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Serra G, Apicella M, Andracchio E, Della Santa G, Lanza C, Trasolini M, Iannoni ME, Maglio G, Vicari S. Factors Associated with High Parent- and Youth-Rated Irritability Score in Early-Onset Mood Disorders: A Cross-Sectional Study with the Affective Reactivity Index (ARI). Brain Sci 2024; 14:611. [PMID: 38928611 PMCID: PMC11201410 DOI: 10.3390/brainsci14060611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 06/03/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024] Open
Abstract
Correct classification of irritability is extremely important to assess prognosis and treatment indications of juvenile mood disorders. We assessed factors associated with low versus high parent- and self-rated irritability using the affective reactivity index (ARI) in a sample of 289 adolescents diagnosed with a bipolar or a major depressive disorder. Bivariate analyses were followed by multilinear logistic regression model. Factors significantly and independently associated with high versus low parent-rated ARI score were: more severe emotional dysregulation and bipolar disorders diagnosis. Factors significantly and independently associated with high versus low self-rated ARI score were: lower children depression rating scale (CDRS-R) difficulty of having fun item score, greater children depression inventory (CDI-2) self-report score, more severe emotional dysregulation, and greater CDRS-R appetite disturbance item score. High parent-rated irritability was strictly related with a bipolar disorder diagnosis, whereas high youth-rated irritability was related to depressive phenotype characterized by appetite/food-intake dysregulation, mood lability, and less anhedonia and apathy.
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Affiliation(s)
- Giulia Serra
- Child & Adolescent Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (E.A.); (G.D.S.); (C.L.); (M.T.); (M.E.I.); (G.M.); (S.V.)
| | - Massimo Apicella
- Child & Adolescent Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (E.A.); (G.D.S.); (C.L.); (M.T.); (M.E.I.); (G.M.); (S.V.)
- Department of Neuroscience, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Elisa Andracchio
- Child & Adolescent Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (E.A.); (G.D.S.); (C.L.); (M.T.); (M.E.I.); (G.M.); (S.V.)
| | - Giorgia Della Santa
- Child & Adolescent Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (E.A.); (G.D.S.); (C.L.); (M.T.); (M.E.I.); (G.M.); (S.V.)
| | - Caterina Lanza
- Child & Adolescent Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (E.A.); (G.D.S.); (C.L.); (M.T.); (M.E.I.); (G.M.); (S.V.)
| | - Monia Trasolini
- Child & Adolescent Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (E.A.); (G.D.S.); (C.L.); (M.T.); (M.E.I.); (G.M.); (S.V.)
| | - Maria Elena Iannoni
- Child & Adolescent Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (E.A.); (G.D.S.); (C.L.); (M.T.); (M.E.I.); (G.M.); (S.V.)
| | - Gino Maglio
- Child & Adolescent Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (E.A.); (G.D.S.); (C.L.); (M.T.); (M.E.I.); (G.M.); (S.V.)
| | - Stefano Vicari
- Child & Adolescent Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (E.A.); (G.D.S.); (C.L.); (M.T.); (M.E.I.); (G.M.); (S.V.)
- Department of Life Science and Public Health, Catholic University of the Sacred Heart, 00168 Rome, Italy
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2
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Abel MR, Henin A, Holmén J, Kagan E, Hamilton A, Noyola N, Hirshfeld-Becker DR. Anxiety and Disruptive Behavior Symptoms and Disorders in Preschool-Age Offspring of Parents With and Without Bipolar Disorder: Associations With Parental Comorbidity. J Atten Disord 2024; 28:625-638. [PMID: 38084063 DOI: 10.1177/10870547231215288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
OBJECTIVE We examined the relative contribution of parental bipolar disorder (BPD) and psychiatric comorbidities (disruptive behavior disorders [DBD] and anxiety disorders) in predicting psychiatric symptoms and disorders in 2-5-year-old offspring. METHODS Participants were 60 families with a parent with BPD and 78 offspring and 70 comparison families in which neither parent had a mood disorder and 91 offspring. Parent and offspring diagnoses and symptoms were assessed using standardized diagnostic interviews and measures, with offspring assessors masked to parental diagnoses. RESULTS Offspring of parents with BPD had significant elevations in behavioral, mood and anxiety disorders and symptoms. Both parental BPD and DBD contributed to elevations in child disruptive behavioral symptoms, whereas child anxiety symptoms were more strongly predicted by comorbid parental anxiety. Parental BPD was a stronger predictor than comorbid DBD of child DBDs. CONCLUSION Some of the elevated risk for disorders in preschoolers is accounted for by parental comorbidity.
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Affiliation(s)
- Madelaine R Abel
- Child Cognitive Behavioral Therapy Program, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Aude Henin
- Child Cognitive Behavioral Therapy Program, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Jordan Holmén
- Child Cognitive Behavioral Therapy Program, Massachusetts General Hospital, Boston, MA, USA
- St. John's University, New York, NY, USA
| | - Elana Kagan
- Child Cognitive Behavioral Therapy Program, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Antonia Hamilton
- Child Cognitive Behavioral Therapy Program, Massachusetts General Hospital, Boston, MA, USA
- Syracuse University, New York, NY, USA
| | - Nestor Noyola
- Child Cognitive Behavioral Therapy Program, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Dina R Hirshfeld-Becker
- Child Cognitive Behavioral Therapy Program, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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3
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O'Connor H, Hutt Vater C, DiSalvo M, Faraone SV, Wozniak J. Stimulant Treatment and Potential Adverse Outcomes in Pediatric Populations With Bipolar Disorder: A Systematic Review of the Literature. J Atten Disord 2024; 28:740-750. [PMID: 38156605 DOI: 10.1177/10870547231218045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To explore outcomes of stimulant treatment for ADHD in pediatric populations with particular attention to bipolar disorder (BPD). METHOD We conducted a literature search of PubMed articles published prior to August 25, 2022 that focused on BPD, mania, and psychosis prior to, or as result of, stimulant treatment. We excluded studies: (1) unrelated to stimulants, (2) general stimulant research, (3) articles older than 40 years, (4) study protocols, or (5) case reports. RESULTS A total of 11 articles met all inclusion/exclusion criteria. Some reports found stimulant treatment safe and well-tolerated in children with comorbid BPD and ADHD. Others found evidence of treatment-emergent mania (TEM), discontinuation, and other adverse events with stimulant treatment. CONCLUSION Poor outcomes associated with stimulant treatment in pediatric populations with BPD necessitate work to identify patients at risk of serious stimulant-related adverse events. Our results were limited by automated search filters and a pediatric, primarily male sample.
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Affiliation(s)
| | | | | | | | - Janet Wozniak
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
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Frahm Laursen M, Correll CU, Licht RW, Rodrigo-Domingo M, Pagsberg AK, Nielsen RE. Characteristics prior to and at time of diagnosis in pediatric bipolar disorder. Nord J Psychiatry 2022; 77:282-292. [PMID: 35816446 DOI: 10.1080/08039488.2022.2096112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Describe symptoms before and at time of register-diagnosis in children and adolescents. METHODS A random sample was selected for chart-review from a Danish nationwide cohort of patients <18 years registered with an incident ICD-10 register-diagnosis of single hypomanic/manic episode or bipolar disorder between 1995 and 2014. Patients with symptoms which adequately documented a BD diagnosis in the chart were included for analysis. RESULTS 521 were diagnosed in the study period. A random sample of 25% were selected, and 106 charts were possible to retrieve, with 48 chart reviews resulting in confirmation of diagnosis. Time from first reported affective symptoms to diagnosis was 2.6 ± 2.7 years for depressive symptoms, 2.5 ± 2.9 years for mixed symptoms, 1.4 ± 1.6 years for hypomanic symptoms, and 0.4 ± 0.5 years for manic symptoms. A hierarchical clustering analysis revealed three patient-profiles: primarily hypomanic/manic, primarily depressive, and more rare, primarily mixed profile. Frequently reported symptoms prior to diagnosis include anhedonia (79%), irritability (71%), hyperactivity (62.5%), decreased energy (62.5%), and psychotic symptoms (52%).Symptoms of ADHD (19%), comorbid ADHD (15%), symptoms of anxiety (52%), comorbid anxiety (4%), suicidal thoughts (50%), suicide attempts (8%), cutting (23%), substance misuse (21%), and criminal activity (10%) were reported before incident BD diagnosis. CONCLUSION The observed patient-profiles leading to diagnosis were primarily manic or depressive, resembling presentations in adults. The presence of ADHD, anxiety, suicide attempts, cutting, and criminal activity prior to diagnosis emphasizes the need for treatment of children and adolescents with affective symptoms. The gap from appearance of the symptoms to diagnosis suggests a window for earlier treatment.
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Affiliation(s)
- Mathilde Frahm Laursen
- Unit for Psychiatric Research, Psychiatry, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Christoph U Correll
- Psychiatry Research, Northwell Health, The Zucker Hillside Hospital, New York, NY, USA.,Department of Psychiatry and Molecular Medicine, Zucker School of Medicine, Hempstead, NY, USA.,Center for Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA.,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Rasmus W Licht
- Unit for Psychiatric Research, Psychiatry, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - María Rodrigo-Domingo
- Unit for Psychiatric Research, Psychiatry, Aalborg University Hospital, Aalborg, Denmark
| | - Anne Katrine Pagsberg
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - René Ernst Nielsen
- Unit for Psychiatric Research, Psychiatry, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Psychiatry, Aalborg University Hospital, Aalborg, Denmark
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Wozniak J, DiSalvo M, Farrell A, Vaudreuil C, Uchida M, Ceranoglu TA, Joshi G, Cook E, Faraone SV, Biederman J. Findings from a pilot open-label trial of N-acetylcysteine for the treatment of pediatric mania and hypomania. BMC Psychiatry 2022; 22:314. [PMID: 35505312 PMCID: PMC9066881 DOI: 10.1186/s12888-022-03943-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 04/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pediatric bipolar disorder is a highly prevalent and morbid disorder and is considered a prevalent public health concern. Currently approved treatments often pose the risk of serious side effects. Therefore, this study assessed the efficacy and tolerability of N-acetylcysteine (NAC), in children and adolescents with bipolar spectrum disorder. METHODS We conducted a 12-week open-label trial of NAC for treatment of mania and hypomania in children and adolescents ages 5-17 with bipolar spectrum disorder including participants with full and subthreshold manic symptoms, accepting those with and without mixed states with co-occurring depression, and Young Mania Rating Scale scores ≥ 20 and < 40. Symptoms of mania and depression were assessed using the Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HDRS), Children's Depression Rating Scale (CDRS), and Clinical Global Impression (CGI) Severity (CGI-S) and Improvement (CGI-I) scales for mania and depression. RESULTS This study had a high drop-out rate with only 53% completing all 12 weeks. There was a significant reduction in YMRS, HDRS, and CDRS mean scores from baseline to endpoint. Of the 24 exposed participants, 54% had an anti-manic response measured by a reduction in YMRS ≥ 30% and 46% had a CGI-I mania score ≤ 2 at endpoint. Additionally, 62% of participants had an anti-depressive response measured by a reduction in HDRS ≥ 30%, 31% had an anti-depressive response measured by a reduction in CDRS ≥ 30%, and 38% had a CGI-I depression score ≤ 2 at endpoint. CONCLUSIONS These pilot open-label findings in a small sample provide preliminary data supporting the tolerability and safety of NAC in a pediatric population. The findings of this pilot scale study indicating improvement in mania and depression are promising, but require replication with a monotherapy randomized placebo controlled clinical trial and larger sample. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02357290 . First Registration 06/02/2015.
