1. Part V: Other Psychological Disorders

2. Bipolar Disorder Chapter 19 Joseph C. Blader and Gabrielle A. Carlson

3. HISTORICAL CONTEXT Emil Kraepelin (1921) coined manic-depressive insanity as a cyclical disturbance of depression and manic excitement. 1920s and 1930s concluded that Kraepelin' s conception of manic-depression occurred among youth but was rare. 1950s Lithium's efficacy for the treatment of acute mania was established. Past 20 years recognition of frequent onset of BPD in mid- to late-adolescence, with possible prodromal signs evident even earlier.

4. DIAGNOSTIC CRITERIA AND CLINICAL PRESENTATION In most formal definitions, BPD comprises: Episodes of depression; interspersed to greater or lesser degree Episodes of manic (or mixed) symptoms Intervals between episodes during which mood state and functioning may vary widely both across patients and for the same person over time An overall course of illness that is chronic (American Psychiatric Association, 2000; Goodwin & Jamison, 2007; World Health Organization, 2010)

5. DIAGNOSTIC CRITERIA AND CLINICAL PRESENTATION Bipolar I Disorder BPDI is the diagnosis applied to either: A person experiencing an episode of mania or a mixed episode. One who is experiencing an episode of major depressive disorder or of hypomania but has had a manic or mixed episode in the past.

6. DIAGNOSTIC CRITERIA AND CLINICAL PRESENTATION Other Forms of BPD: Bipolar II Disorder and Cyclothymic Disorder BPDII and cyclothymia involve episodes of hypomania. Hypomania differs from mania chiefly in terms of severity and level of impairment. Cyclothymic disorder is a still milder form of BPD. BPDII is the diagnosis applied for an individual who is experiencing either: An episode of hypomania. An episode of major depression but who also had a prior episode of hypomania but never had a full manic episode.

7. PREVALENCE BPD among adults in the United States is generally agreed to be about 1% to 1.5%, with lifetime prevalence of disorders in the BPD spectrum around 4.5% (Kessler et al., 2006; Merikangas et al., 2007). Lifetime prevalence among adolescents for bipolar I or II disorder combined of 2.9%. Prevalence increases with age during adolescence and 89.7% of adolescents with these disorders were classified as manifesting “severe” impairment.

8. DEVELOPMENTAL PROGRESSION Adolescent-Onset BPD: High rates of serial hospitalizations Substance-abuse Suicide attempts or actual suicides Less robust response to lithium and divalproex Generally worse interepisode functioning than adult-onset BPD Risk for adverse outcomes rises with earlier onset, presence of psychotic features, mixed features, and low socioeconomic resources (Birmaher, et al., 2006).

9. COURSE AND OUTCOMES OF BIPOLAR DISORDER IN ADULTHOOD With age depressive episodes become more frequent and longer. In the best of cases, functioning between episodes of mood disturbance can be quite good and a stable, tolerant family and a social milieu can act as a buffer. A less fortunate outcomes can lead to: A downward drift socially as interpersonal and occupational functioning become increasingly erratic and inadequate Interepisode recovery is less successful Sources of social support may become alienated Legal entanglements Criminal activity Alcohol and drug abuse

10. CONCEPTUAL AND PRACTICAL ISSUES IN THE DIAGNOSIS OF BIPOLAR DISORDER AMONG YOUTH Symptom Differences and Confounding Comorbidities An elevated or euphoric mood Extreme irritability Grandiosity Decreased need for sleep Increased talkativeness Distractibility Increases in goal-directed activity Psychomotor agitation Excessive involvement in pleasurable activities Psychotic symptoms

11. CONCEPTUAL AND PRACTICAL ISSUES IN THE DIAGNOSIS OF BIPOLAR DISORDER AMONG YOUTH Distinct Periods of Mood Symptoms or Exacerbation Rapid cycling: Is defined by at least four episodes in a year. Episodicity: Implies an onset with a significant change from ordinary functioning. Periods of remission that occur spontaneously are very uncommon among children, which is yet another deviation from BPD’s episodic nature.

12. ALTERNATIVE APPROACHES TO EMOTIONAL VOLATILITY IN YOUTH Persistence Versus Transience of Mood Disturbance A number of children do show persistent negative mood that changes only minimally with positive events. Children who manifest with significant irritability are, in fact, highly overreactive to events. Ultradian cycling: Cycles appear many times within a single day.

13. DISTINGUISHING NARROW, INTERMEDIATE, AND BROAD PHENOTYPES Narrow phenotype: Has a symptom presentation, course, and episodicity fully aligned with current criteria for (adult) BPD, with the additional requirement that the mood abnormality be euphoria or signs of pathological grandiosity. One intermediate phenotype encompasses manic episodes that last from 1 to 3 days. Current nomenclature would classify a number of these situations as bipolar disorder not otherwise specified (NOS). The other intermediate phenotype allows irritability to be the main mood aberration, so long as there is also evidence of well- demarcated episodes. Broad phenotype: Denoted as severely disturbed behavior and mood dysregulation, which essentially describes chronic negative emotional reactivity and impulsivity.

14. RISK FACTORS AND ETIOLOGICAL FORMULATIONS Depression Patients who develop BPD often experience depression as their first episode Biological Susceptibility Factors Heritability and genetic markers Neurodevelopmental antecedents Disturbances of the sleep-wake cycle Cognitive Factors and Other Potential Markers Impaired response inhibitions and other executive functions Deficits related to attention and inhibitory controls Tendency to exaggerate and dwell on misfortunes

15. RISK FACTORS AND ETIOLOGICAL FORMULATIONS Neuroanatomical and Neurophysiological Factors Reduced amygdala volumes Increased amygdala activity elicited by emotion relevant stimuli Reductions in volume of the anterior cingulate Experiential and Environmental Susceptibility Factors Childhood maltreatment Stress Childhood truama Psychotropic medications

16. COMORBIDITY, SEX DIFFERENCES & CULTURAL FACTORS ADHD is the leading comorbidity among BPD children. Substance abuse is common among adolescents and adults with BPD. Prevalence estimates of comorbid anxiety disorders vary considerably in child BPD. Similar rates of BPD in adolescents but higher rates of males in child samples. May be cultural differences in the use of diagnoses in clinical settings.

17. THEORETICAL SYNTHESIS AND FUTURE DIRECTIONS Forms of very early onset, chronic, and unremitting affective and behavioral volatility have been postulated to constitute a variant of BPD among youth. At this time, it remains uncertain whether these forms of impairment are: Developmental versions of the same disease processes that underlie later-onset BPD. Separate types of illness that might involve perturbations of the same mechanisms of self-control and mood that are implicated in BPD. Fundamentally different problems, such as severe ADHD with ODD, which demonstrate some phenotypic overlap with BPD.