Bipolar Disorder in Adolescence: Diagnosis and Modern Treatment
Renee S. Baker, Feb 8, 2011
Introduction
In the fall of 2007, just a few years ago, Carmen Moreno and her colleagues made national and even international news when they released a report showing that bipolar disorder (BPD) diagnosis had increased by a factor of 40 over a previous ten year period. They based their compelling results on youth doctor office visits and found that for every 100,000 youth, 25 had been diagnosed as BPD in 1994-1995 and then a decade later 1003 had been diagnosed BPD in 2002-2003. In contrast, adult diagnoses only increased by a factor of 1.9 – from 905 to 1679 BPD diagnoses – over the same time period. (2007, Moreno, Laje, Blanco, Jiang, Schmidt, Olfson). The researchers suggest that either historically BPD was under diagnosed in children and adolescents and the problem has now been rectified, or BPD is over diagnosed in this age group today. Without independent diagnostic assessments, they say no hypothesis can be selected.
Articles and entire journal issues have been dedicated to the study of bipolar disorder in children and adolescents (2009a, Post), and as such, Derryck Smith reports that there is no greater controversy in child and adolescent psychiatry than that related to the diagnosis, treatment and ever increasing prevalence of childhood-onset BPD (Smith, 2007). He reminds the reader that classic BPD was described by Kraepelin over 50 years ago as discrete episodes of depression and mania – as reflected in the current DSM-IV-TR criteria. However, he says, in 2001 the National Institute of Mental Health (NIMH) Roundtable agreed on creating two phenotypes for youth with BPD – one that is called “narrow” and aligns itself with DSM criteria and the other that is termed “broad” in which children may be considered BPD if they present with irritability, mood lability, temper tantrums, hyperactivity and poor concentration in non-episodic fashion. He notes Gabrielle Carlson’s 2006 conference discussion that in the Sixties, the precursor to ADHD was called “hyperactive child syndrome” which included irritability, explosiveness and sleep problems. She opined that over the last 30 to 40 years, the criteria for ADHD has been narrowing while the criteria for BPD has been broadening. In other words, it may not be that there is an increase in the prevalence of BPD among youth, but just in the way we diagnose things. Smith states we are likely to see a new set of criteria for BPD in children and adolescents in the upcoming DSM-V, expected out in 2013. (Smith, 2007).
Others believe the widespread occurrence of BPD among youth is akin to a “storm”, so says Robert Post. He believes that of the 1 million children now diagnosed in the U.S. with BPD, the reason for the increase is that people are now beginning to come around to the idea that moody children can actually suffer from a psychiatrically defined mood disorder – a real paradigm shift in thinking. (2009b, Post). He believes what the field of BPD needs now is not the discovery of new treatments which could take too many years to develop, but merely to determine how to deploy and sequence the ones that are already available (2009a, Post).
Parens and Johnston discuss the controversies in child/adolescent onset BPD as well and note that while there seems to be a disagreement about labels, there is agreement that these youth desperately need help (2010, Parens and Johnston). They also note that the United States is also the only country in the world that has such high BPD rates (1000 per 100,000) with Brazil coming in second with no specific rates given. The remainder of world countries are vastly similar to older U.S. rates. England has 1.7 cases per 100,000 and Ireland has 2.2 cases per 100,000 every year. But part of that is that the U.S. falls under the DSM-IV, they say, which has a broader net than the ICD-10 used in Europe. (The ICD criteria requires two manic episodes compared to only one for the DSM – discussed more in the next section.) (2010, Parens and Johnston). All said, the World Health Organization, according to Carta and Angst, has listed BPD is one of the leading causes of disability throughout the world (2005). Incidentally, also supportive of the newer prevalence rates for BPD youth is the fact that about 44% of Bipolar 1 (definition given later) Disorder children become youth adults with Bipolar 1 as well (2008, Primary Psychiatry).
The remainder of this paper is to review the diagnostics for BPD in adolescents as well as to review various treatment options, including pharmacotherapy and psychotherapy options, or the combination thereof. The BPD field is vast and only a sampling is given, yet the field is small enough, especially for youth BPD, where one can easily see gaps in research yet needed.