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Affiliation(s)
- Janet Wozniak
- Clinical and Research Program in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, 55 Fruit St., Warren 705, Boston, MA, USA. .,Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Maura DiSalvo
- grid.32224.350000 0004 0386 9924Clinical and Research Program in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, 55 Fruit St., Warren 705, Boston, MA USA
| | - Abigail Farrell
- grid.32224.350000 0004 0386 9924Clinical and Research Program in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, 55 Fruit St., Warren 705, Boston, MA USA
| | - Carrie Vaudreuil
- grid.32224.350000 0004 0386 9924Clinical and Research Program in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, 55 Fruit St., Warren 705, Boston, MA USA ,grid.38142.3c000000041936754XDepartment of Psychiatry, Harvard Medical School, Boston, MA USA
| | - Mai Uchida
- grid.32224.350000 0004 0386 9924Clinical and Research Program in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, 55 Fruit St., Warren 705, Boston, MA USA ,grid.38142.3c000000041936754XDepartment of Psychiatry, Harvard Medical School, Boston, MA USA
| | - T. Atilla Ceranoglu
- grid.32224.350000 0004 0386 9924Clinical and Research Program in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, 55 Fruit St., Warren 705, Boston, MA USA ,grid.38142.3c000000041936754XDepartment of Psychiatry, Harvard Medical School, Boston, MA USA
| | - Gagan Joshi
- grid.32224.350000 0004 0386 9924Clinical and Research Program in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, 55 Fruit St., Warren 705, Boston, MA USA ,grid.38142.3c000000041936754XDepartment of Psychiatry, Harvard Medical School, Boston, MA USA
| | - Emmaline Cook
- grid.32224.350000 0004 0386 9924Clinical and Research Program in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, 55 Fruit St., Warren 705, Boston, MA USA
| | - Stephen V. Faraone
- grid.411023.50000 0000 9159 4457Department of Psychiatry and Behavioral Sciences, SUNY Upstate Medical University, Syracuse, NY USA
| | - Joseph Biederman
- grid.32224.350000 0004 0386 9924Clinical and Research Program in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, 55 Fruit St., Warren 705, Boston, MA USA ,grid.38142.3c000000041936754XDepartment of Psychiatry, Harvard Medical School, Boston, MA USA
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6
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Sherwood SN, Carlson GA, Freeman AJ. Decreasing rate of inpatient pediatric bipolar disorder diagnosis in the US between 2004 and 2010. Bipolar Disord 2022; 24:149-160. [PMID: 34664344 DOI: 10.1111/bdi.13145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/05/2021] [Accepted: 10/09/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Diagnosis of bipolar disorder (BD) increased substantially among youth between the mid-1990s and mid-2000s in the United States. This dramatic increase in diagnosis resulted in concern regarding the potential for misdiagnosis of BD among youth. However, the rate of BD diagnosis in the United States had not been evaluated nationally since the mid-2000s. It was unclear whether changes in diagnostic rates continued to occur. Therefore, the present study aimed to assess the pattern of longitudinal trends in the rate of national inpatient BD diagnosis subsequent to 2004. METHODS Data included a nationally representative dataset of inpatient hospitalizations between 1996 and 2010. De-identified data were obtained from the National Hospital Discharge Survey (NHDS) conducted annually by the National Center for Health Statistics. RESULTS The proportion of BD diagnoses relative to all psychiatric diagnoses increased between 1996 and 2004 among children and adolescents. The proportion of BD diagnoses then decreased between 2004 and 2010 among children but continued to increase for adolescents. However, population-adjusted rates of BD diagnosis per 10,000 individuals in the general population initially increased until the mid-2000s and then decreased until 2010 for both children and adolescents. CONCLUSIONS Rates of BD diagnosis substantially decreased for youth between the mid-2000s and 2010. This decline coincided with recommendations for more conservative diagnostic practices due to concerns about overdiagnosis and increasing awareness of the side effects of front-line medications used to treat BD in youth. Findings provide insight into changing trends in inpatient service utilization for BD in the United States.
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Affiliation(s)
| | - Gabrielle A Carlson
- Psychiatry and Pediatrics, State University of New York at Stony Brook, East Setauket, New York, USA
| | - Andrew J Freeman
- Department of Psychology, University of Nevada, Las Vegas, Nevada, USA.,Division of Child and Family Services, Nevada Department of Health and Human Services, Las Vegas, Nevada, USA
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Laursen MF, Correll CU, Licht RW, Rodrigo-Domingo M, Pagsberg AK, Ernst Nielsen R. Occurrence and accuracy of a register-based diagnosis of pediatric bipolar disorder: A nationwide cohort study. Aust N Z J Psychiatry 2021; 55:1101-1108. [PMID: 33951969 DOI: 10.1177/00048674211009622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate the accuracy of a diagnosis of pediatric bipolar disorder in the Danish National Register compared to the patient charts. Second, we reported on the occurrence of a diagnosis of pediatric bipolar disorder during the study period. METHODS All persons appearing in the Danish nationwide registers between 1995 and 2014 with an incident ICD-10 diagnosis of single hypomanic/manic episode or a diagnosis of bipolar disorder (summarized as bipolar disorder [BD]) before turning 18 years were identified (n = 521) and a random sample (n = 131) hereof was selected for chart review. Each chart was reviewed by two independent Schedules for Clinical Assessment in Neuropsychiatry (SCAN) certified raters to assess whether symptoms documented in the chart were consistent with a formal diagnosis of BD according to the ICD-10 criteria or not. RESULTS The formal diagnostic criteria for BD according to the ICD-10 were fulfilled in 48 charts (45.3%, 95% CI: [36.1%, 54.8%]) out of 106 reviewable charts, age at index = 16.4 ± 1.6 (range = 9.1-18.3) years. Cohen's Kappa ranged from 94.4% to 100%. The estimate of a lifetime prevalence up till the current age for bipolar disorder for those of aged 5-18 years, was 0.019% in 2014. CONCLUSION Less than half of the register-based pediatric BD diagnoses were confirmed by chart review, which was lower than expected. The occurrence of a register diagnosis of pediatric BD was relatively low.
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Affiliation(s)
- Mathilde Frahm Laursen
- Unit for Psychiatric Research, Department of Psychiatry, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Christoph U Correll
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, New York, NY, USA.,Department of Psychiatry and Molecular Medicine, Zucker School of Medicine, Hempstead, NY, USA.,Center for Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA.,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Rasmus W Licht
- Unit for Psychiatric Research, Department of Psychiatry, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Maria Rodrigo-Domingo
- Unit for Psychiatric Research, Department of Psychiatry, Aalborg University Hospital, Aalborg, Denmark
| | - Anne Katrine Pagsberg
- Child and Adolescent Mental Health Center, Mental Health Services, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - René Ernst Nielsen
- Unit for Psychiatric Research, Department of Psychiatry, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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8
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A novel multidimensional questionnaire for the assessment of emotional dysregulation in adolescents: Reactivity, Intensity, Polarity and Stability questionnaire-youth version (RIPoSt-Y). J Affect Disord 2021; 291:359-367. [PMID: 34089928 DOI: 10.1016/j.jad.2021.05.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/09/2021] [Accepted: 05/23/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The failure to regulate emotions, namely emotional dysregulation (ED), is a relevant construct in adolescent psychiatry, in terms of prognostic and developmental implications. We developed and validated a novel self-report questionnaire for the assessment of ED, the RIPoSt-Y, both in clinical and non-clinical samples. METHODS Items selection and subscales construction were conducted on healthy controls (n=374), while test-retest reliability was evaluated in a subsample (n=72); internal consistency was examined both in the control group and in two clinical samples, respectively including patients with Bipolar Spectrum Disorders (BSD; n=44) and ADHD (n=34). Construct, concurrent and convergent validity were also assessed. RESULTS Thirty-one items were finally retained, and three subscales were identified (Affective Instability, Emotional Reactivity, Interpersonal Sensitivity). Test-retest was significant for each subscale with moderate-to-good correlations, and internal consistency showed good-to-excellent coefficients. Construct validity was supported by significant differences between patients and controls and gender-related differences. Concurrent validity was confirmed through significant associations with two subscales of the CHT-Q, while convergent validity proved to be significant with the CBCL/YSR dysregulation-profile. Cut-offs were also computed to discriminate clinically significant scores of ED. LIMITATIONS The use of a school-based survey to recruit controls could have biased our results; gender distributions between clinical and non-clinical samples were significantly different. CONCLUSIONS Our novel questionnaire proved to be a valid and reliable tool able to assess the presence of ED in youths and to characterize this fundamental construct in its multidimensional facets.
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Tatsiopoulou P, Porfyri GN, Bonti E, Diakogiannis I. Childhood ADHD and Early-Onset Bipolar Disorder Comorbidity: A Case Report. Brain Sci 2020; 10:E883. [PMID: 33233667 PMCID: PMC7699781 DOI: 10.3390/brainsci10110883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/11/2020] [Accepted: 11/18/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Recent research has highlighted an increased rate of co-morbidity between the neurodevelopmental-behavioral disorder of attention deficit hyperactivity disorder (ADHD) and a variety of psychiatric disorders, such as mood disorders or bipolar disorder (BD). The etiology and clinical course of BD are considered to be determined by both genetic and environmental factors, either aggravating or improving. AIM This follow-up study of an adolescent aimed to clarify the co-morbidity between ADHD and BD. We also discuss the controversies surrounding the two diagnoses in younger populations and describe several aspects of concern regarding diagnosis, differential diagnosis, therapeutic planning/intervention, and prognosis. METHODS Reporting of a two-year follow-up study of a bipolar 15-year-old female patient with a previous diagnosis of ADHD during childhood. RESULTS Despite the occurrence of major risk factors, such as early onset and positive family history, the patient's condition rapidly remitted with medication, without relapse and/or rehospitalization during the following two years, due to the stability of her cooperation, and support of a stable and caring familial environment. Early diagnosis of BD and differential diagnoses of ADHD are considered crucial protective factors leading to an appropriate planning of treatment. In addition, parental involvement and empathic attitude towards the patient supported the latter to cooperate and comply with the treatment, enhancing positive outcomes and stability. CONCLUSIONS Research is required into the reliability and validity of diagnostic protocols and criteria for BD in children and adolescents, and also into the development of individualized therapeutic planning.
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Affiliation(s)
- Paraskevi Tatsiopoulou
- 1st Department of Psychiatry, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital “Papageorgiou”, Ring Road Thessaloniki, N. Efkarpia, 54603 Thessaloniki, Greece; (G.-N.P.); (E.B.); (I.D.)
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10
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Cordeiro ML, Farias AC, Whybrow PC, Felden EPG, Cunha A, da Veiga V, Benko CR, McCracken JT. Receiver Operating Characteristic Curve Analysis of Screening Tools for Bipolar Disorder Comorbid With ADHD in Schoolchildren. J Atten Disord 2020; 24:1403-1412. [PMID: 26721636 DOI: 10.1177/1087054715620897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: We compared Child Behavior Checklist (CBCL)-AAA (Attention Problems, Aggressive Behavior, and Anxious/Depressed) and Parent-Young Mania Rating Scale (P-YMRS) profiles in Brazilian children with ADHD, pediatric-onset bipolar disorder (PBD), and PBD + ADHD. Method: Following analyses of variance or Kruskal-Wallis tests with multiple-comparison Least Significant Difference (LSD) or Dunn's Tests, thresholds were determined by Mann-Whitney U Tests and receiver operating characteristic (ROC) plots. Results: Relative to ADHD, PBD and PBD + ADHD groups scored higher on the Anxious/Depressed, Thought Problems, Rule-Breaking, and Aggressive Behavior subscales and Conduct/Delinquency Diagnostic Scale of the CBCL; all three had similar attention problems. The PBD and PBD + ADHD groups scored higher than the ADHD and healthy control (HC) groups on all CBCL problem scales. The AAA-profile ROC had good diagnostic prediction of PBD + ADHD. PBD and PBD-ADHD were associated with (similarly) elevated P-YMRS scores. Conclusion: The CBCL-PBD and P-YMRS can be used to screen for manic behavior and assist in differential diagnosis.
