1 Assessment and Intervention for Bipolar Disorder:New background knowledge offered here and in readings. Very applicable to your practice. Other knowledge will be required, but your prior training and study should have already prepared you for this aspect of the exam. Tonight you get all the “new stuff”

2 It is as if my life were magically run by two electric currents: joyous positive and despairing negative - whichever is running at the moment dominates my life, floods it. Sylvia Plath (2000) The Unabridged Journals of Sylvia Plath, New York: Anchor Books The classic understanding of bipolar (or “manic-depressive”) disorder

3 Presentation Outline Diagnosis Course Co-existing DisabilitiesAssociated Impairments Etiology, Prevalence & Prognosis Treatment In this section we will look first at diagnostic criteria. However, recognizing the fact that juvenile (AKA pediatric or early onset) bipolar disorder can be different from the adult form (which DSM is based upon) we will also explore how symptoms manifest themselves in the school setting. This is, from my experience, a very important part of what school psychologists need to know… We need to know how to recognize bipolar disorder so as to be able to make appropriate referrals.

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6 Diagnosis First, let’s take a look at the big picture and this slide provides such… Consider the various mood states in bipolar disorder as a continuous range. At one end is severe depression, above which is moderate depression and then mild low mood, which many people call "the blues" when it is short-lived but is termed "dysthymia" when it is chronic. Then there is normal or balanced mood, above which comes hypomania (mild to moderate mania), and then severe mania. In some people, however, symptoms of mania and depression may occur together in what is called a mixed bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling extremely energized. Bipolar disorder may manifest as a problem other than mental illness EG: poor school performance or strained interpersonal relationships. Such problems in fact may be signs of an underlying mood disorder. NIMH (2007)

7 DSM-5 Diagnosis Importance of early diagnosisAdolescent bipolar disorder is especially challenging to identify. Characterized by severe affect dysregulation, high levels of agitation, aggression. Relative to adults, children have a mixed presentation, a chronic course, poor response to mood stabilizers, high co-morbidity with ADHD Symptoms similar to other disorders. For example, ADHD, depression, Oppositional Defiant Disorder, Obsessive Compulsive Disorder, and Separation Anxiety Disorder. Treatments differ significantly. The school psychologist may be the first mental health professional to see bipolar. Next, let’s talk about some general diagnostic issues. 1. First, the importance of early diagnosis. Dr. Joseph Biederman said this about the delay of diagnosis at a National Alliance for the Mentally Ill (NAMI) Conference in 1998: “… Once you have ten years of anything unchecked - from a car to your teeth, to some rampant psychopathology - I would propose this is the equivalent to having metastatic disease ten years later. The problem could be different if the diagnosis were made at the beginning… and effective treatments were deployed… It is possible that the prognosis could be very different than the one we see at the end of the line once these children reach adult psychiatry’s shore…” (taken from Bipolar Child, pg. 57). 2. Second, among the challenges associated with diagnosing pediatric BPD is the fact that DSM criteria BPD were written for adults, and until recently it was not believed to exist among children. When DSM BPD criteria were first published there was very little research regarding its prevalence children. In the past several years we have seen a flurry of research. Unfortunately, the DSM is not scheduled to be revised until 2012; although, hopefully at that time it will include a significant change to the BPD criteria. 3. The symptoms of bipolar are similar to other disorders (and thus, pediatric bipolar is often not recognized until late adolescence). 4. Treatments for these disorders can differ remarkably, and therefore, the first and most important step in treating these children is to accurately recognize BPD. 5. While it is unlikely that school psychologist will make a the initial DSM diagnosis, we may be the first mental health professional to see many of the characteristics and to come into contact with the families. In addition, some psychiatrists still believe that BPD doesn’t exist among children. So, we may be working with psychiatrists that need to be “educated.” Something you might hear from a treating physician or psychiatrist is the idea of “ruling out” ADHD or unipolar depression before looking further for bipolar. This can be a very dangerous situation. If there is a question of mood instability, or you see red flags that indicate further exploration regarding BPD, (such as a family history of BPD), BIPOLAR DISORDER SHOULD BE RULED OUT BEFORE ANY OF THE STIMULANT DRUGS OR ANTIDEPRESSANTS ARE PRESCRIBED!!!! Faraon et al. (2003)