Bipolar Disorder Diagnosis in Adolescence
In a recent practitioner review, Baroni of NIMH and colleagues present an assessment of BPD in children and adolescents. Their primary goal was to use a large literature review in conjunction with their own research to provide guidance on how clinicians should assign the BPD diagnoses to children and adolescents. They argue that at this time, the diagnosis of BPD should only given to youth that have a history of mania or hypomania meeting full DSM-IV-TR criteria (4 days for hypomania, 7 for full mania). Their recommendation is consistent with guidelines from both the American Academy of Child and Adolescent Psychiatry and the British National Institute for Health and Clinical Excellence. (2009, Baroni, Lunsford, Luckenbaugh, Towbin and Leibenluft). Further, they want to pass on another key message that youth with severe, non-episodic irritability have no optimum diagnosis, but current evidence suggests that it may be a variant of depression, and differs from youth with BPD.
BPD in the United States is currently diagnosed in both children, adolescents and adults according to the criteria specified in the DSM-IV-TR (APA, 2000). A review of technical definitions for major depressive episode, manic episode, mixed episode and hypomania episode are given in the Appendix 1.
With these definitions, a quick review of BPD may be given – BPD is divided into Bipolar 1 and Bipolar 2 disorders. Bipolar 1 also has several variants, making it a bit more complex, but necessary. Each of these has various specifiers to further delineate the type of BPD, but that is beyond what is needed here.
- Bipolar Disorder 1 – defined by the DSM as follows (partial definitions only)
o BPD1 – Single Manic Episode (presence of only 1 manic episode and no past major depressive episodes)
o BPD1 – Most Recent Episode Hypomanic (currenly or recently hypomanic and previously must have had manic or mixed episode)
o BPD1 – Most Recent Episode Manic (currently or recently in a manic episode)
o BPD1 – Most Recent Episode Mixed (currently or recently in a mixed episode and previously at least on major depressive episode, manic episode or mixed episode)
o BPD1 – Most Recent Episode Depressed (currently or recently in a major depressive episode and there has previously been at least one manic episode or mixed episode)
o BPD1 – Most Recent Episode Unspecified
- Bipolar Disorder 2 – defined by the DSM as a presence or history of having one or more Major Depressive Episodes, with a presence or history of at least one hypomanic episode, and NEVER having had a manic or mixed episode. There are several other criteria not given here.
- Bipolar Not Otherwise Specified – This is often used for youth that have rapidly alternating manic and depressive symptoms where the minimum durations are too short to meet criteria for manic, hypomanic or major depressive episodes. It can also be used for recurrent hypomanic episodes w/o depression.
BPD-1, BPD-2 and BPD-NOS can be diagnosed for children, adolescents and adults according to the above criteria (and details given in the DSM-IV-TR). It is important to note that the Amcerican Academy of Child and Adolescent Psychiatry (AACAP) recommends that caution be taken in making the diagnosis in children younger than six years of age (2010, Pfeifer).
Differential Diagnosis
The most common comorbid condition with BPD is ADHD. To make a distinction between ADHD and BPD, the presence of distinct episodes of mood (mania and depression) should be used (2009, McDougall). ADHD is more constant and bipolar has cycles. Additionally, preliminary research by Luckenbaugh and colleagues demonstrate that BPD children sleep less than their ADHD counterparts.
BPD should be distinguishable from schizophrenia for the same first reason as ADHD…schizophrenia has a gradual decline in functioning, where BPD is episodic in nature (McDougall). Substance misuse can be misleading because of the manic symptoms that some drugs may have. For such reasons, substance abuse or intoxication disorders in youth can be eliminated with the use of urine samples for drug usage. (McDougall)
Pharmacotherapy Treatment Strategies
BPD in children and adolescents is often associated with difficulties in school (lower school performance), an increased risk of substance abuse and substance disorders, and suicide attempts and completions. Hence, it is recommended that the goal of treatment for BPD is to achieve mood stabilization and to improve psychosocial and educational outcomes. (Pfeifer). Treatment plans for BPD typically involve a multidisciplinary approach targeting psychological, biological and social aspects of the disease (Pfeifer). Pharmacological intervention remains the mainstay of treatment at the current moment (Pfeifer). The decisions on what medications to use are based on patterns or history of episodes – mixed, manic and depressive.
