Preschool-onset mania: incidence, phenomenology and family history

A Longitudinal Study of Psychiatric Disorders in Offspring of Parents With Bipolar Disorder From Preschool to Adolescence

OBJECTIVE

To compare the prevalence of psychopathology, particularly bipolar disorder (BD), between preschool offspring of parents with BD and community controls.

METHOD

A total of 116 offspring of BD-I/II parents and 98 controls (53 parents with non-BD psychopathology and 45 healthy parents) were recruited at ages 2 to 5 years and followed on average 9.6 years (on average: 2-5: 1.6 times; after age 5: 4 times) (average ages at intake/last follow-up: 3.8/13.4, retention: 98%). Participants were evaluated with standardized instruments blinded to parental diagnoses.

RESULTS

After adjusting for confounders, offspring of BD parents only showed more attention-deficit/hyperactivity disorder (ADHD) during ages 2 to 5 years than the other 2 groups. After age 5, offspring of BD parents did not differ from offspring of parents with non-BD psychopathology, but they had more anxiety, ADHD, and behavior problems than offspring of healthy parents. Only offspring of BD parents developed BD-I/II: 3.4% (n = 4) and BD-not-otherwise-specified (BD-NOS): 11.2% (n = 13), with mean onset ages 11.4 and 7.4, respectively. About 70% of offspring with BD had non-BD disorders before BD. Only ADHD, diagnosed before age 6 years, and early-onset parental BD were significantly associated with BD risk.

CONCLUSION

Most offspring of BD parents did not develop BD, but they were at specific high risk for developing BD, particularly those with preschool ADHD and early-onset parental BD. BD symptoms were scarce during the preschool years and increased throughout the school age, mainly in the form of BD-NOS, a disorder that conveys poor prognosis and high risk to develop BD-I/II. Developing early interventions to delay or, ideally, to prevent its onset are warranted.

Factors associated with borderline personality disorder in major depressive patients and their relationship to bipolarity

Objective

To analyze the interface between borderline personality disorder (BPD) and bipolarity in depressed patients comorbid with BPD.

Methods

As part of National Multi-site Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1 month apart, 19 (3.9%) had comorbid BPD (BPD+), whereas 474 (96.1%) did not manifest this comorbidity (BPD−).

Results

Compared to BPD (−), BPD (+) patients displayed higher rates of bipolar (BP) disorders and temperaments, an earlier age at onset with a family history of affective illness, more comorbidity, more stressors before the first episode which was more often depressive or mixed, as well as a greater number and severity of affective episodes.

Conclusions

The hypothesis which fitted at best our findings was to consider BPD as a contributory factor in the development of BP disorder, which could have favoured the progression from unipolar major depression to BP disorder. We could not however exclude that some features of BP disorder may have contributed to the development of BPD.

Deficient Emotional Self-Regulation in Preschoolers With ADHD: Identification, Comorbidity, and Interpersonal Functioning

OBJECTIVE

This study aims to develop an age-adjusted Child Behavior Checklist- (CBCL) and Teacher Report Form (TRF)-based method for the detection of deficient emotional self-regulation (DESR) in preschoolers with ADHD and to assess its incidence, comorbidities, and consequences on interpersonal functioning.

METHOD

Eighty-six ADHD preschoolers and 104 controls were assessed using CBCL, TRF/1½ to 5, Psychiatric Interview With Preschool Age Psychiatric Assessment, Leiter-R, and ADHD rating scales.

RESULTS

Greatest sensitivity and specificity were obtained applying slightly lower threshold scores compared with school-age children (CBCL: Anxiety/Depression [A/D] ≥ 59, Attention Problems [AP] ≥ 60, Aggression Behaviors [AB] ≥ 58; TRF: A/D ≥ 59, AP ≥ 60, AB ≥ 60). DESR was detected in 33/86 (38.4%) and in 16/54 (29.6%) ADHD preschoolers versus 2/104 (1.9%) controls using CBCL and TRF, respectively. DESR is associated with significantly greater comorbidity and impairment in interpersonal functioning.

CONCLUSION

Among ADHD preschoolers, DESR (a) requires lower CBCL and TRF threshold scores for detection, compared with school-age children, (b) displays similar incidence rates, and (c) is associated with enhanced psychiatric comorbidity and interpersonal difficulties.

