Early-Onset Bipolar Disorder



Early-Onset Bipolar Disorder


Gretchen R. Gudmundsen Ph.D.,

Stefanie A. Hlastala Ph.D., Kathleen

Myers, M.D. M.P.H., M.S., FAACAP



Introduction

Early onset of bipolar disorder (BD), particularly during prepuberty, is one of the most controversial issues in child and adolescent psychiatry. The past decade has seen investigation into the definition of the disorder, developmentally appropriate expression of manic symptoms, comorbidities that mask mania, neuroimaging, and pharmacological treatment. Much has been learned, but much remains to be understood. This chapter will help primary clinicians to develop an index of suspicion regarding BD when youth present with mood instability and to know when to refer for further evaluation.


Background

Research in the 1980s on the early onset and longitudinal course of major depressive disorder (MDD) revealed that over 5 years 20% to 40% of these youth “switched” from MDD to BD, a rate three to five times higher than that for adult-onset MDD. Then, work in the 1990s suggested that a subset of children diagnosed with severe attention-deficit hyperactivity disorder (ADHD) suffered from BD. These studies paved the way for the investigation of mood instability in youth as many youth with severe irritability and behavioral outbursts were diagnosed with mixed episodes of BD. In an attempt to bring order to the controversy, investigators have proposed two subtypes of early-onset BD: “a narrow phenotype” and a “broad phenotype.” These definitions appear to be gaining acceptance despite the absence of any research demonstrating their validity. The premature reification of these hypothesized “phenotypes” has further complicated scientific and clinical work as their implications for diagnosis, treatment, and prognosis of early-onset BD are unclear. Clinicians continue to face major challenges in diagnosing and treating youth with possible BD.


Clinical Features

The Diagnostic and Statistical Manual, Fourth Edition (DSM-IV), documents two major categories of mood disorders: Depressive Disorders and Bipolar Disorders. The pathognomonic feature distinguishing Bipolar Disorders from Depressive Disorders is the experience of mania or hypomania, as shown in Table 12-1.

In depressive disorders, individuals experience a change from normal mood (euthymia) to depression, while in BD moods alternate between two poles, depression and mania, in addition to euthymia. These episodes may vary in the severity and duration and be separated by months, weeks, days, or hours, in part defining the two major subtypes of BD recognized by DSM-IV and described in Table 12-2.

As noted in Table 12-2, Bipolar-I Disorder (BD-I) requires the occurrence of at least one manic or mixed episode with marked impairment of at least 1 week or requiring hospitalization.
The presence of psychotic symptoms mandates a diagnosis of BD-I. Bipolar-II Disorder (BD-II) differs from BD-I in that the manic symptoms are of shorter duration and are less severe and, thus, termed hypomanic. Hypomania may not cause marked impairment, although it is sufficiently severe to constitute a departure from normal, or to be noted by others, and often involves later regrettable behaviors.








TABLE 12-1 Characteristics of DSM-IV Manic and Hypomanic Episodes























Type of Episode


Duration


Salient/Diagnostic Symptoms


Differentiating Features


Manic episode


At least 1 week, or any length if hospitalized


A distinct period of abnormally and persistently elevated, expansive, or irritable mood, that includes three or more of following (four if mood is mostly irritable)




  • increased self-esteem or grandiosity



  • decreased need for sleep



  • more talkative or pressure to keep talking



  • flight of ideas or racing thoughts



  • distractibility



  • increased goal-directed activity or psychomotor agitation



  • involvement in pleasurable activities with increased potential for harm.


