Pediatric bipolar disorder comes of age

Neural mechanisms of face emotion processing in youths and adults with bipolar disorder

OBJECTIVES

Little is known about potential differences in the pathophysiology of bipolar disorder (BD) across development. The present study aimed to characterize age-related neural mechanisms of BD.

METHODS

Youths and adults with and without BD (N = 108, age range = 9.8-55.9 years) completed an emotional face labeling task during fMRI acquisition. We leveraged three different fMRI analytic tools to identify age-related neural mechanisms of BD, investigating (a) change in neural responses over the course of the task, (b) neural activation averaged across the entire task, and (c) amygdala functional connectivity.

RESULTS

We found converging Age Group × Diagnosis patterns across all three analytic methods. Compared to healthy youths vs adults, youths vs adults with BD show an altered pattern in response to repeated presentation of emotional faces in medial prefrontal, amygdala, and temporoparietal regions, as well as amygdala-temporoparietal connectivity. Specifically, medial prefrontal and lingual activation decreases over the course of repeated emotional face presentations in healthy youths vs adults but increases in youths with BD compared to adults with BD. Moreover, youths vs adults with BD show less medial prefrontal activation and amygdala-temporoparietal junction connectivity averaged over the task, but this difference is not found for healthy youths vs adults.

CONCLUSION

Although longitudinal confirmation and replication will be necessary, these findings suggest that neural development may be aberrant in BD and that some neural mechanisms mediating BD may differ in adults vs children with the illness.

Abnormal Functional Connectivity Between Default and Salience Networks in Pediatric Bipolar Disorder

BACKGROUND

Pediatric bipolar disorder (PBD) (occurring prior to 18 years of age) is a developmental brain disorder that is among the most severe and disabling psychiatric conditions affecting youth. Despite increasing evidence that brain connectivity is atypical in adults with bipolar disorder, it is not clear how brain connectivity may be altered in youths with PBD.

METHODS

This cross-sectional resting-state functional magnetic resonance imaging study included 80 participants recruited over 4 years: 32 youths with PBD, currently euthymic (13 males; 15.1 years old), and 48 healthy control (HC) subjects (27 males; 14.5 years old). Functional connectivity between eight major intrinsic connectivity networks, along with connectivity measurements between 333 brain regions, was compared between PBD and HC subjects. Additionally, connectivity differences were evaluated between PBD and HC samples in negatively correlated connections, as defined by 839 subjects of the Human Connectome Project dataset.

RESULTS

We found increased inter- but not intranetwork functional connectivity in PBD between the default mode and salience networks (p = .0017). Throughout the brain, atypical connections showed failure to develop anticorrelation with age during adolescence in PBD but not HC samples among connections that exhibit negative correlation in adulthood.

CONCLUSIONS

Youths with PBD demonstrate reduced anticorrelation between default mode and salience networks. Further evaluation of the interaction between these networks is needed in development and with other mood states such as depression and mania to clarify if this atypical connectivity is a PBD trait biomarker.

Pediatric Bipolar Disorder

The diagnosis of bipolar disorder (BD) in youth is confusing and controversial. Controversy notwithstanding, youth diagnosed with BD have high behavioral health needs and are at elevated risk for problematic long-term psychosocial functioning and complex psychiatric medication regimens. Pediatricians and other primary care providers (PCPs) can play an important role in the assessment and treatment of youth diagnosed with BD and the recently created and also controversial diagnosis of disruptive mood dysregulation disorder (DMDD). This article provides information on the definitions, background, and presentation of pediatric bipolar disorder (PBD), how to differentiate PBD from other psychiatric disorders, effective psychiatric and psychosocial interventions for PBD, potential roles for PCPs, and what is known about DMDD. [Pediatr Ann. 2016;45(10):e362-e366.].

Prevalence of bipolar disorder diagnoses and psychotropic drug therapy among privately insured children and adolescents

STUDY OBJECTIVES

To estimate the treated prevalence of bipolar disorder in a privately insured population, describe the characteristics of children and adolescents receiving these diagnoses, and describe patterns of their psychotropic drug therapy.

DESIGN

Retrospective, repeated cross-sectional study.

DATA SOURCE

MarketScan Commercial Claims and Encounters inpatient, outpatient, and pharmacy claims databases.

PATIENTS

A total of 22,360 children and adolescents (aged 0-17 yrs) with one inpatient or two or more outpatient claims for any bipolar spectrum disorder between January 1, 2005, and December 31, 2007.