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9 DSM-5 Diagnosis Diagnostic Classifications Bipolar I DisorderOne or more Manic Episode or Mixed Manic Episode Minor or Major Depressive Episodes often present May have psychotic symptoms Specifiers: anxious distress, mixed features, rapid cycling, melancholic features, atypical features, mood-congruent psychotic features, mood incongruent psychotic features, catatonia, peripartium onset, seasonal pattern Severity Ratings: Mild, Moderate, Severe (DSM-5, p. 154) Bipolar disorder is commonly categorized as either Type I, where an individual experiences full-blown mania, or Type II, in which the hypomanic "highs" do not go to the extremes of mania. Type II is more difficult to diagnose (hypomanic episodes may simply appear as a period of successful high productivity and is reported less frequently than a distressing depression). Psychosis can occur in Type I, particularly in manic periods. There are also 'rapid cycling' subtypes. Because there is so much variation in severity/nature, the concept of a bipolar spectrum has been offered. Bipolar Disorder I: In adults, mania is usually episodic with an elevation of mood and increased energy and activity. In children, mania is commonly chronic rather than episodic, and usually presents with irritability, anxiety, and depression (or in mixed states). In adults and children, during depression there is lowering of mood and decreased energy and activity. During a mixed episode both mania and depression can occur on the same day. Many people with bipolar disorder experience severe anxiety and are very irritable (to the point of rage) when in a manic state, while others are euphoric and grandiose. DSM-5 states prevalence rate of 1.8% in US and non US community samples for pediatric population; 2.7% for youths age 12 years or older HOWEVER: Since 1990, 40% increase in dx of childhood bipolar disorder Special Note: Suicide risk much higher in this population: Monitoring is warranted DSM-5 does not distinguish between child/adolescent onset and adult onset and symptoms Bi Polar I : Average age of onset 18 for Bipolar I, ups can be wonderful; eventually euphoria leads to impatient irritability, restless agitation, then utter exhaustion; expressive thoughts may become delusions Many have lifetime episodes one or more manic episodes or mixed episodes with or without major depressive episodes. A depressive episode is not required but are often part of the course of the illness. Full blown mania In children, mania is commonly chronic rather than episodic, and usually presents with irritability, anxiety, and depression (or in mixed states). In adults and children, during depression there is lowering of mood and decreased energy and activity. During a mixed episode both mania and depression can occur on the same day. Many experience severe anxiety and are very irritable (to the point of rage) when in a manic state OR others are euphoric and grandiose DSM 5 focuses on increased activity AND energy levels APA (2013)

10 DSM-5 Diagnosis Diagnostic Classifications Bipolar II DisorderOne or more Major Depressive Episode One or more Hypomanic Episode No full Manic or Mixed Manic Episodes Specifiers: anxious distress, mixed features, rapid cycling, melancholic features, atypical features, mood-congruent psychotic features, mood incongruent psychotic features, catatonia, peripartium onset, seasonal patter Severity Ratings: Mild, Moderate, Severe (DSM-5, p. 154) Bipolar Disorder II: Characterized by one or more Major Depressive Episodes accompanied by at least one Hypomanic Episode. The key difference between bipolar I and bipolar II is that bipolar II has hypomanic but not manic episodes. In addition, while those with bipolar I disorder may experience additional psychotic symptoms such as delusions and hallucinations, bipolar II by does not have psychotic features. Bipolar II: average age onset is mid-20’s Must have major depressive episodes One clear but hypomanic episode (less sever than manic but same symptoms of elevated mood, expansive self-confidence, infectious joking, increased energy, intrusive sociability, less need for sleep and rest Key = usually does not cause clinically significant impairment Never had full-blown manic episode Bipolar II consisting of recurrent intermittent hypomanic and depressive episodes. [Less severe for of mania(hypomania)]. No full mania or psychotic episodes One or more Major Depressive Episodes accompanied by at least one Hypomanic Episode. The key difference between bipolar I and bipolar II is that bipolar II has hypomanic but not manic episodes. more difficult to diagnose (hypomanic episodes may simply appear as a period of successful high productivity and is reported less frequently than a distressing depression). bipolar II by does not have psychotic features. APA (2013)

