Parental Reports of Prodromal Psychopathology in Pediatric Bipolar Disorder

Sleep Deprivation and Insomnia in Adolescence: Implications for Mental Health

Sleep changes significantly throughout the human lifespan. Physiological modifications in sleep regulation, in common with many mammals (especially in the circadian rhythms), predispose adolescents to sleep loss until early adulthood. Adolescents are one-sixth of all human beings and are at high risk for mental diseases (particularly mood disorders) and self-injury. This has been attributed to the incredible number of changes occurring in a limited time window that encompasses rapid biological and psychosocial modifications, which predispose teens to at-risk behaviors. Adolescents’ sleep patterns have been investigated as a biunivocal cause for potential damaging conditions, in which insufficient sleep may be both a cause and a consequence of mental health problems. The recent COVID-19 pandemic in particular has made a detrimental contribution to many adolescents’ mental health and sleep quality. In this review, we aim to summarize the knowledge in the field and to explore implications for adolescents’ (and future adults’) mental and physical health, as well as to outline potential strategies of prevention.

Detection of bipolar disorder in the prodromal phase: A systematic review of assessment instruments

BACKGROUND

Early detection of prodromal symptoms may contribute to improving the prognosis of patients with bipolar disorder (BD). The main objective of this systematic review is to present the different procedures for the identification of initial and relapse prodromes in these patients.

METHODS

PsycINFO, Web of Science and PubMed databases were searched using a predetermined strategy, until January 4, 2022. Then, by means of a regulated process, studies that used a BD prodrome detection procedure, in English-language and all ages participants were selected. Quantitative and qualitative studies were assessed using a modified version of the Newcastle-Ottawa Scale and by Critical Appraisals Skills Programme checklist, respectively.

RESULTS

Forty-five studies were selected. Of these, 26 used procedures for identifying initial prodromes (n = 8014) and 19 used procedures for detecting relapse prodromes (n = 1136). The interview was the most used method in the detection of both types of prodromes (k = 30 papers, n = 4068). It was variable in its degree of structure. Mobile applications and digital technologies are gaining importance in the detection of the relapse prodromes.

LIMITATIONS

A retrospective design in most papers, small samples sizes, existence of persistent subsyndromal symptoms and difficulty to identify the end of the prodrome and the onset of the disorder.

CONCLUSIONS

There is a wide variety of assessment instruments to detect prodromes in BD, among which the clinical interview is most frequently used. Future research should consider development of a brief tool to be applied in different formats to patients and family members.

Amygdala structure and function in paediatric bipolar disorder and high-risk youth: A systematic review of magnetic resonance imaging findings

OBJECTIVE

Converging evidence from structural and functional magnetic resonance imaging (MRI) studies points to amygdala alteration as crucial in the development of paediatric bipolar disorder (pBP). The high number of recent studies prompted us to comprehensively evaluate findings. We aimed to systematically review structural and functional MRI studies investigating the amygdala in patients with pBP and in youth at high-risk (HR) for developing pBP.

METHODS

We searched PubMed from any time to 25 September 2020 using: 'amygdala AND (MRI OR magnetic resonance imaging) AND bipolar AND (pediatr* OR child OR children OR childhood OR adolescent OR adolescents OR adolescence OR young OR familial OR at-risk OR sibling* OR offspring OR high risk)'. In this review, we adhered to the PRISMA statement.

RESULTS

Amygdala hyperactivity to emotional stimuli is the most commonly reported finding in youth with pBP and HR compared to healthy peers (HC), whereas findings from structural MRI studies are inconsistent.

CONCLUSIONS

Hyperactivation of the amygdala might be an endophenotype of pBP.

The relationship between sleep and depression and bipolar disorder in children and young people

BACKGROUND

Sleep difficulties are often reported in practice, and are part of the diagnostic criteria for depression and bipolar disorder.

AIMS

To inform the understanding of the relationship between sleep and both depression and bipolar disorder.

METHOD

We conducted a narrative literature review of affective disorders and sleep difficulties in children and young people.

RESULTS

Specific sleep disorders, such as parasomnias, narcolepsy and sleep-related movement disorders, are associated with depression, whereas insomnia, obstructive sleep apnoea and circadian rhythm disorders are associated with both depression and bipolar disorder in children and young people. Conversely, children and young people with depression can present with a number of sleep difficulties, and these are associated with higher depression severity and greater fatigue, suicidal ideation, physical complaints, pain and decreased concentration. Sleep disturbances among adolescents with bipolar disorder can affect the severity of depressive and manic symptoms, are a poor prognostic indicator and have been associated with social and academic impairment. Antidepressants and antipsychotics can directly affect sleep architecture, which clinicians need to be aware of. Non-pharmacological interventions for sleep problems could prevent and/or minimise the risk of relapse in affective disorders.