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Affiliation(s)
- Mara L Cordeiro
- University of California, Los Angeles, USA.,Pelé Pequeno Príncipe Research Institute, Curitiba, Brazil.,Faculdades Pequeno Príncipe, Curitiba, Brazil
| | - Antonio C Farias
- Pelé Pequeno Príncipe Research Institute, Curitiba, Brazil.,Children's Hospital Pequeno Príncipe, Curitiba, Brazil
| | | | | | | | | | - Cássia R Benko
- Pelé Pequeno Príncipe Research Institute, Curitiba, Brazil
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Sahu S, Saldanha D, Chaudhury S, Menon P, Marella S, Kalkat VS. Demographic and psychosocial profile of disruptive mood dysregulation disorder in Indian settings. Ind Psychiatry J 2020; 29:228-236. [PMID: 34158706 PMCID: PMC8188932 DOI: 10.4103/ipj.ipj_226_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/06/2020] [Accepted: 01/19/2021] [Indexed: 11/24/2022] Open
Abstract
AIMS The aim of this study was to assess the demographic and psychosocial profile of the children with and without disruptive mood dysregulation disorder (DMDD) attending psychiatric and pediatric OPD and evaluation of the phenomenology of children diagnosed with DMDD. MATERIALS AND METHODS Children of 6-16 years attending the psychiatric outpatient department were screened by self-made peer-reviewed questionnaire and further underwent diagnostic evaluation using DSM 5 diagnostic criteria. Socioeconomic status (SES) was assessed using the Kuppuswamy scale. Affective Reactivity Index (ARI) was used to measure the severity of irritability. Overall behavioral problems were assessed on Conner's parent rating scale and impairment in functioning on the Children's Global Assessment of Functioning Scale. RESULTS A total of nine subjects were diagnosed with DMDD out of 500. The mean age of children with DMDD was higher than other children. DMDD children had better SES. Multiple psychosocial factors such as broken family, family history of psychiatric illness, and childhood adversities including sexual abuse were found to be a contributory factor. Those diagnosed with DMDD had significant conduct and learning problem along with moderate to severe irritability and a mean CGAS value of 50.66 which implies that children with DMDD had moderate impairment in functioning. CONCLUSIONS DMDD cases have male preponderance, urban background, and belong to upper and middle socioeconomic strata. Conduct problems, academic decline, hyperactivity, impulsivity, and mild degree of impairment in anxiety, along with moderate to severe irritability produce impairment in their overall functioning of these children.
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Affiliation(s)
- Samiksha Sahu
- Department of Psychiatry, Gandhi Medical College and Hamidia Hospital, Bhopal, Madhya Pradesh, India
| | - Daniel Saldanha
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pune, Maharashtra, India
| | - Suprakash Chaudhury
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pune, Maharashtra, India
| | - Preethi Menon
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pune, Maharashtra, India
| | - Shivaji Marella
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pune, Maharashtra, India
| | - Vasdev Singh Kalkat
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pune, Maharashtra, India
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12
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Azorin J, Kaladjian A, Adida M, Fakra E, Belzeaux R, Hantouche E, Lancrenon S. Factors associated with borderline personality disorder in major depressive patients and their relationship to bipolarity. Eur Psychiatry 2020; 28:463-8. [DOI: 10.1016/j.eurpsy.2012.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 11/12/2012] [Accepted: 11/23/2012] [Indexed: 12/31/2022] Open
Abstract
AbstractObjectiveTo analyze the interface between borderline personality disorder (BPD) and bipolarity in depressed patients comorbid with BPD.MethodsAs 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−).ResultsCompared 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.ConclusionsThe 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.
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13
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Jirsaraie RJ, Kaczkurkin AN, Rush S, Piiwia K, Adebimpe A, Bassett DS, Bourque J, Calkins ME, Cieslak M, Ciric R, Cook PA, Davila D, Elliott MA, Leibenluft E, Murtha K, Roalf DR, Rosen AFG, Ruparel K, Shinohara RT, Sotiras A, Wolf DH, Davatzikos C, Satterthwaite TD. Accelerated cortical thinning within structural brain networks is associated with irritability in youth. Neuropsychopharmacology 2019; 44:2254-2262. [PMID: 31476764 PMCID: PMC6897907 DOI: 10.1038/s41386-019-0508-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/01/2019] [Accepted: 08/14/2019] [Indexed: 11/09/2022]
Abstract
Irritability is an important dimension of psychopathology that spans multiple clinical diagnostic categories, yet its relationship to patterns of brain development remains sparsely explored. Here, we examined how transdiagnostic symptoms of irritability relate to the development of structural brain networks. All participants (n = 137, 83 females) completed structural brain imaging with 3 Tesla MRI at two timepoints (mean age at follow-up: 21.1 years, mean inter-scan interval: 5.2 years). Irritability at follow-up was assessed using the Affective Reactivity Index, and cortical thickness was quantified using Advanced Normalization Tools software. Structural covariance networks were delineated using non-negative matrix factorization, a multivariate analysis technique. Both cross-sectional and longitudinal associations with irritability at follow-up were evaluated using generalized additive models with penalized splines. The False Discovery Rate (q < 0.05) was used to correct for multiple comparisons. Cross-sectional analysis of follow-up data revealed that 11 of the 24 covariance networks were associated with irritability, with higher levels of irritability being associated with thinner cortex. Longitudinal analyses further revealed that accelerated cortical thinning within nine networks was related to irritability at follow-up. Effects were particularly prominent in brain regions implicated in emotion regulation, including the orbitofrontal, lateral temporal, and medial temporal cortex. Collectively, these findings suggest that irritability is associated with widespread reductions in cortical thickness and accelerated cortical thinning, particularly within the frontal and temporal cortex. Aberrant structural maturation of regions important for emotional regulation may in part underlie symptoms of irritability.
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Affiliation(s)
- Robert J Jirsaraie
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Antonia N Kaczkurkin
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Sage Rush
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Kayla Piiwia
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Azeez Adebimpe
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Danielle S Bassett
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.,Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, 19104, USA.,Department of Electrical & Systems Engineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, 19104, USA.,Department of Physics & Astronomy, College of Arts & Sciences, University of Pennsylvania, Philadelphia, PA, 19104, USA.,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Josiane Bourque
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Monica E Calkins
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Matthew Cieslak
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Rastko Ciric
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Philip A Cook
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Diego Davila
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Mark A Elliott
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Ellen Leibenluft
- Section on Mood Dysregulation and Neuroscience, National Institute of Mental Health (NIMH), 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Kristin Murtha
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - David R Roalf
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Adon F G Rosen
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Kosha Ruparel
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Russell T Shinohara
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Aristeidis Sotiras
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Daniel H Wolf
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Christos Davatzikos
- Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, 19104, USA.,Department of Electrical & Systems Engineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, 19104, USA.,Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Theodore D Satterthwaite
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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Wolraich ML, Hagan JF, Allan C, Chan E, Davison D, Earls M, Evans SW, Flinn SK, Froehlich T, Frost J, Holbrook JR, Lehmann CU, Lessin HR, Okechukwu K, Pierce KL, Winner JD, Zurhellen W. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics 2019; 144:e20192528. [PMID: 31570648 PMCID: PMC7067282 DOI: 10.1542/peds.2019-2528] [Citation(s) in RCA: 567] [Impact Index Per Article: 113.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is 1 of the most common neurobehavioral disorders of childhood and can profoundly affect children's academic achievement, well-being, and social interactions. The American Academy of Pediatrics first published clinical recommendations for evaluation and diagnosis of pediatric ADHD in 2000; recommendations for treatment followed in 2001. The guidelines were revised in 2011 and published with an accompanying process of care algorithm (PoCA) providing discrete and manageable steps by which clinicians could fulfill the clinical guideline's recommendations. Since the release of the 2011 guideline, the Diagnostic and Statistical Manual of Mental Disorders has been revised to the fifth edition, and new ADHD-related research has been published. These publications do not support dramatic changes to the previous recommendations. Therefore, only incremental updates have been made in this guideline revision, including the addition of a key action statement related to diagnosis and treatment of comorbid conditions in children and adolescents with ADHD. The accompanying process of care algorithm has also been updated to assist in implementing the guideline recommendations. Throughout the process of revising the guideline and algorithm, numerous systemic barriers were identified that restrict and/or hamper pediatric clinicians' ability to adopt their recommendations. Therefore, the subcommittee created a companion article (available in the Supplemental Information) on systemic barriers to the care of children and adolescents with ADHD, which identifies the major systemic-level barriers and presents recommendations to address those barriers; in this article, we support the recommendations of the clinical practice guideline and accompanying process of care algorithm.
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Affiliation(s)
- Mark L. Wolraich
- Section of Developmental and Behavioral Pediatrics, University of Oklahoma, Oklahoma City, Oklahoma
| | - Joseph F. Hagan
- Department of Pediatrics, The Robert Larner, MD, College of Medicine, The University of Vermont, Burlington, Vermont
- Hagan, Rinehart, and Connolly Pediatricians, PLLC, Burlington, Vermont
| | - Carla Allan
- Division of Developmental and Behavioral Health, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Eugenia Chan
- Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Dale Davison
- Children and Adults with Attention-Deficit/Hyperactivity Disorder, Lanham, Maryland
- Dale Davison, LLC, Skokie, Illinois
| | - Marian Earls
- Community Care of North Carolina, Raleigh, North Carolina
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Steven W. Evans
- Department of Psychology, Ohio University, Athens, Ohio
- Center for Intervention Research in Schools, Ohio University, Athens, Ohio
| | | | - Tanya Froehlich
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer Frost
- Swope Health Services, Kansas City, Kansas
- American Academy of Family Physicians, Leawood, Kansas
| | - Joseph R. Holbrook
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christoph Ulrich Lehmann
- Departments of Biomedical Informatics and Pediatrics, Vanderbilt University, Nashville, Tennessee
| | | | | | - Karen L. Pierce
- American Academy of Child and Adolescent Psychiatry, Washington, District of Columbia
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Estrada-Prat X, Álvarez-Guerrico I, Batlle-Vila S, Camprodon-Rosanas E, Martín-López LM, Álvarez E, Romero S, Elices M, Pérez V. Sleep alterations in pediatric bipolar disorder versus attention deficit disorder. Psychiatry Res 2019; 275:39-45. [PMID: 30878855 DOI: 10.1016/j.psychres.2019.01.108] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/21/2019] [Accepted: 01/21/2019] [Indexed: 12/01/2022]
Abstract
Bipolar disorder (BD) and attention deficit/hyperactivity disorder (ADHD) share numerous clinical features, which can make the differential diagnosis challenging. Studies conducted in adults suggest that patients with BD and ADHD have different sleep patterns. However, in pediatric populations, data on these potential differences are scant. The present preliminary study was conducted to identify potential differences in sleep alterations among youths diagnosed with BD or ADHD compared to healthy controls (HC). A total of 26 patients diagnosed with BD (n = 13) or ADHD (n = 13) were compared to 26 sex- and age-matched HC ([HCBD], n = 13, and [HCADHD], n = 13). All participants underwent polysomnography. The mean duration of stage N2 sleep was shorter in the BD group than in controls (HCBD). The BD group also had higher (non-significant) REM density (REMd) scores than controls while mean REMd scores were lower in the ADHD group versus controls. Compared to the ADHD group, the BD group presented a shorter N2 stage, a longer first REM sleep duration (R1), and greater REMd. According to our findings, these three variables-N2 stage, REMd, and R1-appear to differentiate patients with BD from those with ADHD and from HC.
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Affiliation(s)
- Xavier Estrada-Prat
- Child and Adolescent Psychiatry and Psychology Department of Hospital Sant Joan de Déu of Barcelona, Spain; Departament de Psiquiatria i Medicina Legal, Universitat Autònoma de Barcelona, Spain
| | - Ion Álvarez-Guerrico
- Neurology and Clinical Neurophysiology Department, Hospital del Mar, Barcelona, Spain
| | - Santiago Batlle-Vila
- Child and Adolescent Psychiatry and Psychology Department of Hospital Sant Joan de Déu of Barcelona, Spain; Departament de Psiquiatria i Medicina Legal, Universitat Autònoma de Barcelona, Spain; Institut de Neuropsiquiatria i Addiccions (INAD), Centre de Salut Mental Infantil i Juvenil (CSMIJ) Sant Martí-La Mina, Parc de Salut Mar, Barcelona, Spain
| | - Ester Camprodon-Rosanas
- Child and Adolescent Psychiatry and Psychology Department of Hospital Sant Joan de Déu of Barcelona, Spain; Children and Adolescent Mental Health Research Group, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Luís Miguel Martín-López
- INAD, CSMIJ Ciutat Vella, Parc de Salut Mar, Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain
| | - Enric Álvarez
- Departament de Psiquiatria i Medicina Legal, Universitat Autònoma de Barcelona, Spain; Servei de Psiquiatria, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain
| | - Soledad Romero
- Servei de Psiquiatria i Psicologia Infantil i Juvenil, 2017SGR88, Instituto de Neurociencias, Hospital Clínic i Provincial, Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain
| | - Matilde Elices
- Mental Health Research Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain.
| | - Víctor Pérez
- Departament de Psiquiatria i Medicina Legal, Universitat Autònoma de Barcelona, Spain; Mental Health Research Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain; INAD, Hospital del Mar, Barcelona, Spain
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16
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Ribeiro-Fernández M, Díez-Suárez A, Soutullo C. Phenomenology and diagnostic stability of paediatric bipolar disorder in a Spanish sample. J Affect Disord 2019; 242:224-233. [PMID: 30205288 DOI: 10.1016/j.jad.2018.08.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 06/28/2018] [Accepted: 08/12/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Paediatric bipolar disorder (BD) has gained validity, and substantial research in the last 20 years has dissipated the controversy surrounding it. However, data on the prevalence, prodromes, phenomenology, and longitudinal stability of paediatric BD are still required. METHODS We reviewed the medical records of all patients (n = 72) with DSM-IV BD evaluated over a 15-year period. We assessed the most frequently present symptoms prior to and at the time of diagnosis, the diagnostic stability of the disorder and its subtypes (I, II and NOS). RESULTS Patients [75% boys, median age (interquartile range, IQR) at diagnosis 12.6 (9.6-15.7) years] underwent follow up for a median period of 3.86 (1.8-5.9) years. There was a median delay from symptom onset to diagnosis of 2.3 (1.2-4.8) years. At the time of diagnosis, 37.5% had BD-I, 8.3% BD-II, and 54.2% BD-NOS. At follow-up, 62.5% had BD-I, 8.3% had BD-II, and 23.6% had BD-NOS, whereas 4.2% no longer met the DSM-IV criteria for BD. LIMITATIONS Our sample size limited the BD subtype analyses. Some of information was collected retrospectively. CONCLUSION 95.8% of our sample retained a BD diagnosis after a median follow-up period of 3.86 years. BD-I patients maintained their diagnosis and subtype of BD. Half of all patients with baseline BD-NOS maintained their BD subtype, but most of the other half showed conversion to BP-I at follow up. Only 4.2% of the sample (all with BD-NOS at baseline) did not meet criteria for BD at follow up, and these patients were stable.
