
Case
15-yo Fernando is brought by his parents for problems with unstable moods. He was previously seen with depressed mood and started on an SSRI trial. Unfortunately, the trial led to a period of worsening characterized by decreased need for sleep, euphoric moods, increased activities (e.g. praying for several hours a day including late at night) and talking non-stop. Afterwards, it was followed by a depressive episode where he was feeling suicidal.
His parents ask: “Do we need to increase the dose of his antidepressant?”
Epidemiology
Bipolar often starts in childhood and young adulthood
- Up to 2/3 of adult patients with a diagnosis of bipolar disorder report that their mood symptoms started in childhood/adolescence (Goldstein, 2006)
- Up to 10% report symptoms started before age 13 (Goldstein, 2006)
Prevalence
-
Adult
- 1% (Lewinsohn, 1995)
-
Youth aged 14-18 (Lewinsohn, 1995)
- 1% with bipolar I, II, cyclothymia
- 6% with Bipolar NOS
- Lifetime rate of bipolar disorder among adolescents is 2.7% (Lewinsohn, 1995; Kessler, 2009; Van Meter, 2011).
Red Flags for Paediatric Bipolar
The following symptoms, especially if episodic, are red flags for bipolar:
- Increased activity and/or elation or sillness
- Decreased need for sleep, e.g. only sleeping a few hours and then not being tired the next day
- Presence of psychotic symptoms (e.g. hallucinations, delusions)
Clinical Presentation
Children/youth with bipolar can present:
- With recurrent episodes of mania or hypomania
- With or without episodes of depression
History
Collateral history from parents (and ideally teachers as well) is important, as children/youth may be poor historians regarding their symptoms. Sample questions to ask, that would need to be modified depending on whether you are asking the child/parent/teacher:
Mood |
Tell me about your child’s moods |
Mania/Hypomania |
Are there high periods? What are the high periods like? During high periods, are there problems with: D)ecreased need for sleep? I)ncreased energy? I)ncreased talkativeness? I)Increased activities or projects? I)ncreased self-esteem or grandiosity? |
Depressive periods |
Are there low periods? What are the low periods like? During low periods, are there problems with: S)leep I)nterests E)nergy down C)oncentration or distractibility? |
Substance Use |
Does your child use any substances? E.g. alcohol? Marijuana? Hallucinogens? |
Mood Charts
Consider asking the parents to help the child/youth with a mood chart.
Websites with free, downloadable mood charts include:
-
Centre for Quality Assessment and Improvement in Mental Health
http://www.cqaimh.org/pdf/tool_edu_moodchart.pdf -
BpChildren
http://www.bpchildren.com/Charting.html -
Psychiatry24x7
http://www.psychiatry24x7.com/bgdisplay.jhtml?itemname=mooddiary
Apps to track moods include:
-
Mood tracker app
https://www.moodtracker.com/index.php
Screening Tools
Parent General Behavior Inventory 10-item (PGBI-10M)
- 10-item scale for parents to screen for bipolar in their children
-
Scoring instructions
- Scores from each question are added together to form a total score, with higher scores indicating a greater severity of symptoms.
- Scores range from 0 to 30.
- Low scores of 5 and below indicate a very low risk of a bipolar diagnosis.
- High scores of 18 and over indicate a high risk of a diagnosis of bipolar disorder, increasing the likelihood by a factor of seven or greater.
-
Reference:
- Youngstrom, 2008
- Link
7 Up 7 Down Inventory
- 14-question inventory to screen for bipolar developed by Dr. Youngstrom
- Link
Child bipolar questionnaire (CBQ)
- 65 question inventory to screen for bipolar.
- Free to use, though registration is required.
- Link
Diagnosis of Bipolar in Children/Youth under DSM-5
Is it normal vs. bipolar/hypomania?