CONCLUSIONS

Sleep difficulties can occur before, during and after an episode of depression or bipolar disorder, and have a higher prevalence in affective disorders compared with the general population. A multi-modal approach would include the treatment of both the affective and specific sleep disorder. Further research is needed in this field to understand the impact of combined interventions on clinical outcomes.

Temperament Profiles of Children and Adolescents with Psychotic and Mood Disorders

BACKGROUND

Psychiatric disorders are often linked to dysfunctions within neurotransmitter systems, and the same systems play a role in healthy temperaments. Development of a common bio-behavioural taxonomy based on functionality of neurotransmitter systems suggests examining temperament profiles in patients with various psychiatric disorders.

OBJECTIVE

(1) To investigate temperament profiles in two age groups of children with delusional disorders; (2) to investigate temperament profiles in adolescents with mood disorders; (3) to investigate temperament profiles in in vitro fertilisation (IVF) children.

METHODS

Sample: in total 171 participants (M/F = 91/80), healthy children and teenagers (volunteers); two age groups of children with psychotic disorders; teens with mood disorders (clients of the Federal Mental Health Center) and healthy IVF. Parents of participants completed a test based on the neurochemical model Functional Ensemble of Temperament (FET).

RESULTS AND CONCLUSIONS

(1) Both age groups of children with psychotic disorders had significantly lower scores on the scales of physical endurance, tempo, plasticity, and self-satisfaction, in comparison to healthy controls; the psychotic group aged 5-11 had also lower scores on the impulsivity scale, whereas the psychotic group 12-17 had lower scores on the social endurance and social tempo scales and higher neuroticism. (2) Teens with mood disorders had lower scores on the self-confidence-satisfaction scale and higher scores on the impulsivity scale, in comparison to controls. (3) No difference between IVF and naturally conceived children were found. The results show the benefits of using the FET framework for structuring the correspondence between psychiatric disorders and temperament as it differentiates between social versus physical aspects of behaviour and orientational versus executive aspects.

Prodromal symptoms of Chinese patients with bipolar disorder

OBJECTIVE

This study aimed to assess the clinical phenomenology and characteristics of prodromal symptoms in Chinese patients with bipolar disorder (BPD) prior to their index mood episode.

METHODS

Semi-structured interviews [Bipolar Prodrome Symptom Scale-Retrospective (BPSS-R)] were administered to patients within 3 years of BPD (I and II) onset.

RESULTS

120 stable inpatients and outpatients were included (65% males, mean age: 26.5±10.0 years). Feeling extremely energetic (61.8%), overly cheerful (49.1%), racing thoughts (48.2%), overly talkative (47.3%), and decreased need for sleep (43.6%) most frequently preceded the first (hypo)manic episode, whereas depressed mood (78.5%), tiredness (53.9%), reduction of enjoyment (52.3%), trouble concentrating (49.2%) and insomnia (47.7%) often occurred prior to the index depressive episode. The prevalence of anxiety or nervousness (p = 0.009), social isolation (p = 0.004), and losing temper (p < 0.001) differed significantly depending on the different episodes. Prior to any depressive episode, insomnia (p = 0.035) lasted significantly longer and sleeping too much (p = 0.033) was more severe, whereas oppositionality (p < 0.001), hallucinations (p = 0.024) and psychosis index score (p = 0.044) were more severe before any (hypo) manic episode. Furthermore, depressed mood (p = 0.006) was more frequent prior to depression, while anxiety or nervousness (p = 0.018), oppositionality (p = 0.001), and psychosis index score (p = 0.009) were more frequent before any (hypo) manic episode.

CONCLUSIONS

Characteristic affective and psychotic symptoms, including depressed mood and subthreshold hypo (manic) symptoms occurred in the prodromal phase. The pre-depression prodromal symptoms lasted longer than the pre-(hypo) mania prodromal symptoms. Our findings indicated that identifying prodromal symptoms of BPD may be beneficial for early diagnosis and intervention before the development of full episodes.