Temper Loss and Persistent Irritability in Preschoolers: Implications for Diagnosing Disruptive Mood Dysregulation Disorder in Early Childhood

Disruptive Mood Dysregulation Disorder (DMDD) is a new and controversial child psychiatric disorder characterized by persistent irritability and frequent temper loss. Among the controversies surrounding DMDD is whether the age of onset criterion-that DMDD may not be diagnosed before age 6 years-is justified. This study examined DMDD symptoms and associated patterns of psychiatric comorbidity, behavioral, and family functioning in a sample of 139 preschoolers (ages 4-0 to 5-11 years) admitted to an early childhood psychiatric day treatment program. DMDD symptoms were common in this acute clinical sample, with 63 children (45.3 %) presenting with frequent temper outbursts and chronic irritability. As compared to children who did not present with DMDD symptoms, these children demonstrated more aggression and emotional reactivity and lower receptive language skills, with high rates of comorbidity with the disruptive behavior disorders. Findings contribute to an emerging literature on preschool DMDD, with implications for early childhood psychiatric assessment and clinical interventions.

The evaluation of mood condition among depressed adolescent students in Isfahan after 6 years

BACKGROUND

This study has carried out to find the recovery rate, depression recurrence, changing of diagnose into bipolar mood disorder (BMD) and appearing other psychiatric disorders including obsessive compulsive disorder, oppositional defiant disorder (ODD), substance induced disorders, attention deficit and hyperactivity disorder, and anxiety disorders after 6 years among students having major depression disorder in Isfahan and its relation to some demographic factors.

MATERIALS AND METHODS

In this historical cohort study, 278 students studying in guidance school, in 2006 being 11-16-year-old and were diagnosed to have major depressive disorder participated. Data collection was done by completing children depression on inventory, Young Maria Rating Scale and also final diagnosis determination through interview by psychiatrists. To analyze the data, in addition to use descriptive statistics, multinomial and multiple logistic regressions were used to evaluate the relationships. All the analyses were done using SPSS 20.

RESULTS

About 34.9 of adolescents have suffered from depression after 6 years. Depression in 12.2% has been changed into BMD. The BMD morbidity chance was less in girls rather than depression one. The ratio of drug abuse in girls was less than boys (odds ratio [OR] = 0.471, P = 0.046). Students received no treatment or only pharmacotherapy, were more caught by ODD in comparison with those cases who received both pharmacotherapy and psychotherapy (P = 0.005, 0.038 and OR = 4.29 and 5.88).

CONCLUSION

About half of students after 6 years are caught by depression or BMD. It reveals the importance of this disorder and its role in making behavioral problems for adolescents in their future.

Widespread white matter tract aberrations in youth with familial risk for bipolar disorder

Few studies have examined multiple measures of white matter (WM) differences in youth with familial risk for bipolar disorder (FR-BD). To investigate WM in the FR-BD group, we used three measures of WM structure and two methods of analysis. We used fractional anisotropy (FA), axial diffusivity (AD), and radial diffusivity (RD) to analyze diffusion tensor imaging (DTI) findings in 25 youth with familial risk for bipolar disorder, defined as having both a parent with BD and mood dysregulation, and 16 sex-, age-, and IQ-matched healthy controls. We conducted a whole brain voxelwise analysis using tract based spatial statistics (TBSS). Subsequently, we conducted a complementary atlas-based, region-of-interest analysis using Diffeomap to confirm results seen in TBSS. When TBSS was used, significant widespread between-group differences were found showing increased FA, increased AD, and decreased RD in the FR-BD group in the bilateral uncinate fasciculus, cingulum, cingulate, superior fronto-occipital fasciculus (SFOF), superior longitudinal fasciculus (SLF), inferior longitudinal fasciculus, and corpus callosum. Atlas-based analysis confirmed significant between-group differences, with increased FA and decreased RD in the FR-BD group in the SLF, cingulum, and SFOF. We found significant widespread WM tract aberrations in youth with familial risk for BD using two complementary methods of DTI analysis.

Behavior and emotion modulation deficits in preschoolers at risk for bipolar disorder

BACKGROUND

Bipolar disorder (BD) is highly familial, but studies have yet to examine preschoolers at risk for BD using standardized, developmentally appropriate clinical assessment tools. We used such methods to test whether preschoolers at familial risk for BD have more observed difficulty modulating emotions and behaviors than do low-risk preschoolers. Identification of emotional and behavioral difficulties in at-risk preschoolers is crucial for developing new approaches for early intervention and prevention of BD.

METHODS

Using the standardized disruptive behavior diagnostic observation schedule (DB-DOS) protocol for preschoolers, we compared 23 preschoolers (M(age): 4.53 ± 0.73 years; 18 males) with a first-degree relative with BD to 21 preschoolers (M(age): 4.65 ± 0.84 years; 11 males) without a family history of BD. We characterized psychopathology in this sample using the Preschool Aged Psychiatric Assessment and behavioral and emotional problems using the Child Behavior Checklist.

RESULTS

High-risk preschoolers demonstrated significantly more intense, pervasive, and clinically concerning problems in anger modulation and behavior dysregulation on the DB-DOS than the low-risk group. High-risk relative to low-risk preschoolers, were also more likely to have maternal-reported anxiety and oppositional defiant disorders and internalizing and externalizing problems.