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15 DSM-5 Diagnosis Diagnostic Classifications CyclothymiaFor at least 2 years (1 in children and adolescents), numerous periods with hypomanic symptoms that do not meet the criteria for hypomanic Present at least ½ the time and not without for longer than 2 months Criteria for major depressive, manic, or hypomanic episode have never been met 1. Another diagnostic classification is Cyclothymia, which is a chronic, but less extreme/severe, form of bipolar disorder consisting of short periods of depression alternating with short periods of hypomania. The onset of each phase is separated by short periods of normal mood. This diagnosis is excluded if the patient has had either a full blown manic episode or a major depressive episode. A single episode of hypomania is sufficient to diagnose cyclothymic disorder; however, most individuals also have periods of depression. Cyclothymia is a form of bipolar disorder, consisting of recurrent hypomanic symptoms, but no full manic episodes or full major depressive episodes. chronic, but less extreme/severe, form of bipolar disorder consisting of short periods of depression alternating with short periods of hypomania. The onset of each phase is separated by short periods of normal mood. This diagnosis is excluded if the patient has had either a full blown manic episode or a major depressive episode – if this occurs than change to major depressive disorder to Bipolar 1 A single episode of hypomania is sufficient to diagnose cyclothymic disorder; however, most individuals also have periods of depression. Unspecified Bipolar and Related Disorder (comparable to BP-NOS in DSM-IV-TR) Symptoms characteristic of bipolar and related disorder but do not meet full criteria … Most use BPNOS for children adult criteria require well-defined and discrete episodes of abnormal mood and this is often missing in children childhood onset frequently has insidious onset with affective storms Some studies have shown a 40% increase in BPNOS diagnosis with children/adolescents *Berstein, B & Pataki, C. (2011). Pediatric Bipolar Affective Disorder: Background, APA (2013)

16 DSM-5 Diagnosis Diagnostic ClassificationsUnspecified Bipolar and Related Disorder Bipolar features that do not meet criteria for any specific bipolar disorder. 2. If an individual clearly seems to be suffering from some type of bipolar disorder, but does not meet the criteria for one of the conditions laid out above, he or she receives a diagnosis of Bipolar Disorder NOS (Not Otherwise Specified). Many times pediatric bipolar disorder is classified NOS. Unspecified Bipolar and Related Disorder (comparable to BP-NOS in DSM-IV-TR) Symptoms characteristic of bipolar and related disorder but do not meet full criteria … Most use BPNOS for children adult criteria require well-defined and discrete episodes of abnormal mood and this is often missing in children childhood onset frequently has insidious onset with affective storms Some studies have shown a 40% increase in BPNOS diagnosis with children/adolescents APA (2013)

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18 DSM-5 Diagnosis Manic Episode CriteriaA distinct period of abnormally and persistently elevated, expansive, or irritable mood. Lasting at least 1 week. Three or more (four if the mood is only irritable) of the following symptoms: Inflated self-esteem or grandiosity Decreased need for sleep Pressured speech or more talkative than usual Flight of ideas or racing thoughts Distractibility Psychomotor agitation or increase in goal-directed activity Hedonistic interests Inflated self-esteem or grandiosity Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) APA (2013

19 DSM-5 Diagnosis Manic Episode Criteria (cont.)Causes marked impairment in occupational functioning in usual social activities or relationships, or Necessitates hospitalization to prevent harm to self or others, or Has psychotic features Not due to substance use or abuse (e.g., drug abuse, medication, other treatment), or a general medial condition (e.g., hyperthyroidism). A full manic episode emerging during antidepressant treatment NOTE: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and therefore a bipolar I diagnosis. APA (2013)

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21 Diagnosis: Manic Symptoms at SchoolSymptom/Definition Example Euphoria: Elevated (too happy, silly, giddy) and expansive (about everything) mood, “out of the blue” or as an inappropriate reaction to external events for an extended period of time. A child laughs hysterically for 30 minutes after a mildly funny comment by a peer and despite other students staring at him. Irritability: Energized, angry, raging, or intensely irritable mood, “out of the blue” or as an inappropriate reaction to external events for an extended period of time. In reaction to meeting a substitute teacher, a child flies into a violent 20-minute rage. Inflated Self-Esteem or Grandiosity: Believing, talking or acting as if he is considerably better at something or has special powers or abilities despite clear evidence to the contrary A child believes and tells others she is able to fly from the top of the school building. What the school psychologist may see that may be pediatric bipolar disorder (from a chapter in the NASP publication Children’s Needs III). From Lofthouse & Fristad (2006, p. 215)

