By: Marie Huang<\/p>\n
–<\/p>\n
The amphitheater at Nassau University Medical Center fills up slowly as Dr. Alan Jay Cohen, a psychiatrist from Oakland, California, makes his way up to the podium to lead a talk about bipolar disorder, specifically differentiating between its presentations in adults versus in developing children.<\/p>\n
Among nonprofessionals, bipolar disorder is simply a psychiatric disorder characterized by drastic changes of the mood or \u201cmood swings.\u201d\u00a0 The infamous symptoms of rapid cycling between mania and depression, when viewed in an adult, automatically give physicians and the layperson alike the impression that the patient is bipolar. \u00a0Oftentimes, this becomes the final diagnosis, and the patient takes a mood stabilizer, like lithium, to modify the reuptake of certain neurotransmitters (causing this constant flux in personality). However, despite popular belief, bipolar disorder is not as easy to diagnose and treat. \u00a0Other comorbidities often exist alongside, and, like any other disorder or disease, need to meet criteria for diagnosis. \u00a0It is important to note that the disorder even shares many of the same features as attention-deficit\/hyperactivity disorder (ADHD); so, it is essential that psychiatrists perform a differential diagnosis to rule out, or in, alternative personality disorders.<\/p>\n
With the publication of the text revision for DSM-IV in 2000, one would expect it to include clear-cut criteria for the diagnosis of mania in children and adolescents. \u00a0Come DSM-V (expected release is later this year), it is likely that the criteria will still not be included. \u00a0So, could we apply same adult criteria to children?<\/p>\n
Dr. Cohen comments that the characteristics of manic episodes seen in adults may vary widely and even be absent in children and adolescents.<\/p>\n
In adults, the disorder has conveniently numbered subtypes, known as Bipolar Disorder I, Bipolar Disorder II, and Bipolar Disorder Not Otherwise Specified (NOS). \u00a0\u201cBipolar Disorder I\u201d is known to contain a flux of mixed and manic episodes, where depression may be absent. \u00a0Bipolar Disorder II presents with a constant cycling between hypomania and depression, where mania may be absent.\u00a0 Bipolar Disorder NOS is a category in which most pediatric patients fall in because they may not always present with the same symptoms that make it easy to categorize them into the other subtypes (more suitable for adults).\u00a0 This subtype is a \u201csubthreshold bipolar disorder,\u201d and requires further mood monitoring.<\/p>\n
As mentioned, without formal criteria for mania in children, pediatric psychiatrists utilize the same benchmarks for adults.\u00a0 They somehow tweak these for their young patients. \u00a0For adults, a manic episode, by definition, is a distinct period of abnormality, where the patient is in \u201ca persistently elevated or irritable mood that lasts at least a week<\/i> or any duration if hospitalization is necessary.\u201d \u00a0This elevated mood is \u201csilly\u201d because the patient will appear very jubilant, despite bad news and incidents (which do not typically call for excitement or happiness).\u00a0 If the patient meets three of more of the following symptoms, a diagnosis for mania is proper: inflated self-esteem\/grandiosity, decreased need for sleep, distractibility, pressure to keep talking, racing thoughts, excessive involvement in pleasurable activity, and\/or increased goal-directed productivity.<\/p>\n
One should not confuse manic episodes with those of hypomania, which happens to share many of the same characteristics but with decreased severity. \u00a0In hypomania, the criteria for adults focus mainly on the duration of the episode and not so much on its mood. \u00a0It is a distinct period of persistently elevated or irritable mood lasting at least 4 days<\/i>. \u00a0Symptoms are very similar to those of a manic episode, but are not \u201cserious enough\u201d to require hospital admission.\u00a0 Here, the euphoric mood does not necessarily interfere with daily performance or productivity. \u00a0In fact, it may drastically increase goal-directed productivity and focus, which the patient will most likely see as a benefit. \u00a0As time goes on and the patient is continually hypomanic, hypomania may transform into mania, where racing thoughts suddenly become too much to handle.<\/p>\n
On the opposite side of the spectrum lies the major depressive episodes, specifically defined as distinct periods of depression where the patient is \u201cdown in the dumps\u201d most of the day and nearly every day. \u00a0A firm diagnosis of this episode in adults must meet five or more symptoms listed in DSM-IV over a two-week period.\u00a0 These symptoms are, of course, popularly associated with major depressive disorder, and include fatigue, significant weight loss (due to loss of appetite), feelings of guilt and worthlessness, insomnia, loss of interest in pastimes, and suicidal ideations.<\/p>\n
Dr. Cohen mentions that many children may not display the common signs of depression, but, instead, exhibit heavily irritable moods with no cause. \u00a0It is vital not to jump to conclusions to categorize mood episodes, especially the major depressive. \u00a0Always ask the patient what exactly provoked them to determine whether the child\/adolescent (or adult) has a legitimate reason to be dwelling in that mood. \u00a0Do not assume that the patient has bipolar disorder because he\/she has apparent mood swings. \u00a0Always access the flipside, determine what type of episode the patient cycles between, and determine whether there is a reason for the changes. \u00a0Doing so may prevent erroneous diagnoses and unnecessary treatment.<\/p>\n