CONCLUSIONS

Clinically concerning problems in anger modulation and behavior regulation, measured during standardized laboratory observation, differentiate preschoolers at high familial risk for BD from those at low risk. Investigation in a large longitudinal sample is critical for replication and for determining whether these observed behavioral differences can be reliably used as prodromal indicators of mood disorders.

Placebo-controlled trial of valproic Acid versus risperidone in children 3-7 years of age with bipolar I disorder

OBJECTIVE

The objective of this study was to determine the efficacy and safety of valproic acid versus risperidone in children, 3-7 years of age, with bipolar I disorder (BPD), during a mixed or manic episode.

METHODS

Forty-six children with Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text Revision (DSM-IV-TR) diagnosis of bipolar disorder, manic, hypomanic, or mixed episode, were recruited over a 6 year period from two academic outpatient programs for a double-blinded, placebo-controlled trial in which subjects were randomized in a 2:2:1 ratio to risperidone solution, valproic acid, or placebo.

RESULTS

After 6 weeks of treatment, the least-mean Young Mania Rating Scale (YMRS) total scores change, adjusted for baseline YMRS scores, from baseline by treatment group was: Valproic acid 10.0±2.46 (p=0.50); risperidone 18.82±1.55 (p=0.008); and placebo 4.29±3.56 (F=3.93, p=0.02). The mixed models for repeated measure (MMRM) analysis found a significant difference for risperidone-treated subjects versus placebo treated subjects (p=0.008) but not for valproic acid-treated subjects versus placebo-treated subjects (p=0.50). Treatment with risperidone over 6 weeks led to increased prolactin levels, liver functions, metabolic measures, and weight/body mass index (BMI). Treatment with valproic acid led to increases in weight/BMI and decreases in total red blood cells (RBC), hemoglobin, and hematocrit.

CONCLUSIONS

In this small sample of preschool children with BPD, risperidone demonstrated clear efficacy versus placebo, whereas valproic acid did not. The laboratory and weight findings suggest that younger children with BPD are more sensitive to the effects of both of these psychotropics, and that, therefore, frequent laboratory and weight monitoring are warranted.

Age differences in the phenomenology of pediatric bipolar disorder

BACKGROUND

The primary purpose of this study was to explore whether age differences in the phenomenology of bipolar disorders from 4 to 17 years of age exist.

METHODS

Outcome measures included questionnaires pertaining to mood symptoms, psychosocial functioning, and family history of psychiatric illness. Phenomenology was examined in two diagnostic groups: syndromal bipolar disorder (bipolar I or II) and subsyndromal bipolar disorder (bipolar disorder not otherwise specified or cyclothymia) and across six age cohorts: 4-6, 7-8, 9-10, 11-13, and 14-17 years. Analyses examined linear and non-linear age effects on clinician-rated measures of mood and psychosocial functioning.

RESULTS

Participants were 535 outpatients (339 males) ages 4-17 years. The proportion diagnosed with comorbid ADHD was significantly lower in the oldest age group. Age groups showed significant moderate decreases in motor activity, aggression, and irritability with age. Many symptoms of depression showed significant increases with age. BP I cases showed much higher manic symptoms, and BP I and BP II cases indicated slightly to moderately higher depressive symptoms, compared to subsyndromal cases. These patterns held after adjusting for comorbid ADHD, and age did not interact with syndrome status. There were also age differences in total scores for measures of mood symptoms and psychosocial functioning.

LIMITATIONS

Mood ratings were completed based on the same interview that informed the research diagnoses. Also, mood episode at time of interview was not captured.

CONCLUSIONS

These findings affirm the existence of bipolar disorder from pre-school children through adolescence, with a similar clinical presentation across a wide developmental age span.

Bipolar Disorder in Children and Adolescents Recognised in the UK: A Clinic-Based Study

BACKGROUND

  Diagnoses of paediatric bipolar disorder have increased over the last two decades in the United States, where high levels of comorbidity with ADHD have also been reported.

AIMS

  To explore how British clinicians apply these diagnoses.

METHOD

  We compared 378 young people under the age of 18 who received a diagnosis of bipolar disorder and/or ADHD from a large NHS mental health trust between 1992 and 2007.

RESULTS

  Children with bipolar disorder were rare in this sample (n = 35, 1.0%), particularly under the age of 13 (n = 9, 0.3%). Children with bipolar disorder presented more often with affective and psychotic symptoms than children with ADHD. Irritability was common in both disorders. Core ADHD symptoms were prevalent in both conditions but occurred in a greater proportion of children with ADHD.