The AACAP recommends that treatment begin with monotherapy and if a partial response is noted, the initial therapy can be augemented with another agent. Currently, the AACAP recommends lithium, divalproex sodium (valproate semisodium) and the atypical antipsychotics as first-line agents for the treatment of youth – children as well as adolescents – with BPD (Pfeifer). Note that almost all BPD medications have some type of adverse effects from nausea and rashes to weight gain and pregnancy complications.
The medications available for children and adolescents are generally available on a limited basis and there are less choices available than with adult patients with BPD. Commonly used medications with children and adolescents that have BPD are given in Appendix 2 with brief commentary.
An example treatment algorithm for pediatric bipolar disorder was given by Brown University (2005) for Bipolar 1 with no psychosis. The first stage of the algorithm begins with monotherapy using a mood stabilizer or atypical antipsychotic medication. If there is partial improvement, then one can augment with another first line recommendation. The second stage is monotherapy with an alternative drug, and then augmentation. The third stage is a possible medication combination such as lithium plus an atypical. The fourth stage is a combination of 2-3 mood stabilizers. The fifth stage is alternate monotherapy with oxcarbazepine, ziprasidone, or aripiprazole. And the sixth and final stage is for nonresponse cases or intolerable side effect cases. In this stage, clozapine for children or adolescents, or electroconvulsive therapy for adolescents only.
Psychotherapeutic Treatment Strategies
Although it is generally recognized that pharmacotherapy treatment is the first line of treatment in BPD, evidence is further accumulating that pscychotherapeutic interventions are important in treating and coping with BPD (Hatchett, 2009). Inder and colleagues take a developmental perspective when working with BPD clients (Inder, Crowe, Moor, Luty, Carter, and Joyce, 2008). They see identity as a framework from which individuals interact with the world and have studied how BPD impacts that development. In particular BPD clients developed varying senses of self based upon their varying mood states – hence often developing different and contradictory selves resulting in confusion in who their “real self” was. They henceforth lacked an internalized sense of sameness, lacked a coherent self-evaluation and varying negative self perceptions. By focusing therapy on integration and understanding BPD effects on self, they could build a life trajectory that was more solid and stable. (Crowe, Inder, Joyce, Moor, Carter and Luty, 2008).
David Miklowitz found that episodes of BPD were strongly associated with family discord, criticism and conflict (2007). Hence, he says, there is increasing evidence that family psychoeducational treatments are effective in relapse prevention and symptom control when combined with standard pharmacotherapy. Family-focused therapy (FFT) involves the client and one or more of their relatives for a 9 month program (21 sessions) that begins immediately after an acute episode of mania, depression or mixed disorder. The FFT program consists of three modules including psychoeducation (educating the client about BPD, warning signs, relapse prevention and so on), communication enhancement training (effective speaking, listening and negotiating skills, with homework practice) and problem solving skills training (identifying specific family problems, brainstorming solutions, evaluating solutions, and so on). Miklowitz found in two trials that school age children with BPD were much stabilized with FFT or with FFT and cognitive behavioral therapy.
Goldstein, Miklowitz and Mullen (2006) found that there was no significant difference in social skills knowledge between adolescents with BPD and those without BPD. But, they found that the BPD youth had a harder time with the performance of those social skills, particularly in times of stressful situations. They suggest that youth are able to manage those situations with dialectical behavior therapy in order to regulate emotion (learning mindfulness of emotions, reducing emotional reactivity, and increasing positive emotional events) and reduce distress.
One final approach by Lewis Mehl-Madrona (2010) employs the power of story to heal the individual with BPD. He says while the biomedical paradigm diagnoses BPD through applying a set of criteria in cookbook fashion, it also generates a set of medications to be applied in cookbook fashion. Narrative psychiatry approaches, he says, on the other hand, generate action plans that are unique to the people that are creating them. While he does not avoid using the DSM as it is a way to communicate and categorize, he prefers to use SPECT (single photon emissions computed tomography) scans, which demonstrate blood flow through various regions of the brain, because they generate a more reliable story about what is happening in a person’s brain. He says that our (social) relationships with clients can change dendritic connections in the brain, in the nervous system, and can change regional blood flow and metabolism, and can transform the story we tell about who we think we are. In other words, by sharing and changing story, we change the brain and find healing in the process. Mehl-Madrona says that community is ultimately essential to the healing process.