Cortical Correlates of Impulsive Aggressive Behavior in Pediatric Bipolar Disorder

Background: Impulsive aggression represents a frequent characteristic of pediatric bipolar disorder (PBD). Cortical alterations associated with impulsive aggression and its multiple facets have not been investigated yet in youth with bipolar disorder. Aim: To investigate the relationship between cortical thickness and facets of impulsive aggression in youth with PBD. Materials and Methods: Twenty-three youth with PBD and 23 healthy controls (HC) were administered the aggression questionnaire (AQ) and underwent 3T magnetic resonance imaging scan. Cortical thickness was assessed with FreeSurfer. Canonical correlation analyses were used to investigate the relationship between AQ total and subscale scores and cortical thickness in youth with PBD. Results: Youth with PBD had increased scores in the subscales of AQ-anger and AQ-hostility and cortical thinning in in areas belonging to the affective network (AN), frontoparietal network (FPN) and cingulo-opercular network (CON), i.e., right rostral anterior cingulate, right caudal anterior cingulate, right lateral orbitofrontal, right medial orbitofrontal, left and right inferior parietal, left posterior cingulate, left and right supramarginal left lingual cortices. Greater thickness in these networks positively correlated with the AQ-hostility subscale and negatively correlated with AQ-anger subscale. Conclusions: The opposite patterns observed between areas belonging to AN, FPN, CON, and the two facets of IA, namely anger and hostility, corroborate clinical findings supporting the different nature of these two constructs.

Demographic and Clinical Characteristics, Including Subsyndromal Symptoms Across Bipolar-Spectrum Disorders in Adolescents

Objectives: Bipolar disorder (BD) is a debilitating illness that often starts at an early age. Prevention of first and subsequent mood episodes, which are usually preceded by a period characterized by subthreshold symptoms is important. We compared demographic and clinical characteristics including severity and duration of subsyndromal symptoms across adolescents with three different bipolar-spectrum disorders. Methods: Syndromal and subsyndromal psychopathology were assessed in adolescent inpatients (age = 12-18 years) with a clinical mood disorder diagnosis. Assessments included the validated Bipolar Prodrome Symptom Interview and Scale-Prospective (BPSS-P). We compared phenomenology across patients with a research consensus conference-confirmed DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) diagnoses of BD-I, BD-not otherwise specified (NOS), or mood disorder (MD) NOS. Results: Seventy-six adolescents (age = 15.6 ± 1.4 years, females = 59.2%) were included (BD-I = 24; BD-NOS = 29; MD-NOS = 23) in this study. Median baseline global assessment of functioning scale score was 21 (interquartile range = 17-40; between-group p = 0.31). Comorbidity was frequent, and similar across groups, including disruptive behavior disorders (55.5%, p = 0.27), anxiety disorders (40.8%, p = 0.98), and personality disorder traits (25.0%, p = 0.21). Mania symptoms (most frequent: irritability = 93.4%, p = 0.82) and depressive symptoms (most frequent: depressed mood = 81.6%, p = 0.14) were common in all three BD-spectrum groups. Manic and depressive symptoms were more severe in both BD-I and BD-NOS versus MD-NOS (p < 0.0001). Median duration of subthreshold manic symptoms was shorter in MD-NOS versus BD-NOS (11.7 vs. 20.4 weeks, p = 0.002) and substantial in both groups. The most used psychotropics upon discharge were antipsychotics (65.8%; BD-I = 79.2%; BD-NOS = 62.1%; MD-NOS = 56.5%, p = 0.227), followed by mood stabilizers (43.4%; BD-I = 66.7%; BD-NOS = 31.0%; MD-NOS = 34.8%, p = 0.02) and antidepressants (19.7%; BD-I = 20.8%; BD-NOS = 10.3%; MD-NOS = 30.4%). Conclusions: Youth with BD-I, BD-NOS, and MD-NOS experience considerable symptomatology and are functionally impaired, with few differences observed in psychiatric comorbidity and clinical severity. Moreover, youth with BD-NOS and MD-NOS undergo a period with subthreshold manic symptoms, enabling identification and, possibly, preventive intervention of those at risk for developing BD or other affective episodes requiring hospitalization.