CONCLUSION

  Our findings suggest that psychiatrists in England use the traditional adult criteria of bipolar disorder rather than the broader criteria being adopted by some practitioners in the US.

Psychiatric disorders in preschool offspring of parents with bipolar disorder: the Pittsburgh Bipolar Offspring Study (BIOS)

OBJECTIVE

The authors evaluated lifetime prevalence and specificity of DSM-IV psychiatric disorders and severity of depressive and manic symptoms at intake in preschool offspring of parents with bipolar I and II disorders.

METHOD

A total of 121 offspring ages 2-5 years from 83 parents with bipolar disorder and 102 offspring of 65 demographically matched comparison parents (29 with non-bipolar psychiatric disorders and 36 without any lifetime psychopathology) were recruited for the study. Parents with bipolar disorder were recruited through advertisements and adult outpatient clinics, and comparison parents were ascertained at random from the community. Participants were evaluated with standardized instruments. All staff were blind to parental diagnoses.

RESULTS

After adjustment for within-family correlations and both biological parents' non-bipolar psychopathology, offspring of parents with bipolar disorder, particularly those older than age 4, showed an eightfold greater lifetime prevalence of attention deficit hyperactivity disorder (ADHD) and significantly higher rates of having two or more psychiatric disorders compared to the offspring of the comparison parents. While only three offspring of parents with bipolar disorder had mood disorders, offspring of parents with bipolar disorder, especially those with ADHD and oppositional defiant disorder, had significantly more severe current manic and depressive symptoms than comparison offspring.

CONCLUSIONS

Preschool offspring of parents with bipolar disorder have an elevated risk for ADHD and have greater levels of subthreshold manic and depressive symptoms than children of comparison parents. Longitudinal follow-up is warranted to evaluate whether these children are at high risk for developing mood and other psychiatric disorders.

Preschool Bipolar Disorder

Although some empirical work has now been added to the larger body of case material, preschool bipolar disorder (BPD) remains a highly ambiguous diagnostic area. This is notable in the context of the significant progress that has been made in many other areas of psychopathology in the preschool period. While there is a need for well controlled empirical investigations in this area, a small but growing body of empirical literature suggests that some form of the disorder may arise as early as age 3. The need for large scale and focused studies of this issue is underscored by the high and increasing rates of prescriptions of atypical antipsychotics and other mood stabilizing agents for preschool children with presumptive clinical diagnosis of BPD or a related variant. Clarifying the nosology of preschool BPD may also be important to better understand of the developmental psychopathology of the disorder during childhood. Data elucidating this developmental trajectory could then inform the design of earlier potentially preventive interventions that may have implications for the disorder across the lifespan.

Clinical characteristics of bipolar vs. unipolar depression in preschool children: an empirical investigation

BACKGROUND

Despite retrospective reports of the onset of childhood bipolar disorder during the preschool period, few studies have investigated whether mania symptoms can be identified in preschoolers. A group of children with a cluster of mania symptoms that showed discriminant validity from other disruptive disorders was identified in a large preschool sample. These empirical data add to descriptive studies of mania in clinical preschool populations. An investigation of the characteristics of depression among putative bipolar preschoolers may inform the controversial nosologic questions that surround the diagnosis in this young age group.

METHOD

This study, conducted from 2002 to 2007, investigated major depressive disorder (MDD) symptoms and severity in preschoolers with a bipolar syndrome in comparison to those with unipolar MDD, identified by an age-appropriate structured psychiatric interview, the Preschool Age Psychiatric Assessment (based on DSM-IV).

RESULTS

Twenty-one preschoolers were identified who met DSM-IV symptom criteria for bipolar I disorder and MDD and were compared to 54 preschoolers with unipolar MDD. The bipolar depressed preschoolers had significantly higher depression severity (p < .0001) and higher rates of comorbidity than did those with unipolar depression. The study is limited by the exploratory nature of clinical mania characteristics in preschoolers as well as reliance on parent reports of these symptoms.

CONCLUSIONS

These findings suggest that, similar to adult bipolar patients, preschoolers with a putative bipolar syndrome experience clinically significant and severe depression. Symptom characteristics and comorbidity patterns also distinguished this group from the unipolar depressed preschoolers. Our findings underscore the marked depression that characterizes this putative bipolar syndrome and suggest that further investigation of this domain may clarify the nosology of this early-onset disorder.