|
Normal |
Bipolar / Hypomania |
Increased talkativeness |
May be talkative, but can be interrupted |
Tends to be talkative, and hard to interrupt |
Goal directed activity |
May be extremely active (e.g. those with ADHD) or multi-taskers |
Increased activity from baseline, such as: E.g. activities happening at unusual times (e.g. late at night) E.g. developmentally inappropriate (e.g. teenager trying to get major bank loan, business deals) |
Decreased need for sleep |
May occasionally sleep less than usually, but will usually be tired the next |
May sleep only a few hours (if hypomanic), or not sleep at all (if manic), however, will NOT be tired the next day and still appear to be high energy |
Grandiosity |
Many teens may be ‘grandiose’ in that they think they are the “best” and better than others including their parents and adults. |
Increased grandiosity from usual child/youth grandiosity; Grandiosity to an extreme: E.g. believing that one can fly, is invulnerable or other super powers E.g. believing that one is the best sports player even despite being clearly not the best player on the team. |
Elation |
Happy while doing pleasurable activities |
Inappropriately elated, or excessively elated for what might be expected. |
Sexual interest |
May be interested or curious about sex. |
Excessive interest that is inappropriate, e.g. preoccupation with naked people; touching private areas of self or others; wanting to date one’s teacher, etc. The interest is not better explained by history of sexual abuse, exposure to pornography, etc. |
Is it hypomania vs. mania?
|
Hypomania |
Mania |
Severity of symptoms |
Less severe symptoms |
More severe symptom |
Duration |
At least 4-days (by DSM-IV) |
|
Function |
Function may appear to be increased in narrow areas (e.g. more social, energy, creativity), but especially with repeated episodes, may show decline in function |
Function appears to be more obviously impaired |
Is it bipolar vs ADHD?
|
Bipolar |
ADHD |
Age of onset |
Symptom appear age 10 or older |
Symptoms are present from earlier age |
Responsive to stimulants |
Symptoms worse with stimulants |
Symptoms improve with stimulants |
Stability of symptoms |
Symptoms are episodic |
Symptoms are consistently present |
Type of symptoms |
Episodes of increased mood, grandiosity, hypersexuality, less need for sleep |
Inattention, distractibility, problems with low frustration tolerance |
Is there major depression?
Are there symptoms of
- Depressed mood?
-
Neurovegetative symptoms such as problems with
- Decreased sleep
- Decreased energy
- Decreased concentration / increased distractibility
-
Suicidal ideation?
- In particular, is there suicidal ideation that appears far more severe than one would expect, e.g. child with depressive periods with suicidal ideation, despite appearing to have a supportive family, friends and lack of significant psychosocial stressors.
DSM-5 Criteria for Manic Episode
DSM-5 criteria for a manic episode are as follows.
- Distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week (or any duration if hospitalization is necessary).
-
During the period of mood disturbance, 3 or more of the following symptoms persisted (4 if the mood is only irritable) and have been present to a significant degree:
- Inflated self-esteem to levels of grandiosity
- Decreased need for sleep
- More talkativeness than usual, often characterized by pressured speech with a sense of a need to keep talking
- Flight of ideas or a subjective feeling that thoughts are racing
- Distractibility
- Increased goal-directed activity or psychomotor agitation
- Excessive involvement in pleasurable activity that has a high potential for painful consequences (eg, hypersexuality, excessive spending, impetuous traveling)
- Symptoms do not meet the criteria for a mixed episode.
- Mood disturbance is severe enough to cause marked social impairment in occupational functioning, social activities, or relationships with others. Hospitalization may be necessary to prevent harm to self or others or if psychotic features are present.
- Symptoms are not due to the direct physiologic effects of a substance or a general medical condition.
Predictive Factors for Eventual Bipolar Diagnosis
The following are risk factors associated with an eventual diagnosis of bipolar
- Psychosis symptoms, e.g. major depression with psychosis
- Medication-induced mania
- Children has parents with diagnosis of bipolar disorder
- Youth with BP-NOS (40% will be eventually diagnosed with bipolar)
DDx of Bipolar, i.e. “the Moody Child”, i.e. Affect dysregulation
Medical DDx
Sleep Disorders |
Any problems with snoring, restless legs? Patients with sleep disorders may have decreased sleep, but this will be followed by fatigue the next day, unlike mania/hypomania |
Tourette’s |
Any tics? Patients with Tourette’s may have anger and mood dysregulation |
Infectious |
NMDA Encephalitis (Kayser, 2013)
|
Neurologic
|
Head trauma: Any history of head trauma? Brain tumors: Any focal neurologic symptoms? |
Psychiatric / Comorbid DDx
Depressive disorders, e.g. major depression, dysthymic disorder |
With depressive disorders, the depressed periods will resemble the depressed periods in bipolar |
Substance use disorders |
Substance use may be a comorbid condition seen with bipolar, as patients may be impulsive, or may be trying to self-medicate |
