12 months of active symptoms, in contrast to intermittent explosive disorder, which requires only 3 months of symptoms.

Intermittent Explosive Disorder