Current research in child and adolescent bipolar disorder

Although recently more research has considered children with bipolar disorder than in the past, much controversy still surrounds the validity of the diagnosis. Furthermore, questions remain as to whether or not childhood expressions of bipolarity are continuous with adult manifestations of the illness. In order to advance current knowledge of bipolar disorders in children, researchers have begun to conduct phenomenological, longitudinal, treatment, and neuroimaging studies in youths who exhibit symptoms of bipolar illness, as well as offspring of parents with bipolar disorders. Regardless of the differences between research groups regarding how bipolar disorder in children is defined, it is agreed that pediatric bipolarity is a serious and pernicious illness. With early intervention during the period of time in which youths are exhibiting subsyndromal symptoms of pediatric bipolarity, it appears that the progression of the illness to the more malignant manifestation of the disorder may be avoided. This paper will review what is currently known and what still is left to learn about clinically salient topics that pertain to bipolar disorder in children and adolescents.

Pediatric Bipolar Disorder

In the past decade, interest in and research on pediatric bipolar disorder (BD) has increased substantially. Prevalence rates of the disorder have doubled in outpatient settings, while twice as many research articles on pediatric BD were published in the past five years as in the prior decade. This review focuses on recent developments in the study of pediatric BD. We examine current research on the diagnostic boundaries of BD in youths, in particular the issues of episodicity and irritability, and provide assessment guidelines. We review data elucidating the pathophysiology of pediatric BD, with a focus on how these results may inform diagnosis. Finally, we discuss treatment approaches for pediatric BD, particularly psychotherapeutic interventions. Throughout the review, we pay particular attention to youths with severe chronic irritability, hyperarousal, and hyperreactivity, who reflect the population in whom the diagnosis of BD is most debated.

Diagnosis and classification of pediatric bipolar disorder

BACKGROUND

Many children and adolescents with apparent bipolar disorder cannot be meaningfully diagnosed using the DSM-IV. The variety of pediatric bipolar phenotypes observed in clinical practice remains unclarified.

METHOD

130 consecutively evaluated bipolar children and adolescents were assessed using semistructured clinical interviews and operational criteria that abandoned adherence to the DSM-IV cardinal symptom, duration of symptom persistence, and episodicity requirements.

RESULTS

97.6% of the total sample manifested either all three, or two of the three symptoms elation, grandiosity, and racing thoughts, when manic. 96.9% of the total sample exhibited five or more of the eight DSM-IV criterion symptoms when manic. 52.3% of the subjects manifested ultradian cycling; 22.3% manifested chronic mania or chronic simultaneous manic mixed conditions. Only 21.5% could be classified within the Leibenluft et al. [Leibenluft, E., Charney, D.S., Towbin, K.E., Bhangoo, R.K., Pine, D.S., 2003. Defining clinical phenotypes of juvenile mania. Am. J. Psychiatry 160, 430-437.] system. Problematic distractibility-inattention was present in 89.9% and recurrent rage attacks in 48.5% of the total sample. Older subjects exhibited significantly more depressive symptoms, and nonsignificantly greater prevalences of major depression, severe depression, and ultradian cycling than did younger subjects. The number of depressive symptoms was significantly correlated with ultradian cycling.

LIMITATIONS

This study relied upon retrospective as well as current reports of symptoms. The study results cannot be generalized to community samples.

CONCLUSIONS

We propose two testable hypotheses: (1) that the recurrent, or chronic, simultaneous presence of any two of the symptoms elation, grandiosity, and racing thoughts and a total of five DSM-IV manic symptoms (without specific cardinal symptom, duration, or episodicity requirements) will identify nearly all clinic-referred bipolar children and adolescents; and (2) that a comprehensive classification of pediatric bipolar phenotypes based upon pattern of manic symptom episodicity or chronicity and degree of depression will identify subtypes of pediatric bipolar disorder that have greater correspondence with treatment response than do those of the DSM-IV classification. Problematic distractibility-inattention and explosive irritability-rage are highly prevalent; their presences should be specified when indicated.

Preschool Bipolar Disorder: Brazilian children case reports

OBJECTIVE

This study describes the clinical phenomenology and family history of preschool age onset Bipolar Disorder (BD).

METHODS

Eight children and adolescents out of 118 cases (6.78%), both genders, meeting current DSM-IV criteria diagnosis of BD were described. The clinical assessment, CBCL, DICA-IV and CGAS were performed directly with each patient and their parents.

RESULTS

Most (87.5%) presented classical symptoms of mania: euphoria, grandiosity, irritability, psychomotor agitation and agitated sleep or, in the same proportion, sleeplessness. Hyperactivity and increase of energy were found in all eight cases. The clinical course varied from a rapid, ultra-rapid, ultradian cycle to a continued pattern. Five out of eight children (62.5%) presented aggressiveness toward others and one deliberate self-harm. Most (87.5%) had psychiatric family history. The average number of medications used during their life was 4.5 drugs.

LIMITATION

The small sample and retrospective reports of the first manic symptoms in three of the cases (cases V, VI and VII).

CONCLUSION

An important incidence of classical manic features was found in very young children. The clinical course tended to be continuous, and preschool BD seems to have a strong association with affective disorder family history.