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
Baroni, A., Lunsford, J. R., Luckenbaugh, D. A., Towbin, K. E., & Leibenluft, E. (2009). Practitioner review: The assessment of bipolar disorder in children and adolescents. Journal of Child Psychology and Psychiatry, 50(3), 203-215.
Bipolar disorder in children and adolescents: treatment and diagnosis. (2005). Brown University Psychopharmacology Update, 16(4), 1-7.
Carta, M., & Angst, J. (2005). Epidemiological and clinical aspects of bipolar disorders: controversies or a common need to redefine the aims and methodological aspects of surveys. Clinical Practice & Epidemiology in Mental Health, 14. doi:10.1186/1745-0179-1-4
Crowe, M., Inder, M., Joyce, P., Moor, S., Carter, J., & Luty, S. (2009). A developmental approach to the treatment of bipolar disorder: IPSRT with an adolescent. Journal of Clinical Nursing, 18(1), 141-149. Retrieved Feb. 5, 2011 from the EBSCO database.
Goldstein, T. R., Birmaher, B., Axelson, D., Goldstein, B. I., Gill, M., Esposito-Smythers, C., & Keller, M. (2009). Family environment and suicidal ideation among bipolar youth. Archives of Suicide Research, 13(4), 378-388. Retrieved Feb. 6, 2011 from the EBSCO database.
Goldstein, T. R., Miklowitz, D. J., & Mullen, K. L. (2006). Social skills knowledge and performance among adolescents with bipolar disorder. Bipolar Disorders, 8(4), 350-361.
Hatchett, G. T. (2009). The Enigma of Bipolar Disorder in Children and Adolescents. Journal of School Counseling, 7(29. Retrieved Feb. 2, 2011 from the EBSCO database.
Inder, M. L., Crowe, M. T., Moor, S., Luty, S. E., Carter, J. D., & Joyce, P. R. (2008). ‘I actually don’t know who I am’: The impact of bipolar disorder on the development of self. Psychiatry: Interpersonal and Biological Processes, 71(2), 123-133. Retrieved Feb. 5, 2011 from the EBSCO database.
Mansell, W., Powell, S., Pedley, R., Thomas, N., & Jones, S. (2010). The process of recovery from bipolar I disorder: A qualitative analysis of personal accounts in relation to an integrative cognitive model. British Journal of Clinical Psychology, 49(2), 193-215. Retrieved Feb. 5, 2011 from EBSCO database.
McDougall, T. (2009). Nursing children and adolescents with bipolar disorder: assessment, diagnosis, treatment, and management. Journal Of Child And Adolescent Psychiatric Nursing: Official Publication Of The Association Of Child And Adolescent Psychiatric Nurses, Inc, 22(1), 33-39.
Mehl-Madrona, L. (2010). Healing the Mind Through the Power of Story: The Promise of Narrative Psychiatry, Rochester, VT : Bear & Company.
Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M. (2007). National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry, 64(9):1032-9. Retrieved Feb 6, 2011 from PubMed database.
Parens, E., & Johnston, J. (2010). Controversies concerning the diagnosis and treatment of bipolar disorder in children. Child & Adolescent Psychiatry & Mental Health, 4:9, 1-14. Retrieved Feb. 6, 2011 from EBSCO database.
Pfeifer, J., Kowatch, R., & DelBello, M. (2010). Pharmacotherapy of bipolar disorder in children and adolescents: recent progress. CNS Drugs, 24(7), 575-593.
Post, R. M. (2009a). Bipolar disorder, with a focus on childhood-onset bipolar disorder. Psychiatric Annals, 39(10), 874-877. Retrieved Feb. 6, 2011 from EBSCO database.
Post, R. M. (2009b). Childhood-onset bipolar disorder: The perfect storm. Psychiatric Annals, 39(10), 879-886.