22 Diagnosis: Manic Symptoms at SchoolSymptom/Definition Example Decreased Need for Sleep: Unable to fall or stay asleep or waking up too early because of increased energy, leading to a significant reduction in sleep yet feeling well rested. Despite only sleeping 3 hours the night before, a child is still energized throughout the day Increased Speech: Dramatically amplified volume, uninterruptible rate, or pressure to keep talking. A child suddenly begins to talk extremely loudly, more rapidly, and cannot be interrupted by the teacher Flight of Ideas or Racing Thoughts: Report or observation (via speech/writing) of speeded-up, tangential or circumstantial thoughts A teacher cannot follow a child’s rambling speech that is out of character for the child (i.e., not related to any cognitive or language impairment the child might have) From Lofthouse & Fristad (2006, p. 215)

23 Diagnosis: Manic Symptoms at SchoolSymptom/Definition Example Distractibility: Increased inattentiveness beyond child’s baseline attentional capacity. A child is distracted by sounds in the hallway, which would typically not bother her. Increase in Goal-Directed Activity or Psychomotor Agitation: Hyper-focused on making friends, engaging in multiple school projects or hobbies or in sexual encounters, or a striking increase in and duration of energy.. A child starts to rearrange the school library or clean everyone’s desks, or plan to build an elaborate fort in the playground, but never finishes any of these projects. Excessive Involvement in Pleasurable or Dangerous Activities: Sudden unrestrained participation in an action that is likely to lead to painful or very negative consequences. A previously mild-mannered child may write dirty notes to the children in class or attempt to jump out of a moving school bus. From Lofthouse & Fristad (2006, p. 215)

24 Life feels like it is supercharged with possibility… Ordinary activities are extraordinary!” “I become the Energizer Bunny on a supercharger. ‘Why does everybody else need so much sleep?’ I wonder…. Hours pass like minutes, minutes like seconds. If I sleep it is briefly, and I awake refreshed, thinking, ‘This is going to be the best day of my life!’ Patrick E. Jamieson & Moira A. Rynn (2006) Mind Race: A Firsthand Account of One Teenager’s Experience with Bipolar Disorder. New York: Oxford University Press Here are some more quotes of individuals with early-onset bipolar disorder from another book titled: “Intense Minds” by Tracy Anglada. “It feels like I don’t know what to do all of the time, because I don’t know which thought to pick in my head. They are all scrambled.” Alisha, age 7 “My thoughts could race so much that I wouldn’t be able to think straight or concentrate on anything because there would be many thoughts going around in my head at once. It’s like everyone who needed me to answer a question or needed me to do something for them and everything that I needed to do was all swirling around in my mind in a big ball. Every once in a while I could catch a thought, but I couldn’t do anything about that thought because of all the swirling.” Joan “I would toss and turn and have the feeling that my skeleton was going to simply burst through my skin unless I got up and did something.” Grace

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26 DSM-5 Diagnosis Hypomanic Criteria Similarities with Manic EpisodeSame symptoms Differences from Manic Episode Length of time Impairment not as severe May not be viewed by the individual as pathological However, others may be troubled by erratic behavior Hypomania literally means mild mania. Decreased need for sleep and lack of daytime fatigue are red flags. The symptoms are the same as for a Manic Episode. To differentiate from manic, consider the length of time and severity of the impairment. Hypomania is characterized by a CHANGE in functioning that is uncharacteristic and observable to others, whereas mania causes marked IMPAIRMENT in functioning. Individuals in a hypomanic state don’t usually view it as bad, and may feel more confident, more gregarious or outgoing, or more energetic. Not likely to get treatment, or even to be recognized as pathological. A state likely missed in initial diagnosis (the individual may not even remember hypomania). In addition to looking for a decreased need for sleep and lack of daytime fatigue, also ask about periods where the person feels really good, can conquer the world, is going to have great things happen, etc. And the flip side… inquire about periods of time where they may be irritable, have lots of thoughts going through head, need to get lots of things accomplished, and feel that others are moving too slowly.