Sufficiently severe to cause




  • May have psychosis



  • Should have at least one cardinal symptom of elation, euphoria, or grandiosity



  • In children, there are fewer distinct episodes, more rapid cycling, and/or a more chronic course


Hypomanic espomanic episode


At least 4 days


A distinct period of elevated, expansive, or irritable mood along with three of the diagnostic symptoms described above for a manic episode (four symptoms if mood is mostly irritable)




  • Change in functioning, is less severe than in mania



  • Shorter duration than mania



  • No psychosis



  • Often perceived to be a personality style, not an illness


Mixed episode


Nearly every day for at least 1 week


May occur for mania or hypomania


Criteria are met for both a Manic Episode and a Major Depressive Episode, but duration of each is very short or episodes are concurrent.


Term sometimes used interchangeably with “ultradian rapid cycling”




  • Sufficiently severe to cause impairment in social or occupational function, or to require hospitalization



  • May have psychosis



  • Can be difficult to distinguish from other conditions with severe irritability or other forms of affective dysregulation


When criteria for a manic, or hypomanic, episode and a depressive episode occur concurrently for at least 1 week, the mood episode is termed a mixed episode. This is generally difficult

to identify in children due to the co-occurrence of elation, irritability, and depression as the youth quickly cycles between moods. Additionally, if an individual experiences more than four episodes of depression or mania/hypomania in a year, a rapid cycling specifier is used.








TABLE 12-2 Characteristics of DSM-IV Bipolar Disorders

























Diagnosis


Time Course and Relationship to Depressive and Manic Episodes


Differentiating Features


Bipolar I disorder (BD-I)




  • At least one Manic Episode or Mixed Episode.



  • May or may not have had prior Major Depressive Episode




  • Thought to be the most severe form of the illness due to extremes of the mania



  • Cycling less evident in youth as depressive episodes may be less well developed, or short



  • Cycling may not be evident as children may sustain chronic manic states



  • The mania may be “masked” by comorbid ADHD and other disruptive behaviors



  • Must document the pathognomonic features of BD, such as grandiosity and hypersexuality, to distinguish from ADHD and ODD


Bipolar II disorder (BD-II)




  • At least one Major Depressive Episode, and at least one Hypomanic Episode



  • May have multiple recurrent Major Depressive Episode with only intermittently superimposed Hypomanic Episodes



  • No Manic Episodes



  • No psychosis




  • Hypomania not as severe as mania



  • Major Depressive Episodes as severe as in BD-I and can be more difficult to treat, increasing overall severity



  • May be more susceptible to antidepressant-induced “switching”



  • Differentiation from Personality Disorders with affective dysregulation may be difficult, for example, Borderline, Narcissistic, Histrionic


Cyclothymic disorder




  • Numerous cycles of lower grade depression and hypomania



  • Symptoms ongoing for at least one year in children



  • During symptomatic period, no remission of hypomania or depression for more than 2 months at a time



  • No Major Depressive Episode or Mixed Episode occurs during the first year of the disturbance




  • May exist as a distinct disorder, or may be prodromal to later BD-I or BD-II; or may exist intermorbidly between cycles of Major Depressive Episode and Manic Episode



  • May be perceived more as a personality style



  • Diagnosis not often used in children or adults


Bipolar disorder, NOS




  • Diagnosis for individuals who have manic-like and depressive symptoms that do not meet criteria for BD-I or BD-II



  • Criteria for change in functioning not indicated



  • Variable time course



  • Heterogeneous samples in studies




  • Examples include: recurrent Hypomanic Episodes without apparent interepisode depressive symptoms



  • Diagnosis has been applied to children with severe affective instability of uncertain relationship to BD-I and BD-II



  • Most controversial of early-onset BD diagnoses; caution in using this diagnosis


Adapted from American Psychiatric Association. Diagostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: Author; 2000.


Cyclothymia refers to a mood state in which individuals experience numerous periods of hypomanic and depressive symptoms that do not meet criteria for either a full manic or depressive episode, but do cause distress. For youth, these symptoms must occur over a period of at least 1 year without any symptom-free intervals lasting longer than 2 months. Individuals with BD may return to a baseline of cyclothymia much as individuals with MDD may return to a baseline of dysthymia.