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Affiliation(s)
- María Ribeiro-Fernández
- Child and Adolescent Psychiatry Unit, Psychiatry and Clinical Psychology Department, University of Navarra Clinic, Pamplona, Spain; Department of Psychiatry, Complejo Hospitalario de Navarra, Pamplona, Spain; IdiSNA: Navarra Institute for Health Research, Pamplona, Spain
| | - Azucena Díez-Suárez
- Child and Adolescent Psychiatry Unit, Psychiatry and Clinical Psychology Department, University of Navarra Clinic, Pamplona, Spain; IdiSNA: Navarra Institute for Health Research, Pamplona, Spain.
| | - César Soutullo
- Child and Adolescent Psychiatry Unit, Psychiatry and Clinical Psychology Department, University of Navarra Clinic, Pamplona, Spain; IdiSNA: Navarra Institute for Health Research, Pamplona, Spain
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Winters DE, Fukui S, Leibenluft E, Hulvershorn LA. Improvements in Irritability with Open-Label Methylphenidate Treatment in Youth with Comorbid Attention Deficit/Hyperactivity Disorder and Disruptive Mood Dysregulation Disorder. J Child Adolesc Psychopharmacol 2018; 28:298-305. [PMID: 29708762 PMCID: PMC6016730 DOI: 10.1089/cap.2017.0124] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The purpose of this open-label study was to examine the effects of long-acting methylphenidate (MPH) treatment on irritability and related emotional symptoms associated with disruptive mood dysregulation disorder (DMDD) in youth with comorbid attention-deficit/hyperactivity disorder (ADHD). METHODS The sample included 22 medication-free male and female subjects (ages 9-15) who met criteria for both DMDD and ADHD. Participants underwent a 4-week trial of long-acting MPH treatment (Concerta®), with weekly dosing increases until a therapeutic dose was reached. Repeated measures t-tests were used to compare pre- and posttreatment ratings of primary and secondary measures. The primary outcome was self-report irritability. Secondary outcomes included parent and child ratings of emotional frequency, emotional lability, and negative affect (NA). Multiple regression was used to examine the impact baseline hyperactivity, age, gender, race, socioeconomic status, or comorbid diagnosis had on treatment outcomes. RESULTS Significant improvements (medium to large effect sizes) in child-rated irritability as well as parent and child ratings of emotional lability, NA, and anger were found. As anticipated, ADHD symptoms also improved. While a majority of the sample saw improvement in child-rated irritability (71%), symptoms worsened a small proportion (19%), and an even smaller portion experienced no change (10%). No demographics, psychiatric comorbidities, or severity of ADHD symptoms influenced treatment outcomes. CONCLUSIONS Study findings suggest that MPH treatment significantly improved mood and emotional symptoms associated with DMDD comorbid with ADHD. These findings, coupled with good tolerability in this open-label pilot study supports further research into the use of MPH as a first-line treatment for DMDD. Future work examining MPH treatment of youth with DMDD with and without comorbid ADHD is needed.
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Affiliation(s)
- Drew E. Winters
- School of Social Work, Indiana University, Indianapolis, Indiana
| | - Sadaaki Fukui
- School of Social Work, Indiana University, Indianapolis, Indiana
| | - Ellen Leibenluft
- Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland
| | - Leslie A. Hulvershorn
- Section of Child and Adolescent Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana
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18
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Serra G, Uchida M, Battaglia C, Casini MP, De Chiara L, Biederman J, Vicari S, Wozniak J. Pediatric Mania: The Controversy between Euphoria and Irritability. Curr Neuropharmacol 2018; 15:386-393. [PMID: 28503110 PMCID: PMC5405608 DOI: 10.2174/1570159x14666160607100403] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 05/10/2016] [Accepted: 05/24/2016] [Indexed: 01/19/2023] Open
Abstract
Abstract: Pediatric Bipolar Disorder (BD) is a highly morbid pediatric psychiatric disease, consistently associated with family psychiatric history of mood disorders and associated with high levels of morbidity and disability and with a great risk of suicide. While there is a general consensus on the symptomatology of depression in childhood, the phenomenology of pediatric mania is still highly debated and the course and long-term outcome of pediatric BD still need to be clarified. We reviewed the available studies on the phenomenology of pediatric mania with the aim of summarizing the prevalence, demographics, clinical correlates and course of these two types of pediatric mania. Eighteen studies reported the number of subjects presenting with either irritable or elated mood during mania. Irritability has been reported to be the most frequent clinical feature of pediatric mania reaching a sensitivity of 95–100% in several samples. Only half the studies reviewed reported on number of episodes or cycling patterns and the described course was mostly chronic and ultra-rapid whereas the classical episodic presentation was less common. Few long-term outcome studies have reported a diagnostic stability of mania from childhood to young adult age. Future research should focus on the heterogeneity of irritability aiming at differentiating distinct subtypes of pediatric psychiatric disorders with distinct phenomenology, course, outcome and biomarkers. Longitudinal studies of samples attending to mood presentation, irritable versus elated, and course, chronic versus episodic, may help clarify whether these are meaningful distinctions in the course, treatment and outcome of pediatric onset bipolar disorder.
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Affiliation(s)
- Giulia Serra
- Child Psychiatry Unit, Department of Neuroscience Bambino Gesù Children's Hospital, IRCCS Rome, Italy.,Lucio Bini Mood Disorder Center, Rome, Italy.,Harvard Medical School, Department of Psychiatry, Boston, MA, United States
| | - Mai Uchida
- Massachusetts General Hospital, Department of Pediatric Psychopharmacology, Boston, MA, United States.,Harvard Medical School, Department of Psychiatry, Boston, MA, United States
| | - Claudia Battaglia
- Child Psychiatry Unit, Department of Neuroscience Bambino Gesù Children's Hospital, IRCCS Rome, Italy
| | - Maria Pia Casini
- Child Psychiatry Unit, Department of Neuroscience Bambino Gesù Children's Hospital, IRCCS Rome, Italy
| | - Lavinia De Chiara
- NESMOS Department (Neuroscience, Mental Health, and Sensory Organs), Sapienza University, School of Medicine and Psychology, Sant'Andrea Hospital, Rome, Italy.,Lucio Bini Mood Disorder Center, Rome, Italy
| | - Joseph Biederman
- Massachusetts General Hospital, Department of Pediatric Psychopharmacology, Boston, MA, United States.,Harvard Medical School, Department of Psychiatry, Boston, MA, United States
| | - Stefano Vicari
- Child Psychiatry Unit, Department of Neuroscience Bambino Gesù Children's Hospital, IRCCS Rome, Italy
| | - Janet Wozniak
- Massachusetts General Hospital, Department of Pediatric Psychopharmacology, Boston, MA, United States.,Harvard Medical School, Department of Psychiatry, Boston, MA, United States
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Baweja R, Mayes SD, Hameed U, Waxmonsky JG. Disruptive mood dysregulation disorder: current insights. Neuropsychiatr Dis Treat 2016; 12:2115-24. [PMID: 27601906 PMCID: PMC5003560 DOI: 10.2147/ndt.s100312] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Disruptive mood dysregulation disorder (DMDD) was introduced as a new diagnostic entity under the category of depressive disorders in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It was included in DSM-5 primarily to address concerns about the misdiagnosis and consequent overtreatment of bipolar disorder in children and adolescents. DMDD does provide a home for a large percentage of referred children with severe persistent irritability that did not fit well into any DSM, Fourth Edition (DSM-IV) diagnostic category. However, it has been a controversial addition to the DSM-5 due to lack of published validity studies, leading to questions about its validity as a distinct disorder. In this article, the authors discuss the diagnostic criteria, assessment, epidemiology, criticism of the diagnosis, and pathophysiology, as well as treatment and future directions for DMDD. They also review the literature on severe mood dysregulation, as described by the National Institute of Mental Health, as the scientific support for DMDD is based primarily on studies of severe mood dysregulation.
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Affiliation(s)
- Raman Baweja
- Department of Psychiatry, Penn State University College of Medicine, Hershey, PA, USA
| | - Susan D Mayes
- Department of Psychiatry, Penn State University College of Medicine, Hershey, PA, USA
| | - Usman Hameed
- Department of Psychiatry, Penn State University College of Medicine, Hershey, PA, USA
| | - James G Waxmonsky
- Department of Psychiatry, Penn State University College of Medicine, Hershey, PA, USA
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Freed RD, Tompson MC, Otto MW, Nierenberg AA, Henin A. A latent class analysis of parental bipolar disorder: Examining associations with offspring psychopathology. Psychiatry Res 2015; 230:314-22. [PMID: 26394919 DOI: 10.1016/j.psychres.2015.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 08/10/2015] [Accepted: 09/06/2015] [Indexed: 11/28/2022]
Abstract
Bipolar disorder (BD) is highly heterogeneous, and course variations are associated with patient outcomes. This diagnostic complexity challenges identification of patients in greatest need of intervention. Additionally, course variations have implications for offspring risk. First, latent class analysis (LCA) categorized parents with BD based on salient illness characteristics: BD type, onset age, polarity of index episode, pole of majority of episodes, rapid cycling, psychosis, anxiety comorbidity, and substance dependence. Fit indices favored three parental classes with some substantively meaningful patterns. Two classes, labeled "Earlier-Onset Bipolar-I" (EO-I) and "Earlier-Onset Bipolar-II" (EO-II), comprised parents who had a mean onset age in mid-adolescence, with EO-I primarily BD-I parents and EO-II entirely BD-II parents. The third class, labeled "Later-Onset BD" (LO) had an average onset age in adulthood. Classes also varied on probability of anxiety comorbidity, substance dependence, psychosis, rapid cycling, and pole of majority of episodes. Second, we examined rates of disorders in offspring (ages 4-33, Mage=13.46) based on parental latent class membership. Differences emerged for offspring anxiety disorders only such that offspring of EO-I and EO-II parents had higher rates, compared to offspring of LO parents, particularly for daughters. Findings may enhance understanding of BD and its nosology.