27 DSM-5 Diagnosis Major Depressive Episode CriteriaA period of depressed mood or loss of interest or pleasure in nearly all activities In children and adolescents, the mood may be irritable rather than sad. Lasting consistently for at least 2 weeks. Represents a significant change from previous functioning. APA (2013)

28 DSM-5 Diagnosis Major Depressive Episode Criteria (cont.)Five or more of the following symptoms (at least one of which is either (1) or (2): Depressed mood Diminished interest in activities Significant weight loss or gain Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue/loss of energy Feelings of worthlessness/inappropriate guilt Diminished ability to think or concentrate/indecisiveness Suicidal ideation or suicide attempt Depressed mood most of the day, nearly every day as indicated by either subjective report (e.g., feels sad or empty) or observation made by other (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). Significant weight loss when not dieting or weight gain (e.g., a change of more that 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. Insomnia or hypersomnia nearly every day. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). These children are clumsy and often have difficult with PE. Fatigue or loss of energy nearly every day. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). Recurrent thoughts of death (not jus fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. NOTE: Bipolar Depressive Triad = (a) Over-eating, (b) over-sleeping, and (c) excessive physical fatigue may differential bipolar depression from other mood disorders APA (2013)

29 DSM-5 Diagnosis Major Depressive Episode Criteria (cont.)Causes marked impairment in occupational functioning or in usual social activities or relationships Not due to substance use or abuse, or a .general medial condition Not better accounted for by Bereavement After the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation APA (2013)

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31 Diagnosis: Major Depressive Symptoms at SchoolSymptom/Definition Example Depressed Mood: Feels or looks sad or irritable (low energy) for an extended period of time. A child appears down or flat or is cranky or grouchy in class and on the playground. Markedly Diminished Interest or Pleasure in All Activities: Complains of feeling bored or finding nothing fun anymore. A child reports feeling empty or bored and shows no interest in previously enjoyable school or peer activities. Significant Weight Lost/Gain or Appetite Increase/Decrease: Weight change of >5% in 1 month or significant change in appetite. A child looks much thinner and drawn or a great deal heavier, or has no appetite or an exce3sive appetite at lunch time. From Lofthouse & Fristad (2006, p. 216)

32 Diagnosis: Major Depressive Symptoms at SchoolSymptom/Definition Example Insomnia or Hypersomnia: Difficulty falling asleep, staying asleep, waking up too early or sleeping longer and still feeling tired. A child looks worn out, is often groggy or tardy, or reports sleeping through alarm despite getting 12 hours of sleep. Psychomotor Agitation/Retardation: Looks restless or slowed down. A child is extremely fidgety or can’t say seated. His speech or movement is sluggish or he avoids physical activities. Fatigue or Loss of Energy: Complains of feeling tired all the time Child looks or complains of constantly feeling tired even with adequate sleep. From Lofthouse & Fristad (2006, p. 216)

33 Diagnosis: Major Depressive Symptoms at SchoolSymptom/Definition Example Low Self-Esteem, Feelings of Worthlessness or Excessive Guilt: Thinking and saying more negative than positive things about self or feeling extremely bad about things one has done or not done. A child frequently tells herself or others “I’m no good, I hate myself, no one likes me, I can’t do anything.” She feels bad about and dwells on accidentally bumping into someone in the corridor or having not said hello to a friend. Diminished Ability to Think or Concentrate, or Indecisiveness: Increase inattentiveness, beyond child’s baseline attentional capacity; difficulty stringing thoughts together or making choices. A child can’t seem to focus in class, complete work, or choose unstructured class activities. From Lofthouse & Fristad (2006, p. 216)

34 Diagnosis: Major Depressive Symptoms at SchoolSymptom/Definition Example Hopelessness: Negative thoughts or statements about the future. A child frequently thinks or says “nothing will change or will ever be good for me.” Recurrent Thoughts of Death or Suicidality: Obsession with morbid thoughts or events, or suicidal ideation, planning, or attempts to kill self A child talks or draws pictures about death, war casualties, natural disasters, or famine. He reports wanting to be dead, not wanting to live anymore, wishing he’d never been born; he draws pictures of someone shooting or stabbing him, writes a suicide note, gives possessions away or tires to kill self. From Lofthouse & Fristad (2006, p. 216)

35 Bipolar I Major Depressive DisorderAlternative Diagnosis Differential Consideration Major Depressive Disorder Person with depressive Sx never had Manic/Hypomanic episodes Bipolar II Hypomanic episodes, w/o a full Manic episode Cyclothymic Disorder Lesser mood swings of alternating depression -hypomania (never meeting depressive or manic criteria) cause clinically significant distress/impairment Normal Mood Swings Alternating periods of sadness and elevated mood, without clinically significant distress/impairment Schizoaffective Disorder Sx resemble Bipolar I, severe with psychotic features but psychotic Sx occur absent mood Sx Schizophrenia or Delusional Disorder Psychotic symptoms dominate. Occur without prominent mood episodes Substance Induced Bipolar Disorder Stimulant drugs can produce bipolar Sx Source: Francis (2013)