Bipolar Disorder, Not Otherwise Specified (BD, NOS) allows the diagnosis of BD for individuals with more heterogeneity in presentation. For example, some youth may not meet DSM-IV criteria for BD-I or BD-II because of severity or duration criteria; but they may experience impairment due to mood instability. Unfortunately, this heterogeneity introduces laxity into the construct of BD resulting in overdiagnosis. Birmaher has proposed guidelines for standardizing the diagnosis of BD, NOS in youth, which has helped in distinguishing BD-I or BD-II from youth with disruptive disorders.


Developmental Considerations

Recent work has focused on reconciling divergent conceptualizations of how the DSM-IV criteria for BD, particularly mania, apply to youth. As noted, this controversy has led to two conceptualizations of how DSM-IV criteria apply to early-onset BD: a “narrow phenotype” and a “broad phenotype” or “severe mood dysregulation (SMD).” Liebenluft and colleagues have coined the term “narrow phenotype” to describe youth who demonstrate classic DSM-IV criteria for mania, or hypomania,that is, unmodified adult criteria. Geller and colleagues emphasize that core manic symptoms must be present to diagnose BD in children but that children express these symptoms within their developmental capabilities. They have generated examples of child-equivalent classic manic symptoms. For example, adults might run up their credit cards, become sexually promiscuous, or take on multiple new businesses. Equivalent childhood behaviors might include trying to use parents’ credit card, stealing money to give away, expressing inappropriate sexual interest, speaking in an unusually loud and rapid manner, or engaging peers in grandiose activities. These manic symptoms usually occur as part of mixed episodes and must be teased out from their associated disruptive behaviors. Geller’s interpretation of the proposed “narrow phenotype,” then, emphasized unmodified adult criteria but with developmentally appropriate expression.

Liebenluft and colleagues have used the term “broad phenotype” to define youth with SMD evidenced by extreme irritability, anger, aggression, and explosive rages without obvious euphoria or other core manic symptoms. It is difficult to discern cycling in these youth’s mood episodes and frustration seems to provoke dysregulation.

The proposal for these subtypes arises at least in part due to the “mix and match” approach of the DSM-IV nomenclature. This allows the “A criteria” to be met with a predominantly irritable, rather than a euphoric, mood. Then, the requisite four of seven “B criteria items” can be met by symptoms that overlap considerably with ADHD and do not convey the pathognomonic elation traditionally associated with BD. Thus, many investigators and clinicians contend that the “broad phenotype” represents disorders other than BD, such as severe disruptive and/or anxiety disorders. Perhaps, the greatest advantage in identifying such “phenotypes” is teasing out the “narrow phenotype” with traditional manic symptoms for future research and clinical work.

This issue may be at least partially resolved with the next revision of the DSM nomenclature, or DSM-V. Currently, there is a proposal to add a new diagnosis, “temper dysregulation disorder with dysphoria (TDD).” This disorder recognizes many of the features of SMD
proposed by Liebenluft, but also recalls concepts proposed 20 to 30 years ago by Akiskal. In brief, the disorder is characterized by severe recurrent temper outbursts in response to common stressors, which are grossly out of proportion and are not appropriate to the child’s developmental status. These episodes may be manifested verbally and/or behaviorally, such as in the form of verbal rages or physical aggression. They should occur at least three times per week. Mood between temper outbursts is persistently negative (irritable, angry, and/or sad). Onset must be before 10 years of age. The proposed criteria further require that in the past year there has never been a distinct period lasting more than one day during which abnormally elevated or expansive mood was present most of the day, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of three of the adjunctive criterion symptoms, that is, grandiosity or inflated self-esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-directed activity, or excessive involvement in activities with a high potential for painful consequences. A draft proposal of the DSM-V was released for review and comment in 2010. It will be interesting to see how these proposed criteria are critiqued.