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Affiliation(s)
- Rachel D Freed
- Boston University, Department of Psychology, 648 Beacon Street, Boston MA 02215 USA.
| | - Martha C Tompson
- Boston University, Department of Psychology, 648 Beacon Street, Boston MA 02215 USA
| | - Michael W Otto
- Boston University, Department of Psychology, 648 Beacon Street, Boston MA 02215 USA
| | - Andrew A Nierenberg
- Massachusetts General Hospital, Department of Psychiatry, 50 Staniford St, Boston, MA 02114 USA
| | - Aude Henin
- Massachusetts General Hospital, Department of Psychiatry, 151 Merrimac Street, 3rd floor, Boston, MA 02114 USA
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Goetz M, Novak T, Vesela M, Hlavka Z, Brunovsky M, Povazan M, Ptacek R, Sebela A. Early stages of pediatric bipolar disorder: retrospective analysis of a Czech inpatient sample. Neuropsychiatr Dis Treat 2015; 11:2855-64. [PMID: 26604770 PMCID: PMC4639550 DOI: 10.2147/ndt.s79586] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Approximately 30%-60% of adults diagnosed with bipolar disorder (BD) report onset between the ages 15 and 19 years; however, a correct diagnosis is often delayed by several years. Therefore, investigations of the early features of BD are important for adequately understanding the prodromal stages of the illness. METHODS A complete review of the medical records of 46 children and adolescents who were hospitalized for BD at two psychiatric teaching centers in Prague, Czech Republic was performed. Frequency of BD in all inpatients, age of symptom onset, phenomenology of mood episodes, lifetime psychiatric comorbidity, differences between very-early-onset (<13 years of age) and early-onset patients (13-18 years), and differences between the offspring of parents with and without BD were analyzed. RESULTS The sample represents 0.83% of the total number of inpatients (n=5,483) admitted during the study period at both centers. BD often started with depression (56%), followed by hypomania (24%) and mixed episodes (20%). The average age during the first mood episode was 14.9 years (14.6 years for depression and 15.6 years for hypomania). Seven children (15%) experienced their first mood episode before age 13 years (very early onset). Traumatic events, first-degree relatives with mood disorders, and attention deficit hyperactivity disorder were significantly more frequent in the very-early-onset group vs the early-onset group (13-18 years) (P≤0.05). The offspring of bipolar parents were significantly younger at the onset of the first mood episode (13.2 vs 15.4 years; P=0.02) and when experiencing the first mania compared to the offspring of non-BD parents (14.3 vs 15.9 years; P=0.03). Anxiety disorders, substance abuse, specific learning disabilities, and attention deficit hyperactivity disorder were the most frequent lifetime comorbid conditions. CONCLUSION Clinicians must be aware of the potential for childhood BD onset in patients who suffer from recurrent depression, who have first-degree relatives with BD, and who have experienced severe psychosocial stressors.
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Affiliation(s)
- Michal Goetz
- Department of Child Psychiatry, Second Faculty of Medicine, Motol University Hospital, Charles University in Prague, Prague, Czech Republic
| | - Tomas Novak
- National Institute of Mental Health, Klecany and Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Marie Vesela
- Department of Child Psychiatry, Second Faculty of Medicine, Motol University Hospital, Charles University in Prague, Prague, Czech Republic
| | - Zdenek Hlavka
- Department of Probability and Mathematical Statistics, Faculty of Mathematics and Physics, Charles University in Prague, Prague, Czech Republic
| | - Martin Brunovsky
- National Institute of Mental Health, Klecany and Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Michal Povazan
- Children's Department, Bohnice Psychiatric Hospital, Prague, Czech Republic
| | - Radek Ptacek
- Department of Psychiatry, First Faculty of Medicine, General Teaching Hospital, Charles University in Prague, Czech Republic
| | - Antonin Sebela
- National Institute of Mental Health, Klecany and Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
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Shapiro J, Timmins V, Swampillai B, Scavone A, Collinger K, Boulos C, Hatch J, Goldstein BI. Correlates of psychiatric hospitalization in a clinical sample of Canadian adolescents with bipolar disorder. Compr Psychiatry 2014; 55:1855-61. [PMID: 25218398 DOI: 10.1016/j.comppsych.2014.08.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 08/19/2014] [Accepted: 08/20/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To identify factors associated with psychiatric hospitalization among adolescents with bipolar disorder (BD). METHODS Participants were 100 adolescents, ages 13-19, who fulfilled DSM-IV criteria for bipolar I disorder [(BD-I), n=26], bipolar II disorder [(BD-II), n=40], or operationalized criteria for BD not otherwise specified [(BD-NOS), n=34], via the Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version (KSADS-PL). Demographic, clinical, and family history variables were measured via clinical interview with the participant and a parent or guardian. RESULTS The lifetime prevalence of psychiatric hospitalization was 50%. Significant predictors of psychiatric hospitalization in univariate analyses included older age, BD-I, history of suicide attempt, psychosis, lifetime use of second generation antipsychotics (SGAs), lithium, SSRI antidepressants and any medication. BD-II was negatively associated with psychiatric hospitalization. In multivariable analyses, older age, history of suicide attempt, psychosis and use of SGAs were positively associated with hospitalization, whereas BD-II was negatively associated with hospitalization. CONCLUSIONS Psychiatric hospitalization in adolescents with BD is highly prevalent and associated with older age and proxies for greater illness severity. Further studies are needed to identify strategies for reducing the need for psychiatric hospitalizations among adolescents with BD.
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Affiliation(s)
- Joshua Shapiro
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Wilfrid Laurier University, Waterloo, ON, Canada
| | - Vanessa Timmins
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Brenda Swampillai
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Antonette Scavone
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Katelyn Collinger
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Carolyn Boulos
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jessica Hatch
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Benjamin I Goldstein
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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Rao U. DSM-5: disruptive mood dysregulation disorder. Asian J Psychiatr 2014; 11:119-23. [PMID: 25453714 PMCID: PMC4254488 DOI: 10.1016/j.ajp.2014.03.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 02/25/2014] [Accepted: 03/05/2014] [Indexed: 11/19/2022]
Abstract
This paper will describe historical perspectives for the introduction of disruptive mood dysregulation disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), criteria for the diagnosis, as well as information on epidemiology, clinical presentation and longitudinal course, pathophysiology, and treatment. The diagnosis of disruptive mood dysregulation disorder requires frequent, persistent, severe temper outbursts out of proportion to the situation and developmental context in combination with persistent, angry/irritable mood between the temper outbursts. Because of the limited available data, the inclusion of this new diagnosis in DSM-5 has been controversial. Regardless of this controversy, it is clear that youth experiencing such symptoms are highly impaired and utilize significant health services. Therefore, we need to expand our efforts to better understand the complex construct of this phenotype in order to improve the assessment, diagnosis and treatment of this condition.
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Affiliation(s)
- Uma Rao
- Center for Molecular and Behavioral Neuroscience, Department of Psychiatry and Behavioral Sciences, Meharry Medical College, Nashville, TN, USA; Department of Psychiatry, The Kennedy Center, Vanderbilt University, Nashville, TN, USA.
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Correll CU, Hauser M, Penzner JB, Auther AM, Kafantaris V, Saito E, Olvet D, Carrión RE, Birmaher B, Chang KD, DelBello MP, Singh MK, Pavuluri M, Cornblatt BA. Type and duration of subsyndromal symptoms in youth with bipolar I disorder prior to their first manic episode. Bipolar Disord 2014; 16:478-92. [PMID: 24597782 PMCID: PMC4186919 DOI: 10.1111/bdi.12194] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 01/10/2014] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The aim of the present study was to systematically evaluate the prodrome to mania in youth. METHODS New-onset/worsening symptoms/signs of ≥ moderate severity preceding first mania were systematically assessed in 52 youth (16.2 ± 2.8 years) with a research diagnosis of bipolar I disorder (BD-I). Youth and/or caregivers underwent semi-structured interviews, using the Bipolar Prodrome Symptom Scale-Retrospective. RESULTS The mania prodrome was reported to start gradually in most youth (88.5%), with either slow (59.6%) or rapid (28.8%) deterioration, while a rapid-onset-and-deterioration prodrome was rare (11.5%). The manic prodrome, conservatively defined as requiring ≥ 3 symptoms, lasted 10.3 ± 14.4 months [95% confidence interval (CI): 6.3-14.4], being present for ≥ 4 months in 65.4% of subjects. Among prodromal symptoms reported in ≥ 50% of youth, three were subthreshold manic in nature (irritability: 61.5%, racing thoughts: 59.6%, increased energy/activity: 50.0%), two were nonspecific (decreased school/work functioning: 65.4%, mood swings/lability: 57.7%), and one each was depressive (depressed mood: 53.8%) or subthreshold manic/depressive (inattention: 51.9%). A decreasing number of youth had ≥ 1 (84.6%), ≥ 2 (48.1%), or ≥ 3 (26.9%) 'specific' subthreshold mania symptoms (i.e., elation, grandiosity, decreased need for sleep, racing thoughts, or hypersexuality), lasting 9.5 ± 14.9 months (95% CI: 5.0-14.0), 3.5 ± 3.5 months (95% CI: 2.0-4.9), and 3.0 ± 3.2 months (95% CI: 1.0-5.0) for ≥ 1, ≥ 2, or ≥ 3 specific symptoms, respectively. CONCLUSIONS In youth with BD-I, a relatively long, predominantly slow-onset mania prodrome appears to be common, including subthreshold manic and depressive psychopathology symptoms. This suggests that early clinical identification and intervention may be feasible in bipolar disorder. Identifying biological markers associated with clinical symptoms of impending mania may help to increase chances for early detection and prevention before full mania.
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Affiliation(s)
- Christoph U Correll
- The Zucker Hillside Hospital, Psychiatry Research, North Shore-Long Island Jewish Health System, Glen Oaks, NY; Hofstra North Shore-LIJ School of Medicine, Hempstead, NY; The Feinstein Institute for Medical Research, North Shore-Long Island Jewish Health System, Manhasset, NY
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25
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A comparison of bipolar disorders in children in Italy and the United States. J Affect Disord 2014; 159:53-5. [PMID: 24679389 DOI: 10.1016/j.jad.2014.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 12/31/2013] [Accepted: 01/02/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND The clinical presentation of bipolar disorders, though clearly recognized in adolescents, remains controversial in younger children and across cultures. The aim of this study was to compare the clinical presentation of bipolar disorders in Italian and American children between ages 5 and 12 years. METHODS Sixty-seven children from six outpatient programs were enrolled (Italian sample: n=40; American sample: n=28) between January 2010 and June 2011. Children and their parents were interviewed by experienced clinicians using the Washington University in St. Louis Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present, Lifetime Version (WASH-U K-SADS). RESULTS Italian children scored significantly higher on ratings of "elevated mood" (p=0.002), whereas American children scored significantly higher on ratings of "flight of ideas" (p=0.001) and "productivity" (p=0.001). Rates of comorbidity were different between groups. LIMITATIONS Data were acquired from several sites in Italy as compared to from a single American site. Medication and educational information were not systematically collected. Furthermore, the sample collected may only reflect characteristics of a less severely ill group of bipolar children. CONCLUSIONS Our comparison of Italian and American children with early onset bipolar disorders found that the phenotype of bipolar spectrum disorders is largely shared across cultures, although psychiatric comorbidities differed.
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Abstract
There are two divergent viewpoints on the phenomenology and outcome of bipolar I (BP I) disorder in youth. Disparities evolved as unintended consequences from investigators' inconsistencies both in translating the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III, DSM-III-R, and DSM-IV criteria and in operationalizing them differently in their standardized assessments. Rates of conservatively diagnosed BP I are lower both in community studies of youths than in adults and from liberally defined BP I in youths. Rates of co-occurring attention-deficit hyperactivity disorder (ADHD) are lower in conservatively than liberally defined children and adolescents with BP I. Rates of both BP I and of ADHD are lower in offspring of BP I probands, and outcome more closely approximates that of adults with BP I in conservatively versus liberally defined children and teens with BP I. Both perspectives can claim evidence for reliability and validity that support their positions. However, the samples are so different that it is difficult to compare studies conducted from these different perspectives.
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Affiliation(s)
- Gabrielle A. Carlson
- Division of Child and Adolescent Psychiatry, Stony Brook University School of Medicine, Stony Brook, New York 11794
| | - Daniel N. Klein
- Department of Psychology, Stony Brook University, Stony Brook, New York 11794
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Renk K, White R, Lauer BA, McSwiggan M, Puff J, Lowell A. Bipolar disorder in children. PSYCHIATRY JOURNAL 2014; 2014:928685. [PMID: 24800202 PMCID: PMC3994906 DOI: 10.1155/2014/928685] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 12/21/2013] [Indexed: 12/31/2022]
Abstract
Although bipolar disorder historically was thought to only occur rarely in children and adolescents, there has been a significant increase in children and adolescents who are receiving this diagnosis more recently (Carlson, 2005). Nonetheless, the applicability of the current bipolar disorder diagnostic criteria for children, particularly preschool children, remains unclear, even though much work has been focused on this area. As a result, more work needs to be done to further the understanding of bipolar symptoms in children. It is hoped that this paper can assist psychologists and other health service providers in gleaning a snapshot of the literature in this area so that they can gain an understanding of the diagnostic criteria and other behaviors that may be relevant and be informed about potential approaches for assessment and treatment with children who meet bipolar disorder criteria. First, the history of bipolar symptoms and current diagnostic criteria will be discussed. Next, assessment strategies that may prove helpful for identifying bipolar disorder will be discussed. Then, treatments that may have relevance to children and their families will be discussed. Finally, conclusions regarding work with children who may have a bipolar disorder diagnosis will be offered.