White matter abnormalities in children with and at risk for bipolar disorder

OBJECTIVES

Diffusion tensor magnetic resonance imaging (DT-MRI) assesses the integrity of white matter (WM) tracts in the brain. Children with bipolar disorder (BPD) may have WM abnormalities that precede illness onset. To more fully examine this possibility, we scanned children with DSM-IV BPD and compared them to healthy peers and children at risk for BPD (AR-BPD), defined as having a first-degree relative with the disorder.

METHODS

Ten children with BPD, eight healthy controls (HC), and seven AR-BPD, similar in age, had MRI scans on a 1.5 Tesla GE scanner, including a standard DT-MRI sequence (T2-EPI) with 25 axial slices. Fractional anisotropy (FA) values were compared between groups to determine regions of significant difference (p < 0.05).

RESULTS

Compared to HC, children with BPD had decreased FA in right and left superior frontal tracts, including the superior longitudinal fasciculus I (SLF I) and the cingulate-paracingulate WM (CG-PAC(WM)). In addition, the BPD group had reduced FA in left orbital frontal WM and the right corpus callosum body. Compared to AR-BPD, children with BPD showed reduced FA in the right and left CG-PAC(WM). Both the BPD and AR-BPD groups showed reduced FA relative to HC in bilateral SLF I.

CONCLUSIONS

The bilateral SLF I finding in both the BPD and AR-BPD groups may represent a trait-based marker or endophenotype of the disorder. The finding of decreased FA in the right and left CG-PAC(WM) in children with BPD compared to the other two groups may represent a disease-state related finding.

Post-traumatic stress disorder among adolescents with bipolar disorder and its relationship to suicidality

OBJECTIVES

The aims of this cross-sectional pilot study were to ascertain the rates of post-traumatic stress disorder (PTSD) among adolescents with bipolar disorder (BPD) and major depressive disorder (MDD) relative to a comparison group comprised of non-affectively ill patients, and to determine whether PTSD is related to suicidal ideation and attempts. The impetus for the study was born of clinical impressions derived in the course of routine clinical practice.

METHODS

Patients were screened by a single interviewer for BPD, MDD and PTSD, panic disorder, obsessive-compulsive disorder (OCD) and social phobia using the apposite modules from the Structured Clinical Interview for DSM-IV (SCID) and histories of suicidal ideation and attempts. The data were subjected to analysis using a logistic regression model.

RESULTS

The database included 34 patients with BPD, 79 with MDD and 26 with a non-affective disorder. The risk for PTSD for a patient with BPD significantly exceeded that for a patient with MDD [odds ratio (OR) = 4.9, 95% confidence interval (CI) = 1.9-12.2, p = 0.001]. Patients with PTSD had an insignificantly increased risk for suicidal ideation (OR = 2.8, 95% CI = 0.9-8.9, p = 0.069), and a 4.5-fold significantly increased risk of having had a suicide attempt (OR = 4.5, 95% CI = 1.7-11.7, p = 0.002). The relationship between PTSD and suicide attempts remained significant even after controlling for the confounding effects of concurrent panic disorder, OCD and social phobia (OR = 3.4, 95% CI = 1.1-10.0, p = 0.023).

CONCLUSIONS

Patients with BPD have a greater risk for PTSD than those with MDD. Post-traumatic stress disorder is significantly related to history of suicide attempts.

Clinical characteristics of bipolar disorder in very young children

BACKGROUND

Clinical information about bipolar disorder (BPD) in preschool-age (3-7 years old) children is extremely limited. This study examined clinical presentations, applicability of the DSM-IV diagnostic criteria, comorbidity, recovery and relapse rates, as well as some treatment strategies used in the management of BPD in preschoolers.

METHODS

The charts of 26 outpatient children, ages 3-7, refereed to a child psychiatry outpatient clinic with mood and behavioral symptoms, were retrospectively reviewed.

RESULTS

The majority of the patients were referred with the tentative diagnosis of ADHD but the most common diagnoses made by child and adolescent psychiatrists at the time of initial evaluation were BPD NOS (61.5%), followed by BPD I (26.9%), and mood disorder NOS (23.1%). Thirty-eight percent of the patients had one or more comorbid diagnoses. The most common presenting symptoms were irritability (84.6%) and aggression (88.5%). The most widely prescribed class of medications after diagnosis in the clinic was atypical antipsychotics and mood stabilizers. Twenty-six percent of the patients were treated with a combination of atypical antipsychotics and mood stabilizers.

LIMITATIONS

Retrospective design; small sample size; lack of a comparison group.

CONCLUSIONS

The course of BPD with onset in preschool years is complicated with high recovery and relapse rates. The questions of development of age-appropriate diagnostic criteria, long-term prognosis and treatment strategies used in this population require further intensive investigation.

Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder

This practice parameter reviews the literature on the assessment and treatment of children and adolescents with bipolar disorder. The parameter focuses primarily on bipolar 1 disorder because that is the type most often studied in juveniles. The presentation of bipolar disorder in youth, especially children, is often considered atypical compared with that of the classic adult disorder, which is characterized by distinct phases of mania and depression. Children who receive a diagnosis of bipolar disorder in community settings typically present with rapid fluctuations in mood and behavior, often associated with comorbid attention-deficit/hyperactivity disorder and disruptive behavior disorders. Thus, at this time it is not clear whether the atypical forms of juvenile mania and the classic adult form of the disorder represent the same illness. The question of diagnostic continuity has important treatment and prognostic implications. Although more controlled trials are needed, mood stabilizers and atypical antipsychotic agents are generally considered the first line of treatment. Although patients may respond to monotherapy, combination pharmacotherapy is necessary for some youth. Behavioral and psychosocial therapies are also generally indicated for juvenile mania to address disruptive behavior problems and the impact of the illness on family and community functioning.

Dose-response relationship between number of comorbid anxiety disorders in adolescent bipolar/unipolar disorders, and psychosis, suicidality, substance abuse and familiality

OBJECTIVES

To ascertain rates of panic, obsessive-compulsive (OCD) and social phobic disorders among adolescents with bipolar disorder (BP), unipolar major depressive disorder (MDD) and psychiatric comparison patients, to assess their relationships to suicidality, psychosis, comorbidity patterns and familiality.

METHODS

The first author (SCD) interviewed 313 Latino adolescents using a structured interview based on the SCID. Family history was ascertained by live interview or interview by proxy. Patients were classified as BP, MDD, or non-affectively ill comparison controls (CC). Data regarding suicidality and psychosis were collected. Regression analysis was used to test associations and control for confounding effects. Positive likelihood ratios were used to measure the dose-response relationships between number of anxiety disorders and measures of severity of illness and familial loading for affective illness.

RESULTS

Of the total sample, 36.7% were BP, 44.7% MDD and 18.5% CC. In BP vs. MDD the odds of panic disorder were 4.4, of OCD 5.1, and of social phobia 3.3. MDD, in turn, were more likely to have these disorders than CC. BP (but not MDD) with panic disorder and social phobia, were more likely to have suicidal ideation; among the anxiety disorders, only social phobia was associated with having greater odds of suicide attempts. Among BP and MDD, patients with all three anxiety disorders were more likely to be psychotic. Presence of any mood disorder among first-degree relatives substantially increased the odds of having panic disorder and social phobia. The presence of one comorbid anxiety disorder increased the odds of having another. Finally, there were dose-response relationships between number of anxiety disorders and measures of severity of illness and familial loading for affective illness.

LIMITATIONS

Single interviewer using the SCID; cross sectional exploratory study.

CONCLUSIONS

BP adolescents have a greater anxiety disorder burden than their MDD counterparts. The results are compatible with the hypothesis that heavy familial-genetic loading for affective illness in juveniles is associated with bipolarity, cumulative anxiety disorder comorbidity, suicidality and psychosis. These observations are in line with pioneering psychopathologic observation in the early 1900s by two French psychiatrists, Gilbert Ballet and Pierre Kahn, who saw common ground between what until then had been considered the distinct categories of the neuroses and cyclothymic (circular) psychoses. This perspective has much in common with current complex genetic models of anxious diatheses in bipolar disorder.

Developmental differences according to age at onset in juvenile bipolar disorder

BACKGROUND

This study on a large sample of unselected, consecutive children and adolescents referred to a third-level hospital who received a diagnosis of bipolar disorder (BD) was aimed at exploring whether childhood-onset BD, as compared with adolescent-onset BD, presents specific clinical features in terms of severity, functional impairment, course, prevalent mood, pattern of co-morbidity, and treatment outcome.

METHODS

A total of 136 patients, 81 males (59.6%) and 55 females (40.4%), mean age 13.5 +/- 2.9 years, meeting the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnosis of BD according to a structured clinical interview Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (KSADS-PL), were included in the study.

RESULTS

Eighty patients (58.8%) had a childhood-onset BD (before 12 years of age) and 56 (41.2%) had an adolescents-onset BD. Compared with the adolescent-onset BD, patients with childhood-onset were more frequently males and had a more frequent co-morbidity with attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). An episodic course was found in only 42.5% of bipolar children, but 76.8% of youngsters with adolescent-onset BD. Severity, 6-month treatment outcome, prevalent mood (elated versus irritable), and co-morbid anxiety did not differentiate the two groups.