Learning disorders (e.g. NVLD) |
With NVLD, there can be mood dysregulation, especially if there are comorbid issues such as ADHD / sensory issues Is there a verbal / non-verbal split? Does there appear to be average to above average language? Does there appear to be poor non-verbal skills (such as social skills, understanding tone of voice, etc.)? |
Borderline personality traits |
With borderline personality traits, the patient may have angry outbursts usually triggered by perceived rejection or abandonment Does the patient have significant issues with abandonment? Rejection? |
Disruptive mood dysregulation disorder (DMDD) |
Children with DMDD have problems with angry outbursts, however studies show that they are not at risk for developing bipolar disorder in the future (although they are at risk for future depressive/anxiety disorders) Bipolar disorder is episodic, whereas DMDD is more non-episodic Screening questions
|
ADHD
|
With ADHD, symptoms (e.g. hyperactivity, distractibility) tend to be persistent and represent the child’s baseline With bipolar, symptoms are intermittent or episodic with periods of increased energy, and periods of decreased energy |
Autism spectrum disorder (ASD) |
With ASD, there may be problems with emotional regulation, such as meltdowns with changes and transitions; problems seeing other’s perspectives may appear selfish or grandiose. Are there narrow, stereotyped routines? Difficulties with changes/transitions? |
Sensory processing disorder |
With sensory processing disorder, patients may have emotional dysregulation and meltdowns when overstimulated Are there sensitivities to sound? Light? Touch? |
Intermittent explosive disorder |
Are there periods of explosive anger that is disproportionate? |
Physical Exam
There are no specific physical findings in bipolar.
However, physical can help to:
-
Rule out contributory medical conditions such as
- Hyperthyroidism, which can mimic bipolar
- Hypothyroidism, which can mimic depression
- Detect comorbid conditions such as obesity
Investigations
There are no diagnostic investigations for bipolar however investigations may help rule out contributory medical conditions such as:
- B12/folate to rule out B12/folate deficiency
- Thyroid indices such as TSH to help rule out hyperthyroidism
- Sleep studies can help assess sleep problems
When and Where to Refer
Is the patient having clear symptoms of a mania/hypomania, along with significant impairment of function (e.g. unable to attend school; needing constant supervision)?
- Consider referral to emergent psychiatric assessment (such as hospital with psychiatry on-call) (i.e. same day), after speaking with psychiatry on-call
If symptoms are less severe, consider:
- Urgent psychiatric assessment (i.e. follow-up within several days, such as with an “urgent care clinic” if this is available), or
- Speak with your local mental health intake service regarding options.
In general, primary care providers will leave the diagnosis and management of bipolar to psychiatry.
Management: Non-Medication Strategies
Teach child/ parents how to self-regulate:
- Common elements of self-regulation programs include
- Teaching the child about the concept of being
- "Engine running just right” / “Green zone”, i.e. optimal regulation, where one can learn, work and play
- Family is taught how to find activities that provide optimal stimulation for the child/youth
- “Engine running too high” / “Red or yellow zone” (i.e. overstimulated, which can lead to fight / flight / freeze)
- Family is taught strategies how to reduce stimulation when understimulated and/or using soothing, self-regulating strategies
- “Engine running too low” “Blue zone” (i.e. understimulated, which can lead to boredom
- Family is taught strategies how to safely increased stimulation when understimulated
-
Self-regulation programs that many schools use include:
- Zones of Regulation (www.zonesofregulation.com)
-
Alert Program (www.alertprogram.com)
Regular routines to set biorhythms (as used significantly in Ellen Frank’s Interpersonal Social Rhythm Therapy)
- Regular, structured routines as opposed to lack of structure and lack of routines
- Regular morning routine with regular bedtimes
- Avoiding overstimulation through excessive technology use
- School routine
- Afternoon routine
- Evening routine
Medication Management in Primary Care
Although often primary care providers might leave medication management to psychiatrists, there are key interventions that can be started by primary care if there are concerns of bipolar:
-
Stop any stimulants.
- Taper down and stop any antidepressants.
Standard medications that might be recommended by a psychiatrist, that might then be followed by a primary care provider, include the following, depending on the presentation.
- Acute management of mania (CANMAT, 2018)
- 1st line
- Lithium
- Risperidone
- Aripiprazole
- Asenapine
- Quetiapine
- 2nd line
- Olanzapine
- Ziprasidone
- Quetiapine adjunctive
- 3rd line
- Divalproex
- Not recommended
- Oxcarbamazepine (Trileptal) (as large RCT trial showed it was not superior to placebo)
- Oxcarbamazepine (Trileptal) (as large RCT trial showed it was not superior to placebo)
- 1st line
- Acute management of bipolar depression
-
Are there persisting ADHD symptoms such as significant distractibility?