MEASUREMENTS AND MAIN RESULTS

Annual cross-sections were used to estimate the treated prevalence of bipolar disorder diagnoses, patient characteristics, and psychotropic drugs used 30 days after a child's latest recorded bipolar disorder diagnosis within each year. The annual treated prevalence of any bipolar spectrum disorder in this privately insured population was 0.24% in 2005 and 0.26% in 2006 and 2007. Approximately 25% of diagnoses were for children younger than 13 years. Approximately 30% of children had coexisting attention-deficit-hyperactivity disorder during the year. In each year, 35% of patients used no psychotropic drug therapy in the 30-day period after their most recent diagnosis. Twenty-five percent used one psychotropic drug, and 40% used two or more drugs. The most common drug regimens were antipsychotic or mood stabilizer (lithium or anticonvulsant) monotherapy and the combination of mood stabilizers and antipsychotics.

CONCLUSION

Drug therapy patterns suggest that children and adolescents with bipolar diagnoses receive complex treatment regimens, often involving multiple classes of psychotropic drugs. Research on treatment combinations, particularly antipsychotic and mood stabilizer combinations, should be prioritized to better understand the safety and effectiveness of commonly prescribed treatments.

Deficits in emotion recognition in pediatric bipolar disorder: the mediating effects of irritability

BACKGROUND

Pediatric Bipolar Disorder (PBD) is a debilitating condition associated with impairment in many domains. Social functioning is one of the disorder's most notable areas of impairment and this deficit may be in part due to difficulties recognizing affect in others.

METHODS

In the present study, medication naïve youth with PBD were compared to age-matched healthy controls on their ability to (a) distinguish between categorical emotions, such as happiness, anger, and sadness on the Emotion Recognition Test (ER-40) and (b) differentiate between levels of emotional intensity on an adapted version of the Penn Emotional Acuity Task (Chicago-PEAT).

RESULTS

Results indicated that PBD youth misidentified sad, fearful, and neutral faces more often than controls, and PBD girls mislabeled 'very angry' faces more often than healthy girls. A mediation analyses indicated that these diagnostic group differences on emotion recognition were significantly mediated by irritability.

LIMITATIONS

The Chicago-PEAT only examined variations in emotional intensity for the emotions happy and anger. Additionally, all results are correlational; therefore causal inferences cannot be made.

CONCLUSIONS

Supporting previous literature, the present findings highlight the importance of emotion recognition deficits in PBD individuals. Additionally, the irritability associated with PBD may be an important mechanism of this deficit and may thus represent an important target for treatment.

Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths

In recent years, increasing numbers of children have been diagnosed with bipolar disorder. In some cases, children with unstable mood clearly meet current diagnostic criteria for bipolar disorder, and in others, the diagnosis is unclear. Severe mood dysregulation is a syndrome defined to capture the symptomatology of children whose diagnostic status with respect to bipolar disorder is uncertain, that is, those who have severe, nonepisodic irritability and the hyperarousal symptoms characteristic of mania but who lack the well-demarcated periods of elevated or irritable mood characteristic of bipolar disorder. Levels of impairment are comparable between youths with bipolar disorder and those with severe mood dysregulation. An emerging literature compares children with severe mood dysregulation and those with bipolar disorder in longitudinal course, family history, and pathophysiology. Longitudinal data in both clinical and community samples indicate that nonepisodic irritability in youths is common and is associated with an elevated risk for anxiety and unipolar depressive disorders, but not bipolar disorder, in adulthood. Data also suggest that youths with severe mood dysregulation have lower familial rates of bipolar disorder than do those with bipolar disorder. While youths in both patient groups have deficits in face emotion labeling and experience more frustration than do normally developing children, the brain mechanisms mediating these pathophysiologic abnormalities appear to differ between the two patient groups. No specific treatment for severe mood dysregulation currently exists, but verification of its identity as a syndrome distinct from bipolar disorder by further research should include treatment trials.

Adolescent bipolar disorder: a clinical vignette

Adolescence is a vulnerable developmental phase marked by physical, psychological, and social changes that rapidly expose young people to a wide range of new stressors. When differentiating between bipolar disorder and teenage "acting out," a careful history is important. Adolescent bipolar disorder is a psychiatric illness characterized by fluctuating episodes of mood elevation and depression that is frequently neither recognized nor formally diagnosed. Adolescents with bipolar disorder often manifest a more nonepisodic, chronic course with continuous rapid-cycling patterns than do adults. Pharmacologic treatment of adolescent bipolar disorder is difficult and often requires combination therapy to address comorbidities like attention-deficit/hyperactivity disorder and anxiety disorder. Adjuncts to pharmacologic treatment of bipolar disorder can be beneficial. Psychosocial treatments include family education, enhanced parenting techniques, stress management, and the development of effective coping strategies.