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Affiliation(s)
- Kimberly Renk
- University of Central Florida, P.O. Box 161390, Orlando, FL 32816, USA
| | - Rachel White
- University of Central Florida, P.O. Box 161390, Orlando, FL 32816, USA
| | - Brea-Anne Lauer
- University of Central Florida, P.O. Box 161390, Orlando, FL 32816, USA
| | - Meagan McSwiggan
- University of Central Florida, P.O. Box 161390, Orlando, FL 32816, USA
| | - Jayme Puff
- University of Central Florida, P.O. Box 161390, Orlando, FL 32816, USA
| | - Amanda Lowell
- University of Central Florida, P.O. Box 161390, Orlando, FL 32816, USA
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Krieger FV, Leibenluft E, Stringaris A, Polanczyk GV. Irritability in children and adolescents: past concepts, current debates, and future opportunities. BRAZILIAN JOURNAL OF PSYCHIATRY 2014; 35 Suppl 1:S32-9. [PMID: 24142126 DOI: 10.1590/1516-4446-2013-s107] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Irritability is defined as a low threshold to experience anger in response to frustration. It is one of the most common symptoms in youth and is part of the clinical presentation of several disorders. Irritability can present early in life and is a predictor of long-term psychopathology; yet, the diagnostic status of irritability is a matter of intense debate. In the present article, we address two main components of the debate regarding irritability in youth: the misdiagnosis of chronic irritability as pediatric bipolar disorder, and the proposal of a new diagnosis in the DSM-5, disruptive mood dysregulation disorder, whose defining symptoms are chronic irritability and temper outbursts.
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The Val66Met polymorphism at the BDNF gene does not influence Wisconsin Card Sorting Test results in children and adolescents with bipolar disorder. BRAZILIAN JOURNAL OF PSYCHIATRY 2013; 35:44-50. [PMID: 23567599 DOI: 10.1016/j.rbp.2012.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 02/18/2012] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess the role of the Val66Met polymorphism at the brain-derived neurotrophic factor (BDNF) gene on the performance of children and adolescents with bipolar disorder [juvenile bipolar disorder (JBD)] on the Wisconsin Card Sorting Test (WCST). METHODS Children and adolescents were assessed by the K-SADS-PL and a clinical evaluation for BD and comorbid conditions. Manic and depressive symptoms were assessed with the Young Mania Rating Scale and the Children Depression Rating Scale - Reviewed. The Val66Met polymorphism at the BDNF was genotyped from a blood sample. Patients' IQ and executive functions were assessed by a standard cognitive flexibility test (WCST). RESULTS Fifty-three subjects were included in the study. No significant difference was observed between the Val/Val and Val/Met+Met/Met groups on any WCST scores in the MANCOVA (F48,5 = .76; p = .59; Perseverative Errors, p = .66; Nonperseverative Errors, p = .58; Categories Completed, p = .34; Attempts to Reach First Category, p=.64; and Percentage of Conceptual Level Responses, p = .99). CONCLUSIONS Our findings from this sample of children and adolescents with BD do not replicate results from studies of adults and suggest the existence of differences in the neurobiology of this disorder across the life cycle. Investigations of larger samples are necessary to confirm these data.
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Papachristou E, Ormel J, Oldehinkel AJ, Kyriakopoulos M, Reinares M, Reichenberg A, Frangou S. Child Behavior Checklist-Mania Scale (CBCL-MS): development and evaluation of a population-based screening scale for bipolar disorder. PLoS One 2013; 8:e69459. [PMID: 23967059 PMCID: PMC3743889 DOI: 10.1371/journal.pone.0069459] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 06/10/2013] [Indexed: 11/18/2022] Open
Abstract
CONTEXT Early identification of Bipolar Disorder (BD) remains poor despite the high levels of disability associated with the disorder. OBJECTIVE We developed and evaluated a new DSM orientated scale for the identification of young people at risk for BD based on the Child Behavior Checklist (CBCL) and compared its performance against the CBCL-Pediatric Bipolar Disorder (CBCL-PBD) and the CBCL-Externalizing Scale, the two most widely used scales. METHODS The new scale, CBCL-Mania Scale (CBCL-MS), comprises 19 CBCL items that directly correspond to operational criteria for mania. We tested the reliability, longitudinal stability and diagnostic accuracy of the CBCL-MS on data from the TRacking Adolescents' Individual Lives Survey (TRAILS), a prospective epidemiological cohort study of 2230 Dutch youths assessed with the CBCL at ages 11, 13 and 16. At age 19 lifetime psychiatric diagnoses were ascertained with the Composite International Diagnostic Interview. We compared the predictive ability of the CBCL-MS against the CBCL-Externalising Scale and the CBCL-PBD in the TRAILS sample. RESULTS The CBCL-MS had high internal consistency and satisfactory accuracy (area under the curve = 0.64) in this general population sample. Principal Component Analyses, followed by parallel analyses and confirmatory factor analyses, identified four factors corresponding to distractibility/disinhibition, psychosis, increased libido and disrupted sleep. This factor structure remained stable across all assessment ages. Logistic regression analyses showed that the CBCL-MS had significantly higher predictive ability than both the other scales. CONCLUSIONS Our data demonstrate that the CBCL-MS is a promising screening instrument for BD. The factor structure of the CBCL-MS showed remarkable temporal stability between late childhood and early adulthood suggesting that it maps on to meaningful developmental dimensions of liability to BD.
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Affiliation(s)
- Efstathios Papachristou
- Child Psychiatry Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Johan Ormel
- Interdisciplinary Center of Psychpathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Albertine J. Oldehinkel
- Interdisciplinary Center of Psychpathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marinos Kyriakopoulos
- Child Psychiatry Department, Institute of Psychiatry, King's College London, London, United Kingdom
- Child and Adolescent Mental Health Services, Maudsley Hospital, London, United Kingdom
| | - María Reinares
- Child Psychiatry Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Abraham Reichenberg
- Ichan School of Medicine at Mount Sinai, New York City, New York, United States of America
| | - Sophia Frangou
- Ichan School of Medicine at Mount Sinai, New York City, New York, United States of America
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Survey examining the views of Adult Psychiatry Consultants and Senior Registrars regarding ADHD. Ir J Psychol Med 2013; 30:197-203. [DOI: 10.1017/ipm.2013.27] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ObjectivesAttention deficit hyperactivity disorder (ADHD) persists into adulthood in ∼2/3 of patients, yet services for adults are lacking in Ireland. This may involve negative attitudes and beliefs as to the validity of ADHD or lack of knowledge and training in its treatment. The objectives of this study are to explore the views of Adult Psychiatrists regarding ADHD knowledge and the treatment options available and pursued in Ireland.MethodsA questionnaire was constructed based on the stated aims of the study, and was either posted, emailed or handed to 400 Consultants and Senior Registrars throughout the Republic of Ireland between February and December 2011. A total of 92 questionnaires were returned (23%); one was excluded from analysis due to insufficient information entered by the respondent.ResultsSeventy-five per cent of respondents correctly estimated the prevalence rates of adult ADHD to be under 3%, but stated it is currently under-diagnosed (77%). Seventy-four per cent indicated that Adult ADHD should be a diagnostic category in the Diagnostic and Statistical Manual, 5th Edition (DSM V). Sixty-six per cent of respondents were willing to accept referrals of childhood ADHD for ongoing care and a similar number for new ADHD assessments (61%). Less than half (42%) surveyed had actually diagnosed ADHD and of these, only 33% felt confident in managing ADHD in their patients.ConclusionsAlthough there is a general willingness to offer services for new and existing ADHD cases and a recognition that Adult ADHD is valid and under-diagnosed, the low confidence levels when treating ADHD and the perception of under-diagnosis suggests a role for further training and links between child and adult services.
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Hauser M, Correll CU. The significance of at-risk or prodromal symptoms for bipolar I disorder in children and adolescents. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2013; 58:22-31. [PMID: 23327753 PMCID: PMC4010197 DOI: 10.1177/070674371305800106] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
While in the early identification and intervention of psychosis-specific instruments and risk criteria have been generated and validated, research into indicated preventive strategies for bipolar I disorder (BD I) has only recently gained momentum. As the first signs of BD I often start before adulthood, such efforts are especially important in the vulnerable pediatric population. Data are summarized regarding the presence and nature of potentially prodromal, that is, subsyndromal, symptoms prior to BD I, defined by first-episode mania, focusing on pediatric patients. Research indicates the possibility of early identification of youth at clinical high risk for BD. Support for this proposition comes from retrospective studies of BD I patients, as well as prospective studies of community samples, offspring of BD I subjects, youth with depressive disorders, and patients at high risk for psychosis or with bipolar spectrum disorders without lifetime history of mania. These data provide essential insight into potential signs and symptoms that may enable presyndromal identification of BD I in youth. However, except for offspring studies, broader prospective approaches that focus on youth at clinical high risk for BD I and on developing specific interviews and (or) rating scales and risk criteria are mostly missing, or in their early stage. More work is needed to determine valid and sufficiently specific clinical high-risk criteria, to distinguish risk factors, endophenotypes, and comorbidities from prodromal symptomatology, and to develop phase-specific interventions that titrate the risk of intervention to the risk of transition to mania and to functional impairment or distress. Moreover, studies are needed that determine potential differences in prodromal symptoms and trajectories between children, adolescents, and adults, and the best phase-specific interventions.
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Affiliation(s)
- Marta Hauser
- Improve Care, Reduce Costs ICRC Project, The Zucker Hillside Hospital, Division of Psychiatry Research, Glen Oaks, New York, USA
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Age-grouped differences in bipolar mania. Compr Psychiatry 2012; 53:1110-7. [PMID: 22682679 DOI: 10.1016/j.comppsych.2012.04.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 04/11/2012] [Accepted: 04/23/2012] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE This review of published studies compares scores on individual items of mania rating scales that systematically recorded symptom severity in persons diagnosed with bipolar disorder to identify age-grouped differences. METHODS An extensive literature search identified item scores from mania rating scales, with a particular emphasis on baseline Young Mania Rating Scale (YMRS) item scores in published double-blind, placebo-controlled studies of bipolar I manic disorder. These baseline YMRS item scores were assessed as a proportion of the total YMRS score and compared by age group. Additional YMRS item/total scores in subjects with bipolar spectrum disorders were added to expand the analysis. RESULTS Preadolescents with bipolar disorder had significantly higher YMRS item scores than adolescents on aggression, irritability, and motor activity. Young Mania Rating Scale baseline item scores relative to the YMRS total score revealed that adolescents diagnosed with bipolar I mania scored comparatively higher than did adults on YMRS aggression and irritability items, whereas adults with bipolar I manic disorder scored comparatively higher on the grandiosity and sexual interest items. Age-grouped findings from subjects diagnosed with bipolar I, II, and Not Otherwise Specified (NOS) disorders yielded similar age-grouped results. CONCLUSION In age-grouped YMRS item assessments of bipolar mania, anger dyscontrol was most prominent for youth, whereas disordered thought content was paramount for adults.