- Consider low dose stimulants for ADHD symptoms (in conjunction with a mood stabilizer) (March, 2005)
Case, Part 2
You are seeing 15-yo Fernando for severe mood swings. His symptoms have not responded to a trial of psychotherapy. Symptoms worsened with a trial of SSRIs. History reveals episodes of increased mood and energy, decreased need for sleep. These episodes are followed by periods of depression.
You wonder about possible medication-induced bipolar, and thus:
- You stop his antidepressant medications.
- You recommend various lifestyle strategies, in particular sleep hygiene and regular biorhythms.
- You refer him to a child psychiatrist, who confirms your course of action. The child psychiatrist also recommends monitoring for future manic/hypomanic episodes, and should those occur, that the patient be started on mood stabilizer / atypical antipsychotic.
Clinical Practice Guidelines
Kowatch et al.: Treatment Guidelines for Children and Adolescents with Bipolar Disorder, J. Am. Acad. ChildAdo/esc. Psychiatry. 2005;44(3):213-235.
Yatham L et al.: Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder.
Retrieved Jun 11, 2019 from http://www.canmat.org/CANMAT%2...
References
Baldessarini RJ, Bolzani L, Cruz N, Jones PB, Lai M, Lepri B, Perez J, Salvatore P, Tohen M, Tondo L, Vieta E, J Affect Disord. 2010 Feb; 121(1-2):143-6.
Chengappa KN, Kupfer DJ, Frank E, Houck PR, Grochocinski VJ, Cluss PA, Stapf DA
Am J Psychiatry. 2003 Sep; 160(9):1636-42.
Culpepper L: The Diagnosis and Treatment of Bipolar Disorder: Decision-Making in Primary Care, Prim Care Companion CNS Disord. 2014; 16(3).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195640/
Goldstein BI et al.: Further evidence for a developmental subtype of bipolar disorder defined by age at onset: results from the national epidemiologic survey on alcohol and related conditions. Am J Psychiatry. 2006;163(9):1633–6.
Goodwin FK, Jamison K. Manic-Depressive Illness: bipolar disorders and recurrent depression. 2nd ed. New York, N.Y: Oxford University Press; 2007.
Henry DB, Pavuluri MN, Youngstrom E, et al. Accuracy of brief and full forms of the Child Mania Rating Scale. Journal of Clinical Psychology. 2008;64:368–381.
Kayser et al.: Frequency and characteristics of isolated psychiatric episodes in anti-NMDA receptor encephalitis, JAMA Neurol. 2013 Sep 1; 70(9).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809325/
Kessler et al.: National Comorbidity Survey Replication Adolescent Supplement (NCS-A): III. Concordance of DSM-IV/CIDI Diagnoses With Clinical Reassessments, J. Am. Acad. Child & Adolesc. Psychiatr, 2009 Apr; 48(4): 386-399.
Rohde P et al.: Key Characteristics of Major Depressive Disorder Occurring in Childhood, Adolescence, Emerging Adulthood, Adulthood. Clin. Psychol. Sci, 2013 Jan; 1(1).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3833676/
Van Meter et al.: Meta-analysis of epidemiologic studies of pediatric bipolar disorder. J. Clin Psych, 2011 Sep; 72(9):1250-6.
https://www.ncbi.nlm.nih.gov/pubmed/21672501
Youngstrom E et al.: Developing a 10-item mania scale from the Parent General Behavior Inventory for children and adolescents. J Clin Psychiatry. 2008 May;69(5):831-9.
https://www.ncbi.nlm.nih.gov/pubmed/18452343
About this Document
Written by members of the eMentalHealth.ca/PrimaryCare team which includes members of the Department of Psychiatry and Family Medicine at the University of Ottawa. Reviewed by members of the Family Medicine Program at the University of Ottawa, including Dr's Farad Motamedi; Mireille St-Jean; Eric Wooltorton.
Disclaimer
Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a qualified expert or health professional. Always contact a qualified expert or health professional for further information in your specific situation or circumstance.
Creative Commons License
You are free to copy and distribute this material in its entirety as long as 1) this material is not used in any way that suggests we endorse you or your use of the material, 2) this material is not used for commercial purposes (non-commercial), 3) this material is not altered in any way (no derivative works). View full license at http://creativecommons.org/licenses/by-nc-nd/2.5/ca/