Epidemiology

BD-I affects approximately 1% of adults, ranging from 0.8% to 1.6% in different studies. The overall prevalence is higher if BD-II is included as it affects at least another 1% of the population. Rates in childhood have not been established and rates during adolescence have been estimated from relatively small community surveys and retrospective report. Retrospective data indicate that 40% to 60% of bipolar adults report their symptoms to have begun prior to age 19. The few available community studies have found a point prevalence of 0.6% for mania among 14 to 16 years old and a lifetime prevalence of 1% for hypomania in high school students. Interestingly, community studies of “subthreshold BD” in high school students found that 5 years later they had not converted to BD-I, questioning the stability of such diagnoses in early life.

Rates of BD in children can only be estimated. Retrospective adult studies have noted that onset before age 10 is rare (0.3% to 0.5%). Birmaher notes that the prevalence of MDD ranges from 0.4% to 2.5% in children and 0.4% to 8.3% in adolescents and that 20% to 40% will “switch” to BD within 5 years of the initial depressive episode.

Gender differences are also not well established, although prepubertal boys are diagnosed 3.85 times more often than girls. This sex pattern is typical of other early-onset psychiatric disorders. Sex rates are equal during later adolescence, similar to adult BD.


Risk Factors


Heritability

Family studies of adult twins, adoptees, and family aggregation support a genetic contribution to BD with a polygenic transmission. No specific pattern of inheritance and no gene have yet been identified. Studies of early-onset BD are consistent with adult studies indicating an increased loading for all mood disorders in family members, some specificity for increased loading of BD, and family loading that is higher for childhood-onset than for adolescent-onset BD. Earlier onset of BD in adults may further increase the risk of early-onset BD in offspring, as well as push forward the age of onset.


Neurobiology

There is no clear etiology proposed for BD. Current understanding of other psychiatric illnesses does not lend much insight into conceptualizing any neurobiological process that can account for such extreme mood swings. Many untested hypotheses exist focusing on
dysregulation of sodium ion channels, second messenger systems, excitation and inhibition of gamma-aminobutyric acid (GABA), as well as genetically regulated growth factors and neuronal plasticity.

Regarding mood disorders in general, there is evidence supporting a role of both the long (I) and short (s) alleles of the serotonin transporter gene. Preliminary findings indicate that the s allele may increase risk for progression toward BD in offspring of parents with BD. The s allele has been identified as a risk factor for suicidal behavior, which is also common in BD, and for pharmacologically induced mania. The L allele has been associated with prophylactic response to lithium. Additionally, preliminary analyses of adult linkage samples suggest that early-onset BD is associated with the BDNF gene, the GAD1 gene, and the dopamine transporter gene.


Imaging Studies

The role of the central nervous system (CNS) in early-onset BD has focused on both structure and functioning. Structurally, magnetic resonance imaging (MRI) scans have shown abnormalities in both cortical and subcortical regions, particularly pathways associated with emotion regulation, such as decreased volumes of the frontal lobe, amygdala, hippocampus, anterior cingulated gyrus, and the dorsolateral prefrontal cortex. One study of at-risk offsprings with subsyndromal symptoms of BD also showed decreased amygdala volume. Increased ventricular size has also been described. A functional MRI study has shown perturbations in the prefrontallimbic system associated with misinterpretation of stimuli. Such findings suggest a neural basis for the erratic behaviors demonstrated by youth with BD. However, most of these studies have not been replicated; and, not all studies examining the same sections of the brain have found the same abnormalities. The most consistent finding has been decreased amydgala volume.


Environmental Factors


Stress and the Home Environment

While environmental factors do not cause BD, they may potentiate a genetic vulnerability. Indeed, behavioral genetic research suggests that genetically vulnerable individuals are also at greatest environmental risk. Hlastala has shown that either acute (e.g., death of a loved one) or chronic (e.g., chaotic family) stressors may worsen the course of illness in adults with BD. For example, adult patients who live with families characterized by high levels of “expressed emotion” marked by intrusiveness, hostility, and overinvolvement experience higher rates of relapse and hospitalization than patients in families with lower “expressed emotion.” Recently, Kim and colleagues demonstrated similar associations between stress and changes in mood symptoms among adolescents with BD. With preadolescents, Geller has described “low maternal warmth,” a parental behavioral component of expressed emotion, for youth with BD who spend more weeks ill, have higher rates of relapse, and relapse sooner. Thus, the home environment appears to affect the course of illness, providing a focus for intervention.