RESEARCHERS DETERMINE RATES OF CHILD AND ADOLESCENT BIPOLAR I DISORDER BECOMING ADULT BIPOLAR I DISORDER. (2008). Primary Psychiatry, 15(12), 24-25.
Smith, D. H. (2007). Controversies in childhood bipolar disorders. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie, 52(7), 407-408. Retrieved Feb. 6, 2011 from EBSCO database.
Appendix 1 – Mood Episodes
To gain a deeper understanding of BPD diagnosis, an understanding of depression and mania episode criteria must be obtained. Briefly, these mood disorder type episodes are delineated at follows:
- Major Depressive Episode – defined by the DSM as a period of at least 2 weeks during which there is either a depressed mood and/or a loss of pleasure in nearly all of one’s activities. Children and adolescents can be irritable instead of depressed. There are nine symptoms of which five must be present (depressed, no pleasure realized, weight loss or failure to gain weight in youth, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of guilt or worthlessness, lack of focus, and suicidal ideation/ thoughts of death). Several other criteria such as impairment in social functioning must also be met.
- Manic Episode – defined by the DSM by a distinct period during which there is abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week, unless hospitalization is required. There must be at least three of these symptoms: inflated self-esteem/grandiosity, decreased need for sleep, more talkative, flight of ideas, distractibility, increase in goal directed activity or excessive involvement. Several other criteria such as impairment in social functioning must also be met.
- Mixed Episode – defined by the DSM as a period of time lasting at least 1 week in which criteria are met for both Manic Episode and Major Depressive Episode nearly every day. Several other criteria such as impairment in social functioning must also be met.
- Hypomanic Episode – defined by the DSM as a distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood that lasts at least 4 days. There must be at least three of these symptoms (same list as for manic): inflated self-esteem/grandiosity, decreased need for sleep, more talkative, flight of ideas, distractibility, increase in goal directed activity or excessive involvement. Several other criteria EXCEPT impairment in social functioning, etc., must also be met. However, the change during this time must be noticeable by others.
Appendix 2 – Pharmaceuticals to Treat BPD
The following is a list of medications that are available or potentially available to treat child and adolescent BPD. A brief comment of each is included regarding usage and adverse effects. Details are left to the reader (2010, Pfeifer).
- Lithium Salts – considered the gold standard for BPD treatment – has serious side effects such as pregnancy complications, diabetes and thyroid malfunction
- Anti-epileptics – effective in treating manic symptomatology
o Divalproex Sodium (Valproate Semisodium) – questionable effectiveness, may have serious side effects such as pancreatitis and polycystic ovary syndrome
o Lamotrigine – preliminarily effective for depression, but may cause Stevens-Johnson syndrome – a horrible life threatening skin condition
o Carbamazepine – results appear to indicate effective for mood stabilization with adverse effects from the simple rash, sedation, nausea to life threatening aplastic-anemia and Stevens Johnson syndrome
o Oxcarbazepine – No significant difference to placebo – adverse effects may include drowsiness, double vision and fatigue
o Topiramate –not effective for acute mixed or manic states and not better than placebo – adverse effects include decreased appetite, cognitive impairment, kidney stones and peripheral nerve issues.
- Atypical Antipsychotics – second generation antipsychotics (SGAs)
o Clozapine – may be effective in reducing mania in youth – serious adverse effects including loss of white blood cell count – agranulocytosis
o Risperidone –effective for treating child and adolescent mania – may cause restless leg syndrome, diarrhea, Parkinson’s symptoms, and diabetes
o Olanzapine – appears to be efective for treating mania, but has adverse effects such as metabolic changes, weight gain, and lactation regulation issues
o Quetiapine – shows to be effective for acute mania and potentially depression – adverse effects can be increased risk of suicidal thinking
o Ziprasidone –shows to be effective for manic symptoms and has lower risk for metabolic issues than other atypical antipsychotics
o Aripiprazole – showing effective for manic and mixed episodes but has risk of EPS side effects
o Paliperidone – similar to risperidone, new on the market and no data yet
o Omega-3 Fatty Acids – An alternative medication effective for treating depression. Sources of Omega-3 include wild salmon.
o Pharmacogenetics