Pediatric Bipolar Disorder: Onset, Risk Factors, and Protective Factors

The current article discusses the diagnosis of bipolar disorder in children throughout the years as it has evolved, focusing on very early-onset and early-onset bipolar disorder. Proper care of children with bipolar disorder requires a thorough understanding of the subtleties in symptoms at different developmental ages, as well as a shift in diagnostic thinking, which grew to include disruptive mood dysregulation disorder (DMDD). DMDD was added to address potential overdiagnosis of an already unusual diagnosis in young children. Critical discussion of risk factors, protective factors, and lack of data to support protective factors in the literature follows. Implications for advanced practice RNs are included, as these children transition from pediatric practice to adult practice. [Journal of Psychosocial Nursing and Mental Health Services, 57(9), 32-37.].

Clinical and Environmental Risk Factors for Bipolar Disorder: Review of Prospective Studies

After participating in this activity, learners should be better able to:• Evaluate factors that have been identified in prospective studies as predicting the onset of bipolar disorder ABSTRACT: The prodromal phase of bipolar disorder (BD) remains incompletely characterized, limiting early detection of BD and delaying interventions that might limit future morbidity and disability. Retrospective and family-risk studies have consistently found evidence of prodromal psychopathology in subjects later diagnosed with BD. Here, we review prospective studies of clinical risk factors and exposures identified before diagnosis of BD: our findings are consistent with those from retrospective and family-risk studies. Affective psychopathology often precedes diagnosis to suggest a homotypic trajectory in developing BD. Early non-affective (heterotypic) psychopathological disturbances, including anxiety and disruptive behavior disorders, as well as environmental factors and exposures, have been found in prospective studies to increase the risk of BD, but tend to lack specificity in predicting BD. Findings from prospective studies are encouragingly similar to those of retrospective and family-risk studies.

Sleep and Daytime Complaints During Manic and Depressive Episodes in Children and Adolescents With Bipolar Disorder

INTRODUCTION

Depressive and manic episodes of bipolar disorder can interact with sleep complaints, followed by a worsened psychiatric condition. The aim of this study was to examine the interaction of sleep disorders with bipolar disorder in youths during depressive and manic episodes.

METHODS

The target population was children and adolescents drawn from the Children and Adolescents Affective Disorder Program. Clinical assessment for current psychiatric diagnosis was done by direct clinical interview, Diagnostic Interview for Children and Adolescents (DSM-IV), and best-estimated clinical consensus. We applied sleep questionnaires from which we obtained sleep and daytime complaints during manic and depressive episodes. All statistical tests of significance were done using 2-tailed tests with α = 0.05.

RESULTS

Participants in this study comprised 29 children (age = 10 ± 3 years, boys = 23) and 43 adolescents (age = 15 ± 2.4 years, boys = 30). Sleep complaints were observed in 66.4% of participants during manic episodes and 52.3% during depressive episodes. 37.9% of patients had sleep complaints in both episodes. Time in bed was longer during depressive episodes than manic episodes (p = 0.01). We found a high prevalence of nocturnal enuresis in depressive episodes in children and adolescents, which was statistically significant compared with manic episodes (p < 0.05). Unrested sleep was higher in adolescents in both episodes, and it was statistically significant during manic episodes (p < 0.05).

CONCLUSION

According to our analyses, the minority of patients had sleep complaints in both episodes. Our data showed that nocturnal enuresis occurred more frequently during depressive than manic episodes. Further research is necessary to understand the implications of these data.

Children Sleep and Antisocial Behavior: Differential Association of Sleep with Aggression and Rule-Breaking

There is a strong relationship between sleep and behavioral problems. These findings are often interpreted via environmental explanations, such that poor sleep directly exacerbates or causes symptoms of aggression and behavior problems. However, there are other possible explanations, such that the genes predicting poor sleep also predict aggression or rule-breaking. The current study sought to elucidate the origin of this relationship. The sample was composed of 1030 twin pairs (426 monozygotic and 604 dizygotic). The sample was 51.3% male with a mean age of 8.06 years (range 6-11.96; SD = 1.45). Aggression, rule-breaking and sleep were assessed through the Child Behavior Checklist (CBCL). We fitted bivariate Cholesky genetic models to the data, decomposing the variance within, and the covariance among, aggression, rule-breaking, and sleep functioning into their genetic and environmental components. Genetic correlations between all sleep variables and aggression were significant and moderate to large in magnitude, but mostly small and non-significant between sleep and rule-breaking. We did not find evidence of a causal or environmental relationship between the majority of sleep variables and aggression, but rather clear evidence of genetic pleiotropy. However, the pattern of associations between rule-breaking and sleep measures was less consistent. Aggression and rule-breaking appear to be differentially associated with sleep.