Circadian Rhythm Instability

In their classic textbook on manic depressive illness, Goodwin and Jamison articulated an “instability model” of the pathophysiology of BD. In this model, they postulate that circadian instability is “the fundamental dysfunction in manic depressive illness.” Wehr and colleagues have also hypothesized that sleep deprivation/disruption might act as the “final common pathway” to mania, noting that episodes of mania are often preceded by life events interfering with the ability to sleep (e.g., transmeridian flights, childbirth). Malkoff-Schwartz and colleagues conducted studies demonstrating that life events involving social-rhythm disruption (events that influence sleep or wake times, patterns of social stimulation or daily routines) are strongly associated with the onset of manic episodes and more modestly associated with the onset of
depressive episodes in adults with BD. Based on this line of research most psychosocial treatments for BD include some emphasis on increasing routine and attempts to minimize sleep disruption. In particular, Interpersonal and Social Rhythm Therapy (IPSRT), a psychosocial treatment that specifically targets the regularity of a bipolar patients’ sleep and social routines has been proven effective in preventing recurrence of episodes of mania and depression. Furthermore, that protective effect of this treatment was directly related to the extent to which patients increased the regularity of their social rhythms.


Comorbidities

The differential diagnosis of BD in youth cannot be discussed separately from comorbidity. BD involves impaired affective regulation with deficits in processing and organizing, as well as severe emotional outbursts. Not only must BD be teased out from other causes of dysregulation, but some of these disorders may be comorbid with BD.

Mood Disorders Due to a General Medical Condition can be confused with BD especially if they involve the CNS, such as a traumatic brain injury or seizures, or systemic illness such as lupus, hyperthyroidism, or paraneoplastic syndrome. Less well recognized is that many medications may induce a manic episode, such as isoniazid, steroids, sympathomimetics, and antidepressants, as well as illicit substances such as cocaine. Careful medical examination and laboratory screening are indicated when BD is in the differential diagnosis. After medical etiologies have been ruled out, other psychiatric disorders must be considered.

Disruptive Behavior Disorders (DBD) comprise the diagnostic category most commonly needing to be differentiated from BD, as well as the most common comorbidity; and ADHD is the single most relevant of these disorders. Most prepubertal children who meet criteria for prepubertal BD also meet criteria for ADHD, while the converse is not true. Age of onset may help to discriminate between these two disorders with ADHD evident before age 7 and BD usually beginning after age 9. However, many children have prodromal symptoms early in life and age of onset is not easily determined. ADHD and BD symptoms have considerable overlap including increased motor activity, impulsivity, irritability, dysphoria, loquaciousness, poor attention, easy distractibility, and sleep disturbances. However, bipolar youth should demonstrate additional core manic symptoms that cannot be attributed to ADHD, and these symptoms should occur episodically, rather than showing a pervasive pattern as occurs with core ADHD symptoms. Youth with mania will often have middle-of-night awakening that is unusual in ADHD. If ADHD is present, symptoms should be evident after mood stabilization.

Youth with conduct disorders (CD) may have underlying BD that fuels their disruptive behaviors. These youth’s conduct problems cause so much chaos that the underlying mania is not evident. In such cases, the CD should resolve with mood stabilization. It is possible to have CD independent of BD in which case the CD symptoms should persist after mood stabilization.