CONCLUSIONS

Our findings suggest that a very early age at onset may identify a form of BD with a more frequent subcontinuous course and a heavy co-morbidity with ADHD.

"Crying alone with my child:" parenting a school age child diagnosed with bipolar disorder

Recent years have seen a rise in the number of children diagnosed at an early age with bipolar disorder and evidence is increasing that parents are performing most of the caregiving and illness management. This existential phenomenological study describes the personal experience of the parents whose children, age 6-11 years, are diagnosed with Bipolar Disorder. The thematic structure that emerged revealed that the parents in this study, strong advocates for their children, were experiencing unrelenting fear, frustration, loneliness, and hurt. The considerable health implications, affecting both the parent and the child, of lack of respite, loss of self, asynchrony, and chronic fear are discussed. Based on the findings of this study, the psychiatric nurse is in an ideal position to increase interventions that are supportive of parents.

The clinical phenotypes of juvenile bipolar disorder: toward a validation of the episodic-chronic-distinction

BACKGROUND

Recent research has addressed the issue of subtyping juvenile bipolar disorder (JBD). Accordingly, we set out to find out, in a naturalistic sample of bipolar children and adolescents with mania and mixed mania, whether the most useful subtyping should be based on clinical features (elated vs. irritable) or course (episodic vs. chronic).

METHODS

We studied 136 patients, 81 male patients (59.6%) and 55 female patients (40.4%), mean age 13.5 +/- 2.9 years, meeting the DSM-IV diagnosis of bipolar disorder, assessed by a structured clinical interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version [K-SADS-PL]).

RESULTS

Regarding course, 77 patients (56.6%) had an episodic course and 59 patients (43.4%) had a chronic course. Patients with chronic course were significantly younger, had an earlier onset of JBD, and presented a more frequent comorbidity with disruptive behavior disorders. According to the prevalent mood disturbance, 75 patients (55.1%) showed an elated and 61 patients (44.9%) showed an irritable mood. Elated mood was more frequent in patients with episodic course, whereas irritable mood was more frequent in the patients with chronic course.

CONCLUSIONS

These findings suggest that chronic versus episodic course may be a putative differential feature. Further validation of such a distinction would require prospective studies, temperament evaluation, gender and neurobiologic approaches, and differential psychopharmacologic assignment and response.

Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology

We review recent research on the presentation, nosology and epidemiology of behavioral and emotional psychiatric disorders in preschool children (children ages 2 through 5 years old), focusing on the five most common groups of childhood psychiatric disorders: attention deficit hyperactivity disorders, oppositional defiant and conduct disorders, anxiety disorders, and depressive disorders. We review the various approaches to classifying behavioral and emotional dysregulation in preschoolers and determining the boundaries between normative variation and clinically significant presentations. While highlighting the limitations of the current DSM-IV diagnostic criteria for identifying preschool psychopathology and reviewing alternative diagnostic approaches, we also present evidence supporting the reliability and validity of developmentally appropriate criteria for diagnosing psychiatric disorders in children as young as two years old. Despite the relative lack of research on preschool psychopathology compared with studies of the epidemiology of psychiatric disorders in older children, the current evidence now shows quite convincingly that the rates of the common child psychiatric disorders and the patterns of comorbidity among them in preschoolers are similar to those seen in later childhood. We review the implications of these conclusions for research on the etiology, nosology, and development of early onset of psychiatric disorders, and for targeted treatment, early intervention and prevention with young children.

Delayed diagnosis of pediatric bipolar disorder in a community mental health setting

OBJECTIVE

There is evidence that delayed diagnosis is a significant problem in adult bipolar disorder. It is not known if this also occurs among pediatric patients with this illness. The goal of this study was to determine the frequency of delayed and missed diagnosis of pediatric bipolar disorder in a community mental health setting.

METHOD

Charts of youths with a diagnosis of bipolar I or II disorder, cyclothymia, or bipolar disorder not otherwise specified (NOS) who were treated at a community mental health outpatient clinic between February 2000 and April 2003 were retrospectively reviewed.

RESULTS

The mean number of years from the onset of mood symptoms until diagnosis of bipolar disorder was 5 years (SD = 3.5), with a maximum of 12 years. Only 2 patients (4.8%) received the correct diagnosis within the first year following symptom onset. For 33 patients (78.6%), 2 or more years elapsed, for 22 patients (52.4%) 5 or more years elapsed, and for 7 patients (16.7%) 10 or more years elapsed before they were diagnosed correctly.

CONCLUSIONS

Although the study has several limitations, it suggests that delayed and missed diagnosis may be common among pediatric patients with bipolar disorder who receive treatment in community mental health settings. More rigorous studies are warranted and clinicians who work with pediatric patients should be aware of the risk of misdiagnosis of bipolar disorder in this population.