36 Bipolar II Alternative Diagnosis Differential ConsiderationMajor Depressive Disorder No Hx of hypomanic (or manic) episodes Bipolar I At least 1 manic episode Cyclothymic Disorder Mood swings (hypomania to mild depression) cause clinically significant distress/impairment; no history of any Major Depressive Episode Normal Mood Swings Alternately feels a bit high and a bit low, but with no clinically significant distress/impairment Substance Induced Bipolar Disorder Hypomanic episode caused by antidepressant medication or cocaine ADHD Common Sx presentation, but ADHD onset is in early childhood. Course chronic rather than episodic. Does not include features of elevated mood. Source: Francis (2013)

37 Cyclothymic Disorder Alternative Diagnosis Differential ConsiderationNormal Mood Swings Ups &downs without clinically significant distress/impairment Major Depressive Disorder Had a major depressive episode Bipolar I At least one Manic episode Bipolar II At least one clear Major Depressive episode Substance Induced Bipolar Disorder Mood swings caused by antidepressant medication or cocaine. Stimulant drugs can produce bipolar symptoms Source: Francis (2013)

38 I felt like I was a very old woman who was ready to dieI felt like I was a very old woman who was ready to die. She had suffered enough living Abbey Tracy Anglada Intense Minds: Through the Eyes of Young People with Bipolar Disorder (2006) Victoria, BC: Trafford Publishing Here are some more quotes: “Life was a heavy load, and I couldn’t do it right. In fact the load and burden of living was so difficult, and so big, I didn’t think I could accomplish it. I also didn’t know how people could walk down the street looking so happy, because I didn’t know that it wasn’t this way for everyone.” Drew “I felt so heavy. I felt drug down to the point of it being difficult to even sit up in a chair. I was afraid. I was incapable of doing anything but existing. I remember feeling like I was wading through quicksand, just pushing through something so very heavy. Just walking to another room was a challenge. Sitting up was hard. Speaking was too much.” Lee “I felt like life was a burden at times. It is like I never got to the point of being finished or accomplished. Every time I made some progress, then there was another step in front of me, but it usually had a negative feeling, and if something big and unexpected happened, I couldn’t cope.” Todd

39 Presentation Outline Diagnosis Course Co-existing DisabilitiesAssociated Impairments Etiology, Prevalence & Prognosis Treatment Best Practices for the School Psychologist Psycho-Educational Assessment Special Education & Programming Issues School-Based Interventions

40 Co-existing DisabilitiesAttention-deficit/Hyperactivity Disorder (AD/HD) Rates range between 11% and 75% Oppositional Defiant Disorder Rates range between 46.4% and 75% Conduct Disorder Rates range between 5.6 and 37% Anxiety Disorders Rates range betwee12.5% and 56% Substance Abuse Disorders 0 to 40% This is a controversial issue regarding bipolar disorder… Are these really comorbidities? To be honest, we don’t know. 1. Research shows us that BPD is HIGHLY comorbid with ADHD. What are the meds for ADHD? Stimulants. Any concerns about what that might do to a child with bipolar? So, what does research tell us about this medication issue? Some psychiatrists recommend that if there truly needs to be a stimulant added to the med cocktail, the individual is stabilized on a mood stabilizer and then adding a stimulant very slowly & carefully, with lots of observations & checking in to make sure it doesn’t cause a switch to mania. 2. ODD/CD’s = Seems to be an elevated risk for ODD & CD in children with bipolar disorder. Some of the Dxs associated with CD may be due to the behavioral disinhibition, or the irritability & low frustration tolerance associated with BPD. As with ADHD, studies show that these two disorders also exist as a true comorbidity. 3. Anxiety = Adolescents (as opposed to pediatric BPD individuals) tend to develop anxiety disorders more often. 4. Substance = Judd et al. (2003), in a longitudinal study of BPD (average age at onset =20-23 (diffs btwn BP II & I), demonstrated that individuals had an increased risk of substance abuse with between 40 & 50% of the over 200 subjects experiencing this. OTHERS: Used to believe that PDD’s could not have a comorbid mood dx, however, research is showing us that mood d/o’s can occur concurrently with PDD’s, and because no medication for PDD’s specifically, it’s important to address comorbid conditions, because most those conditions can be treated w/medications. In studies of PDD’s (specifically Asperger’s), it’s been shown individuals with PDD’s are 2 to 6 times more likely to develop a comorbid psychiatric condition than their developmentally normal peers, and that over half of individuals with Asperger’s also have mood disorders, and in studies looking at PDD’s and bipolar disorder, there is a significant overrepresentation of children with PDD’s in the overall bipolar disorder group as well as an overrepresentation of children with bipolar disorder in the PDD’s group. Pavuluri et al. (2005)