Youth with oppositional defiant disorder (ODD) often respond to frustration with tantrums. The occurrence of ODD with alcohol-related neurodevelopmental disorders or pervasive developmental disorder (PDD) may, in particular, confer difficulty in dealing with interpersonal demands, frustration, and other social situations that require flexibility and compromise. These youth can respond with serious and prolonged outbursts or “rages” or SMD that can be mistaken for BD.

Anxiety Disorders are common comorbidities with all mood disorders at any age, and a common differential diagnosis for BD in youth due to the severe affective dysregulation that can occur. Youth with post-traumatic stress disorder (PTSD) may dysregulate upon re-exposure to traumatizing stimuli and may report psychotic like symptoms. The history of trauma and symptom activation with re-exposure helps to tease out the diagnosis. During panic attacks,
youth experience surges of anxiety and cognitive distress (decreased concentration, feelings of losing control) and irritability that lead to tantrums. The differential from mania is based on the physiologic arousal during panic and the quick escalation and defervescence of a panic attack. However, this may be more difficult to ascertain in rapid cycling BD. Separation anxiety disorder (SAD) is one of the most common misdiagnoses due to the sudden unprovoked irritability. Also, these youth often have depressive symptoms and sleep disturbances that suggest cycling. The appropriate diagnosis becomes evident when the dysregulation is linked to separation or anticipated separation. Also, the sleep disturbance in SAD usually occurs at the beginning of sleep due to worry, whereas mania is also associated with middle of the night awakening and decreased need for sleep.

Substance-use Disorders are important differential diagnoses as drugs like cocaine and stimulants have “activating” effects and can precipitate mania. The “highs” and “crashes” of amphetamines can mimic the cycling of BD and hallucinogens can mimic a manic psychosis. In these cases, the differential must be delayed until the youth has been detoxified. A time line can determine whether the bipolar symptoms started after the use of substances in which case the diagnosis would be a substance-induced mood disorder, bipolar type; or whether the bipolar symptoms started first and the youth “self-medicated” to treat mood symptoms.

Schizophrenia and Other Psychotic Disorders must be differentiated from a manic psychosis. Manic youth are more likely to experience grandiose or mood congruent delusions and do not exhibit the “negative symptoms” of schizophrenia. Of course, such symptoms must be distinguished from depressive cycles of BD. Schizophrenic youth often show prodromal schizoid traits, while bipolar youth seek others, although unsuccessfully, due to their behavioral difficulties.

Borderline Personality Disorder (BPD) has many features of BD including affective instability, poor impulse control, and interpersonal deficits, and also follows a chronic course. However, youth with BPD are more likely to have been maltreated, self-mutilate, and show a pattern of unstable relationships and disturbed self-image. This differential underscores the importance of a longitudinal perspective.


Clinical Course

BD is considered to be a chronic illness; however, outcomes are variable, with episode recovery rates ranging from 70% to 100% and relapse rates ranging from 35% to 80%. This variability is due in part to the heterogeneity in diagnosis, as well as the samples studied. Geller and colleagues have followed 89 youth aged 6 to 16 years with BD-I for 8 years into young adulthood. They found a mean length of initial episodes of 55 weeks, 88% recovery rate, but a 73% relapse rate. Subjects had a mean of two episodes of mania or mixed episodes during follow-up, but they also had very long episodes and spent many weeks ill. Recent data from the multisite “Course and Outcome of Bipolar Illness in Youth” (COBY) study of 263 youth, 7 to 18 years old, with BD-I, BD-II, or BD, NOS demonstrated similar results, with 82% of youth recovered from their index episode, but 64% had at least one recurrence. During the 2.5-year follow-up, 25% of youth with an initial diagnosis of BD-II converted to BD-I and 38% with an initial diagnosis of BD, NOS converted to BD-I or BD-II. Conversion rates in adults are lower and suggest that the diagnoses of BD-II and BP, NOS are less stable in youth. Overall, early-onset BD appears to portend a poor course, including frequent switches of polarity, mixed episodes, psychosis, comorbidity, suicide risk, and seriously impaired global functioning.