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Parents with bipolar disorder: Are disease characteristics good predictors of psychopathology in offspring? Eur Psychiatry 2012; 28:240-6. [DOI: 10.1016/j.eurpsy.2012.03.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 03/22/2012] [Accepted: 03/29/2012] [Indexed: 01/22/2023] Open
Abstract
AbstractPurposeTo investigate rates of psychopathology in the offspring of subjects with bipolar disorder (BP-offspring) compared to the offspring of healthy subjects (HC-offspring) in a Spanish sample and to study possible predictors of psychopathology in BP-offspring.SubjectsFifty BP-offspring from 36 families and 25 HC-offspring from 25 families.MethodsPsychopathology was compared in BP-offspring and HC-offspring. Factors associated with DSM-IV axis I disorders in BP-offspring were analyzed using logistic regression.ResultsHalf of BP-offspring fulfilled the diagnostic criteria for at least one axis I disorder with attention-deficit/hyperactivity disorder (30%), anxiety disorders (14%) and affective disorders (10%) as the most frequent. After controlling for having more than one sibling in the study, the odds ratio for BP-offspring presenting an axis I disorder was 15.02 when a biological parent had bipolar disorder with a lifetime history of psychotic symptoms and 3.34 when one parent had bipolar II disorder. Moreover, a higher Global Assessment of Functioning score in the biological co-parent was associated with a significantly lower frequency of axis I disorders in BP-offspring.Discussion and conclusionsPsychopathology in BP-offspring should be routinely assessed, with special emphasis on children from parents with specific disease characteristics (psychosis, BP II disorder) in order to establish an early diagnosis and appropriate interventions.
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Kang NR, Kwack YS. Clinical Course of Bipolar Disorder in Children and Adolescents. Soa Chongsonyon Chongsin Uihak 2012. [DOI: 10.5765/jkacap.2012.23.1.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Gunde E, Blagdon R, Hajek T. White matter hyperintensities: from medical comorbidities to bipolar disorders and back. Ann Med 2011; 43:571-80. [PMID: 21749303 PMCID: PMC4831903 DOI: 10.3109/07853890.2011.595733] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
White matter hyperintensities (WMHs) are among the most replicated neuroimaging findings in studies of patients with bipolar disorders (BD). Despite the high rates of WMHs, their role and etiology in BD are not well understood. WMHs occur in multiple other conditions frequently co-morbid with BD. From the available studies it seems that WMHs are not a primary risk factor/endophenotype for BD. More likely, these lesions indicate the presence of medical co-morbidities with specific links to BD. Furthermore, the etiology of the WMHs in BD may represent different processes depending on age. In certain forms of BD, such as pediatric BD, WMHs may represent co-morbidity with developmental disorders. High frequency of migraine in BD and high prevalence of WMHs in migraine may suggest that a substantial proportion of WMHs in early adulthood to midlife BD subjects may be related to co-morbidity with migraine. Among elderly subjects with BD, or those with late-onset BD, WMHs are likely related to the presence of cardiovascular/metabolic disorders. With further research WMHs may enhance our knowledge about various pathological pathways involved in BD, help in decreasing the etiological heterogeneity of BD, and become useful as markers of severity or subtype of BD.
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Affiliation(s)
- Eva Gunde
- Department of Psychiatry, Dalhousie University , Halifax , Canada
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Carlson GA. Diagnostic stability and bipolar disorder in youth. J Am Acad Child Adolesc Psychiatry 2011; 50:1202-4. [PMID: 22115139 PMCID: PMC3224340 DOI: 10.1016/j.jaac.2010.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2010] [Revised: 07/13/2010] [Accepted: 07/15/2010] [Indexed: 10/15/2022]
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Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics 2011; 128:1007-22. [PMID: 22003063 PMCID: PMC4500647 DOI: 10.1542/peds.2011-2654] [Citation(s) in RCA: 1134] [Impact Index Per Article: 87.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood and can profoundly affect the academic achievement, well-being, and social interactions of children; the American Academy of Pediatrics first published clinical recommendations for the diagnosis and evaluation of ADHD in children in 2000; recommendations for treatment followed in 2001.
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Axelson DA, Birmaher B, Strober MA, Goldstein BI, Ha W, Gill MK, Goldstein TR, Yen S, Hower H, Hunt JI, Liao F, Iyengar S, Dickstein D, Kim E, Ryan ND, Frankel E, Keller MB. Course of subthreshold bipolar disorder in youth: diagnostic progression from bipolar disorder not otherwise specified. J Am Acad Child Adolesc Psychiatry 2011; 50:1001-16.e3. [PMID: 21961775 PMCID: PMC3185249 DOI: 10.1016/j.jaac.2011.07.005] [Citation(s) in RCA: 166] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 06/14/2011] [Accepted: 07/01/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the rate of diagnostic conversion from an operationalized diagnosis of bipolar disorder not otherwise specified (BP-NOS) to bipolar I disorder (BP-I) or bipolar II disorder (BP-II) in youth over prospective follow-up and to identify factors associated with conversion. METHOD Subjects were 140 children and adolescents recruited from clinical referrals or advertisement who met operationalized criteria for BP-NOS at intake and participated in at least one follow-up evaluation (91% of initial cohort). Diagnoses were assessed at follow-up interviews using the Longitudinal Interval Follow-Up Evaluation. The mean duration of follow-up was 5 years and the mean interval between assessments was 8.2 months. RESULTS Diagnostic conversion to BP-I or BP-II occurred in 63 subjects (45%): 32 (23%) to BP-I (nine of whom had initially converted to BP-II) and 31 to only BP-II (22%). Median time from intake to conversion was 58 weeks. First- or second-degree family history of mania or hypomania was the strongest baseline predictor of diagnostic conversion (p = .006). Over follow-up, conversion was associated with greater intensity of hypomanic symptoms and with greater exposure to specialized, intensive outpatient psychosocial treatments. There was no association between conversion and exposure to treatment with particular medication classes. CONCLUSIONS Children and adolescents referred with mood symptoms that meet operationalized criteria for BP-NOS, particularly those with a family history of BP, frequently progress to BP-I or BP-II. Efforts to identify these youth and effectively intervene may have the potential to curtail the progression of mood disorders in this high-risk population.
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Affiliation(s)
- David A Axelson
- University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, PA 15213, USA.
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Escamilla I, Wozniak J, Soutullo CA, Gamazo-Garrán P, Figueroa-Quintana A, Biederman J. Pediatric bipolar disorder in a Spanish sample: results after 2.6years of follow-up. J Affect Disord 2011; 132:270-4. [PMID: 21334070 DOI: 10.1016/j.jad.2011.01.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 01/13/2011] [Accepted: 01/15/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Bipolar disorder (BD) often starts in childhood or adolescence. There is considerable scepticism outside the United States over the validity, stability and prevalence of BD in children and adolescents. Persistence of course lends support to the validity of a diagnosis. OBJECTIVES To describe the longitudinal course of pediatric BD in a Spanish sample over a median follow-up period of 2.6years and to examine risk factors associated with outcome. METHODS We retrospectively reviewed the medical records of all children and adolescents (N=38) with DSM-IV-TR BD-I, II and NOS evaluated in the Child and Adolescent Psychiatry Unit, University of Navarra (Pamplona, Spain) from 1999 to 2005. We used the NIMH Lifetime Mood Chart and the Clinical Global Impression-Severity Scale to assess clinical course. RESULTS 79% (N=30) were boys and 21% (N=8) were girls; 44.7% (N=17) had BD-I, 5.3% (N=2) BD-II, and 50% (N=19) BD-NOS. Median (inter-quartile range: IQR: Q25; Q75) age at diagnosis was 13.9 (10.64; 15.84). Median follow-up period was 2.6years (0.91; 3.66). Mean percentage of time in an episode was 46.17% (23.36; 75.26), and it was longer in younger children (p<0.05). 2.6% had rapid cycling. At the end of follow-up, only 47% achieved remission or recovery. Younger children showed a worse treatment response (p<0.05). We found higher rates of hospitalization in children with ADHD (21%) (p<0.05). CONCLUSION Children with BD had a chronic course with little interepisodic recovery. BD can be diagnosed in children using DSM-IV-TR criteria. An early age of onset and ADHD comorbidity are risk factors for worse prognosis.
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Affiliation(s)
- Inmaculada Escamilla
- Child and Adolescent Psychiatry Unit, Department of Psychiatry and Medical Psychology, University of Navarra Clinic (Madrid Campus), Madrid, Spain.
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Abstract
Rates of bipolar disorder in any sample will depend on the sample studied, the interview used, with whom, how the information is integrated, the criteria applied, and the conceptualisation of a manic episode and its symptoms. A cross-national diagnostic study is needed to determine the implications of different approaches and definitions.
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Leibenluft E. Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths. Am J Psychiatry 2011; 168:129-42. [PMID: 21123313 PMCID: PMC3396206 DOI: 10.1176/appi.ajp.2010.10050766] [Citation(s) in RCA: 319] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- Ellen Leibenluft
- Section on Bipolar Spectrum Disorders, Emotion and Development Branch, NIMH, Bethesda, MD 20892-2670, USA.
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Robbins BD, Higgins M, Fisher M, Over K. Conflicts of interest in research on antipsychotic treatment of pediatric bipolar disorder, temper dysregulation disorder, and attenuated psychotic symptoms syndrome: Exploring the unholy alliance between big pharma and psychiatry. ACTA ACUST UNITED AC 2011. [DOI: 10.1002/jpoc.20039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Parens E, Johnston J. Controversies concerning the diagnosis and treatment of bipolar disorder in children. Child Adolesc Psychiatry Ment Health 2010; 4:9. [PMID: 20219111 PMCID: PMC2846895 DOI: 10.1186/1753-2000-4-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Accepted: 03/10/2010] [Indexed: 11/22/2022] Open
Abstract
This commentary grows out of an interdisciplinary workshop focused on controversies surrounding the diagnosis and treatment of bipolar disorder (BP) in children. Although debate about the occurrence and frequency of BP in children is more than 50 years old, it increased in the mid 1990s when researchers adapted the DSM account of bipolar symptoms to diagnose children. We offer a brief history of the debate from the mid 90s through the present, ending with current efforts to distinguish between a small number of children whose behaviors closely fit DSM criteria for BP, and a significantly larger number of children who have been receiving a BP diagnosis but whose behaviors do not closely fit those criteria. We agree with one emerging approach, which gives part or all of that larger number of children a new diagnosis called Severe Mood Dysregulation or Temper Dysregulation Disorder with Dysphoria.Three major concerns arose about interpreting the DSM criteria more loosely in children than in adults. If clinicians offer a treatment for disorder A, but the patient has disorder B, treatment may be compromised. Because DSM's diagnostic labels are meant to facilitate research, when they are applied inconsistently, such research is compromised. And because BP has a strong genetic component, the label can distract attention from the family or social context.Once a BP diagnosis is made, concerns remain regarding the primary, pharmacological mode of treatment: data supporting the efficacy of the often complex regimens are weak and side effects can be significant. However, more than is widely appreciated, data do support the efficacy of the psychosocial treatments that should accompany pharmacotherapy. Physicians, educators, and families should adopt a multimodal approach, which focuses as much on the child's context as on her body. If physicians are to fulfill their ethical obligation to facilitate truly informed consent, they must be forthcoming with families about the relevant uncertainties and complexities.
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Affiliation(s)
- Erik Parens
- The Hastings Center, Garrison, NY 10524, USA.
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Singh MK, Chang KD, Mazaika P, Garrett A, Adleman N, Kelley R, Howe M, Reiss A. Neural correlates of response inhibition in pediatric bipolar disorder. J Child Adolesc Psychopharmacol 2010; 20:15-24. [PMID: 20166792 PMCID: PMC2835388 DOI: 10.1089/cap.2009.0004] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Pediatric bipolar disorder is characterized by core deficits in mood and executive function and commonly co-occurs with attention-deficit/hyperactivity disorder (ADHD). We aimed to examine response inhibition in this population, as an element of executive function, which, if aberrant, may interfere with learning and information processing. METHODS Children (9-18 years) with bipolar I or II disorder (BD, n = 26) and age, gender, and intelligence quotient (IQ) comparable healthy children (HC, n = 22) without any psychopathology were given a standardized Go/NoGo computerized task measuring response inhibition. A whole-brain functional magnetic resonance imaging (MRI) group analysis was performed using statistical parametric mapping software (SPM2) for comparing NoGo to Go epochs. RESULTS There were no statistically significant group differences between groups in age, gender, or ethnicity. The BD group had high rates of co-morbid disorders, including 81% with ADHD, 62% with oppositional defiant disorder (ODD), and 46% with anxiety disorders. This BD group had fewer correct responses on Go (84% vs. 96%, T[46] = 3.35, p = 0.002) and overall (85% vs. 94%, T[46] = 4.12, p = 0.0002) trials as compared to the HC group. However, there were no statistically significant group differences in response inhibition on NoGo trials (p = 0.11). In the NoGo-Go contrast, the BD group showed increased neural activation in the right dorsolateral prefrontal cortex (DLPFC) compared to HC (T[46] = 4.21, p < 0.001). CONCLUSIONS During accurate NoGo but impaired Go trial performance, children with BD showed increased right DLPFC activation versus controls, suggesting increased recruitment of executive control regions for accurate response inhibition. Studies relating these results to mood regulation in pediatric BD are warranted.