In children, causeless, frequent mood changes are the \u201cpediatric bipolar pattern.\u201d \u00a0Although youngsters who exhibit this pattern have bipolar disorder, they do not exactly meet the criteria for manic\/hypomanic\/depressive episodes, and do not present with distinct mood swings. \u00a0Therefore, many are under the Bipolar Disorder NOS subtype. \u00a0As previously mentioned, it is important that the psychiatrist check for other possible comorbidities and clearly differentiate between symptoms of ADHD and bipolar disorder. \u00a0Both, ADHD and bipolar patients may display irritability, hyperactivity, and distractibility.<\/p>\n
To diagnose bipolar disorder, there are two sets of cardinal symptoms to note. \u00a0Cardinal symptoms I include extreme mood liability, grandiose behaviors, and mania. \u00a0Parents often feel as if they are \u201ctiptoeing around their own house\u201d or \u201cwalking on egg shells\u201d when it comes to trying not to set off the belligerent and irritable moods of their children. \u00a0Cardinal symptoms II include sleep disturbances and often-dangerous thrill-seeking behavior.<\/p>\n
In order to differentiate between the subtypes and ADHD, parents ought to keep a diary to chart the moods of their child. \u00a0Tools that also aid in diagnosis involve clinical assessment components.\u00a0 These include patient\/parent interviews, school observations, and mood rating scales. \u00a0The acronym, FIND, which stands for Frequency (How often?), Intensity (How strongly?), Number (How much?), and Duration (How long?), will allow the psychiatrist to obtain a more complete picture of the disorder as it pertains to the child. \u00a0Like every disease, family history may play a significant role and needs consideration.<\/p>\n
Mainstay treatments of bipolar disorder usually include one or two mood stabilizers and a second-generation antipsychotic (with or without the presence of psychosis). \u00a0Briefly, useful mood stabilizers include lithium, topiramate, lamotrigine, gabapentin, and oxcarbazepine. \u00a0Atypical antipsychotics, with some evidence in the management of the disorder, include olanzapine, risperidone, and clozapine. \u00a0Although antipsychotics decrease aggressiveness and agitation, they have sedating properties and may cognitively impair the patient, which proves to be a huge disadvantage in children. \u00a0There have been no placebo-controlled trials to determine an optimal treatment plan, most likely due to ethical violations that are associated with simply giving a placebo to a child who is quite literally \u201cout of his mind.\u201d \u00a0Despite promising results, it is common to witness the relapse of bipolar symptoms in a patient who had once been mood stabilized by medication. \u00a0The fast physiological development of children and adolescents explains these high rates of relapse.\u00a0 Regardless, family support has a positive effect on the child\u2019s condition while these medications take four to eight months to show maximum effect.<\/p>\n
Although DSM-IV does not paint a full picture of bipolar disorder in children and adolescents, many psychiatrists utilize other criteria that have been put together to set a suitable benchmark for diagnosis in youngsters.<\/p>\n
In conclusion, as with everything else in the medical field, bipolar disorder requires case-by-case assessment. \u00a0It may present itself very differently in children as opposed to adults, and by close mood monitoring and an eye for key symptoms, one can properly diagnose this disorder in children.\u00a0 This leads to proper management and treatment of, what is undoubtedly, a very complicated disease state.<\/p>\n
SOURCES:<\/span><\/b><\/p>\n By: Marie Huang – The amphitheater at Nassau University Medical Center fills up slowly as Dr. Alan Jay Cohen, a psychiatrist from Oakland, California, makes his way up to the podium to lead a talk about bipolar disorder, specifically differentiating between its presentations in adults versus in developing children. Among nonprofessionals, bipolar disorder is simply…<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[7],"tags":[343,2249,76,702,1566,120,198,200,15,60,2227,314,1071,97,1249,1290,14,361,210,363,968,1625,1545,19,704,2260,214,169,447,187,2252,1663,16,623,59,1061],"class_list":["post-413","post","type-post","status-publish","format-standard","hentry","category-clinical","tag-and","tag-antipsychotic","tag-bipolar","tag-children","tag-complete","tag-condition","tag-daily","tag-diary","tag-disease","tag-disorder","tag-ebola-virus-disease","tag-for","tag-gabapentin","tag-july","tag-lamotrigine","tag-lithium","tag-medication","tag-mixed","tag-note","tag-of","tag-one","tag-or","tag-oxcarbazepine","tag-patient","tag-pediatric","tag-pressure","tag-publication","tag-relapse","tag-release","tag-side","tag-symptoms","tag-topiramate","tag-treatment","tag-type","tag-weight","tag-with"],"views":672,"_links":{"self":[{"href":"https:\/\/rhochistj.org\/RhoChiPost\/wp-json\/wp\/v2\/posts\/413","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/rhochistj.org\/RhoChiPost\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/rhochistj.org\/RhoChiPost\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/rhochistj.org\/RhoChiPost\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/rhochistj.org\/RhoChiPost\/wp-json\/wp\/v2\/comments?post=413"}],"version-history":[{"count":0,"href":"https:\/\/rhochistj.org\/RhoChiPost\/wp-json\/wp\/v2\/posts\/413\/revisions"}],"wp:attachment":[{"href":"https:\/\/rhochistj.org\/RhoChiPost\/wp-json\/wp\/v2\/media?parent=413"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/rhochistj.org\/RhoChiPost\/wp-json\/wp\/v2\/categories?post=413"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/rhochistj.org\/RhoChiPost\/wp-json\/wp\/v2\/tags?post=413"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}\n