When depression is the initial presentation of BD, the “switch” into mania is obvious due to the rapid resolution of the depression and the emergence of core manic symptoms. However, if irritability is the primary presenting symptom, adults may think that the youth is just getting more moody or aggressive as part of the depression, or due to comorbid ADHD. The eventual emergence of elation, grandiosity, racing thoughts, pressured speech,
and the lack of need for sleep clarifies the diagnosis. However, if the development of mania is gradual or a mixed episode comprises the first presentation, the clinical picture can be murky.


Assessment

The essentials of assessment for BD in youth are summarized in Table 12-3.


History Gathering

The American Academy of Child and Adolescent Psychiatry notes that the aims of the clinical interview are to obtain a detailed history of symptom onset, duration, and intensity; develop a time line of symptoms; perform a developmentally appropriate mental-status examination; and review the child’s functioning across settings. A time line of mood symptoms using holidays and important events as anchors to assess the chronology of symptoms can help to delineate a pattern of some cyclicity. It is important to cue the family and child regarding periods of increased goal-directed activity, irritability, amount or rate of speech, excessive involvement in pleasurable activities, delusions or hallucinations, and decreased need for sleep. In addition, major changes in function, such as worsening performance at school or social isolation may elucidate mood changes. It is also important to interview the child alone about possible abuse or substance use. A complicating factor in teasing out cyclicity is that the winters are often more difficult for individuals with mood disorders but they also occur in the mid school year which is a difficult time for many youth and may suggest cycling during the winter time.

A developmental history includes a chronological picture of the child’s growth and development, including early temperament that may be prodromal to BD, the need for sleep and disrupted sleep (especially waking in the middle of the night), stressors that exacerbate temperamental features, and emotional milestones that vary by childhood disorder. Assessing peer relationships and academic performance helps to determine the degree of impairment. The parents’ view of the family dynamics provides context that may relate to comorbidity or the differential diagnosis, and sets the tone for interventions. Of course, a family history of mood disorders increases the suspicion of BD in the youth.








TABLE 12-3 Essentials of Assessment for Early-Onset Bipolar Disorder































Physical examination, review of systems, and laboratory testing are included to rule out suspected medical etiologies including neurological, systemic, and substance-induced disorders.



The clinical interview of the youth is the cornerstone of assessment for BD. Although many young patients lack insight regarding their manic symptoms, they can often describe their internal states.



A longitudinal perspective with a time line of symptom evolution is needed to demonstrate cyclicity and understand the youth’s illness.



The child or adolescent interview should include open-ended questions and discussion of unrelated topics in order to assess thought processes.



Always inquire about psychotic symptoms.



Always inquire about suicidality which is a risk during both depressed and manic stages due to impaired judgment.



For older children and adolescents part of the interview should occur without parental presence in order to assess risk-taking behavior, such as substance abuse, sexuality, and legal transgressions.



Family members’ behavioral observations provide corollary information regarding the patient’s range of difficulties and comorbidity.



School performance and interpersonal relationships should be assessed to determine the youth’s functional impairment and educational needs.




Mental-Status Examination

The mental-status examination of a bipolar child in a depressed state is consistent with that of unipolar depression as described in the depression chapter of this text, although there may be more psychotic symptoms. The child in a manic state will show motor function that is hyperactive and, unlike most youth with ADHD, may describe a subjective need to move. Speech will show an increased production, rate and volume, possibly tangentiality. The youth will be difficult to redirect and will often be self-aggrandizing. Usually, the child will seem truly unable to control himself. Inappropriate sexual themes may arise, although this may not come up in the interview. The child may also display poor impulse control and can be threatening or assaultive when crossed. Insight and judgment are impaired, the degree of which will help to determine disposition, that is, the need for hospitalization.

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Jun 29, 2016 | Posted by in PSYCHIATRY | Comments Off on Early-Onset Bipolar Disorder

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