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Affiliation(s)
- Manpreet K. Singh
- Pediatric Bipolar Disorders Program, Stanford University School of Medicine, Stanford, California.,Center for Interdisciplinary Brain Sciences Research, Stanford University School of Medicine, Stanford, California
| | - Kiki D. Chang
- Pediatric Bipolar Disorders Program, Stanford University School of Medicine, Stanford, California
| | - Paul Mazaika
- Center for Interdisciplinary Brain Sciences Research, Stanford University School of Medicine, Stanford, California
| | - Amy Garrett
- Center for Interdisciplinary Brain Sciences Research, Stanford University School of Medicine, Stanford, California
| | - Nancy Adleman
- Center for Interdisciplinary Brain Sciences Research, Stanford University School of Medicine, Stanford, California
| | - Ryan Kelley
- Center for Interdisciplinary Brain Sciences Research, Stanford University School of Medicine, Stanford, California
| | - Meghan Howe
- Pediatric Bipolar Disorders Program, Stanford University School of Medicine, Stanford, California
| | - Allan Reiss
- Center for Interdisciplinary Brain Sciences Research, Stanford University School of Medicine, Stanford, California
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Soutullo CA, Escamilla-Canales I, Wozniak J, Gamazo-Garrán P, Figueroa-Quintana A, Biederman J. Pediatric bipolar disorder in a Spanish sample: features before and at the time of diagnosis. J Affect Disord 2009; 118:39-47. [PMID: 19285348 DOI: 10.1016/j.jad.2009.02.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Revised: 02/11/2009] [Accepted: 02/12/2009] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Bipolar disorder (BD) often starts in childhood or adolescence. Diagnostic delay is common and may have a negative impact on treatment response and outcome. OBJECTIVES To describe the clinical characteristics and symptoms of children with BD prior to their diagnosis and at the time of diagnosis in a sample in Spain. METHODS We retrospectively reviewed the medical records of all children and adolescents (N=38) with a DSM-IV diagnosis of BD evaluated in the Child & Adolescent Psychiatry Unit, University of Navarra, over a 6-year period. We collected the DSM-IV symptoms of BD prior and at the time of diagnosis using the K-SADS-PL interview template. RESULTS BD was diagnosed in close to 4% of clinic patients. Thirty (79%) were boys and 8 (21%) were girls; 17 (44.7%) had BD-1, 2 (5.3%) BD-2, and 19 (49.9%) BD-NOS. Median age at diagnosis was 13.9 (10.6;15.9). Delay of diagnosis was 1.5 (0.7;3.4) years. Symptoms of BD were similar to those reported in U.S. samples with high rates of severe irritability (94.6%) and psychiatric comorbidity: 92.1% of the BD children had at least one comorbid disorder and 18.4% had three comorbidities, most frequently ADHD (21%) and substance abuse (18.4%). CONCLUSIONS Clinical findings in this Spanish sample of children with BD closely resembles those described in U.S. clinics. Diagnostic delay, as in the U.S., and frequent misdiagnosis may explain low prevalence estimates found outside the U.S.
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Affiliation(s)
- Cesar A Soutullo
- Child & Adolescent Psychiatry Unit, Department of Psychiatry & Medical Psychology, Clínica Universitaria, University of Navarra, Pamplona, Spain.
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Papolos D, Mattis S, Golshan S, Molay F. Fear of harm, a possible phenotype of pediatric bipolar disorder: a dimensional approach to diagnosis for genotyping psychiatric syndromes. J Affect Disord 2009; 118:28-38. [PMID: 19631388 DOI: 10.1016/j.jad.2009.06.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Revised: 06/09/2009] [Accepted: 06/15/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND In a prior concordance study of affected sibling pairs with a community diagnosis of pediatric bipolar disorder (PBD) a behavioral phenotype termed Fear of Harm (FOH) was found to have one of the strongest concordance coefficients (rho) between probands and siblings, and the widest contrasts between the rho-estimates for the proband/sibling vs. proband/comparison pairs [Papolos, D., Hennen, J., Cockerham, M.S, Lachman, H., 2007]. A strategy for identifying phenotypic subtypes: concordance of symptom dimensions between sibling pairs who met screening criteria for a genetic linkage study of childhood-onset bipolar disorder using the Child Bipolar Questionnaire (CBQ) was employed. J. Affect. Disord. 99, 27-36.]. We used the Child Bipolar Questionnaire (OUT) (CBQ) to further elucidate this behavioral phenotype of PBD. We hypothesized that selective factors including parent reported symptoms of mania and depression, would be distinguishing features of impairment between groups defined by 1) the magnitude of their score on a continuous measure of FOH, and 2) the high FOH group would have significantly greater levels of severity on course of illness variables. These measures included earlier age of onset of first psychiatric symptoms, first hospitalization, and frequency of psychiatric hospitalizations, as well as, degree of social impairment as determined by exposure to the juvenile justice system and school performance problems. METHODS The sample was comprised of children with community diagnoses of bipolar disorder or at risk for the illness based on enriched family history with multiple first degree relatives diagnosed with BPD (N=5335). Included were all subjects who had >40 positively endorsed CBQ symptom items at frequencies of very often, almost always, and always. This group was divided randomly into two groups, the exploratory group (N=2668) and the hypothesis testing (study) group (N=2666). The exploratory group was used for the development of hypotheses and the study group was used to test these hypotheses on a new set of data. All results reported here derive from the latter group. In subsequent analyses, we classified each child as having a high degree of FOH, low FOH, or no FOH. We examined a subset of the sample for differences in age of onset of first psychiatric symptoms, course of illness and measures of symptom severity. These groups were compared using the chi-square procedure for categorical data and the Analysis of Variance (ANOVA) with Scheffe pair wise tests for continuous variables. The Child Bipolar Questionnaire V.2.0, the Yale-Brown Obsessive Compulsive Scale (YBOCS) and the Overt Aggression Scale (OAS) were the principal instruments used to obtain diagnostic information for this study. RESULTS We found that children representative of the FOH phenotype when compared to children with PBD who lack this trait had higher indices of severity of mania and depression, as well as other indices that reflect severity and course of illness. Trait factors were derived from a factor analysis of CBQ in a large population of children diagnosed with or at risk for PBD, and used to further elucidate trait features of children with FOH. Children with the FOH traits were also more likely to be defined by six CBQ factors; Sleep/Arousal, Harm to Self and Others, Territorial Aggression, Anxiety, Self-esteem, Psychosis/Parasomnias/Sweet Cravings/Obsessions (PPSO). LIMITATIONS This data is derived from samples enriched with bipolar disorder cases. Further validation is needed with samples in which childhood-onset BD is rarer and diagnoses more diverse. Clinician diagnosis was not validated via research interview. CONCLUSIONS The FOH phenotype, as defined by a metric derived from combining items from the YBOCS/OAS, is a clinically homogeneous behavioral phenotype of PBD with early age of onset, severe manic and depressive symptoms, and significant social impairment that is strongly associated with 6 CBQ factors and can be easily identified using the CBQ. Through the examination of dimensional features of PBD in an enriched sample of large size, we were able to further refine a phenotype and identify clinical dimensions potentially linked to endophenotypic markers that may prove fruitful in differential diagnosis, treatment and etiological studies of PBD. The nature of the sets of specific symptoms that comprise the FOH factors enabled us to propose a biological model for the phenotype (OUT) that involves a complex orexigenic circuit which links hypothalamic, limbic, and other brain nuclei primarily responsible for the regulation of behavioral and proposed physiological features of the FOH phenotype.
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Affiliation(s)
- Demitri Papolos
- Juvenile Bipolar Research Foundation, 22 Crescent Road, Westport, CT 06880, USA.
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Doyle AE, Wozniak J, Wilens TE, Henin A, Seidman LJ, Petty C, Fried R, Gross LM, Faraone SV, Biederman J. Neurocognitive impairment in unaffected siblings of youth with bipolar disorder. Psychol Med 2009; 39:1253-63. [PMID: 19079809 PMCID: PMC2853769 DOI: 10.1017/s0033291708004832] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND There is growing evidence for the familiality of pediatric bipolar disorder (BPD) and its association with impairments on measures of processing speed, verbal learning and 'executive' functions. The current study investigated whether these neurocognitive impairments index the familial risk underlying the diagnosis. METHOD Subjects were 170 youth with BPD (mean age 12.3 years), their 118 non-mood-disordered siblings and 79 non-mood-disordered controls. Groups were compared on a battery of neuropsychological tests from the Wechsler Intelligence Scales, the Stroop Color Word Test, the Wisconsin Card Sorting Test (WCST), the Rey-Osterrieth Complex Figure (ROCF), an auditory working memory Continuous Performance Test (CPT) and the California Verbal Learning Test-Children's Version (CVLT-C). Measures were factor analyzed for data reduction purposes. All analyses controlled for age, sex and attention-deficit/hyperactivity disorder (ADHD). RESULTS Principal components analyses with a promax rotation yielded three factors reflecting: (1) processing speed/verbal learning, (2) working memory/interference control and (3) abstract problem solving. The CPT working memory measure with interference filtering demands (WM INT) was only administered to subjects aged > or =12 years and was therefore analyzed separately. BPD youth showed impairments versus controls and unaffected relatives on all three factors and on the WM INT. Unaffected relatives exhibited impairments versus controls on the abstract problem-solving factor and the WM INT. They also showed a statistical trend (p=0.07) towards worse performance on the working memory/interference control factor. CONCLUSIONS Neurocognitive impairments in executive functions may reflect the familial neurobiological risk mechanisms underlying pediatric BPD and may have utility as endophenotypes in molecular genetic studies of the condition.
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Affiliation(s)
- A E Doyle
- Pediatric Psychopharmacology Unit, Massachusetts General Hospital, Child Psychiatry Service, 55 Fruit Street, Boston, MA 02114, USA.
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Dilsaver SC, Akiskal HS. "Mixed hypomania" in children and adolescents: is it a pediatric bipolar phenotype with extreme diurnal variation between depression and hypomania? J Affect Disord 2009; 116:12-7. [PMID: 19007995 DOI: 10.1016/j.jad.2008.10.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Revised: 09/10/2008] [Accepted: 10/21/2008] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although DSM-IV and the literature on pediatric bipolarity recognize mania and mixed phases neither recognizes states of "mixed hypomania." There has been preliminary presentation of the latter phenomenon in the adult bipolar literature. The authors herein describe this phenomenon in a consecutive clinical series of bipolar children and adolescents. METHODS This exploratory study involved 47 consecutive bipolar patients between the ages of 7 and 17 years presenting to an outpatient clinic. They were evaluated using a structured instrument designed to ascertain the presence of major depressive episodes (MDE), hypomania, mania, psychotic disorders, behavioral disorders such as oppositional defiant disorder and conduct disorder and substance use disorders. We defined mixed hypomania as MDE and hypomania coexisting over at least 2 weeks. RESULTS Of 47 patients, 9 girls (42.9%) and 9 boys (34.6%) were bipolar II mixed. This paper focuses on them. The mean ages of the bipolar II girls and boys were 14.3 (1.9) years and 12.0 (3.4) years, respectively (p<0.05, t=2.45, df=17). This mixed subgroup tended to experience rising mood in the evening, often with spikes of euphoria; a history of late afternoon to evening increased talkativeness or pressured speech was common. Some patients exhibited flight of ideas. Psychomotor acceleration, heightened level of energy, and increased goal directed activity between 1900 and 0300 were frequently reported. Retrospectively obtained circadian information revealed, in most cases an age inappropriate phase delay of sleep onset: After falling asleep in the early hours of the morning the patients awoke feeling depressed, lethargic and as if they could sleep throughout much of the day. LIMITATION Cross-sectional, exploratory study based on a relatively small sample size and in need of replication in other clinical settings. CONCLUSION Mixed hypomania was a common phenomenon in pediatric bipolar II patients. It is apt to go unrecognized in cross-sectional assessments done in the morning or in the early or mid-afternoon. Those with this proposed phenotype would appear "depressed" at these times. Alternatively, what we have proposed can also be described as severe diurnal variation between depression and hypomania in the evening. Further study is required combining 24-hour clinical observation and state of the art technologically derived data.
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