41 Co-existing DisabilitiesAD/HD Criteria Comparison Bipolar Disorder (mania) 1. More talkative than usual, or pressure to keep talking 2. Distractibility 3. Increase in goal directed activity or psychomotor agitation AD/HD 1. Often talks excessively 2. Is often easily distracted by extraneous stimuli 3. Is often “on the go” or often acts as if “driven by a motor” We discussed the DSM criteria for a manic phase of bipolar, three of the criteria for ADHD overlap… A study by Geller and colleagues (1998) indicated that there are some fundamental ways to differentiate between the two. They found that bipolar children are significantly more likely to experience elated moods (16 times more likely), grandiosity (11 times more likely), decreased need for sleep (9 times more likely) , hypersexuality (5 times more likely), and irritable moods (1.5 times more likely). Differentiation = irritable and/or elated mood, grandiosity, decreased need for sleep, hypersexuality, and age of symptom onset (Geller et al., 1998).

42 Co-existing DisabilitiesDevelopmental Differences Children have higher rates of ADHD than do adolescents Adolescents have higher rates of substance abuse Risk of substance abuse 8.8 times higher in adolescent-onset bipolar disorder than childhood-onset bipolar disorder Children have higher rates of pervasive developmental disorder (particularly Asperger’s Disorder, 11%) Similar but not comorbid Unipolar Depression Schizophrenia When thinking about diagnosis, it’s important to think about some other disorders that bipolar disorder might be masquerading as, or may be confused with, but don’t co-occur with… Unipolar depression. BE VERY CAREFUL if you learn of this diagnosis… May have missed Sx (particularly hypomanic Sx), family history… In a study by Geller & colleagues in 2001 (American Journal of Psychiatry) almost 50% of the subjects originally Dx’d with MDD converted to a BP diagnosis… 2. Schizophrenia--confusion w/psychotic features. Pavuluri et al. (2005)

43 Presentation Outline Diagnosis Course Co-existing DisabilitiesAssociated Impairments Etiology, Prevalence & Prognosis Treatment Best Practices for School Psychologists

44 Associated ImpairmentsSuicidal Behaviors Prevalence of suicide attempts 40-45% Age of first attempt Multiple attempts Severity of attempts Suicidal ideation With regard to suicide attempts, individuals with BPD have significantly higher rates, even when compared with other psychopathologies such as unipolar depression. Prevalence data indicates that between 40 & 45% of individuals with bpd attempt suicide. Those with a subsyndromal bipolar have been indicated to have a similar rate of suicide attempt as individuals with a unipolar depression, at about 18%. Individuals with BPD tended to be young when attempting suicide for the first time (around 13 years old), a higher percentage of multiple attempts (87% vs 50% major depression), and have more serious attempts. In addition, individuals with BPD report significantly more suicidal ideation (thoughts, feelings) than individuals with subsyndromal BPD or unipolar depression (BPD = 72%; SBDP = 41%; udprn = 52%).

45 Associated ImpairmentsCognitive Deficits Executive Functions Attention Memory Sensory-Motor Integration Nonverbal Problem-Solving Academic Deficits Mathematics It has been suggested that cognitive deficits are a better predictor of outcome than are symptoms. Recent studies have indicated that there are specific deficits evident across phases (including recovery) and subtypes of the disorder. Executive functioning deficits have consistently been indicated for individuals with BPD. The domains that are primarily compromised include: problem-solving, planning, self monitoring, and temporal sequencing of information. Executive functions tend to be more impaired during the manic phase. These individuals exhibit more errors due to difficulties with planning and impulse control (response inhibition). Individuals in the depressive phases tend to take longer to respond, and show increased difficulties with decision-making tasks. Much research has supported BPD individuals difficulty maintaining attention. Specific areas of impairment include: selective, sustained, & set-shifting. Obviously these diff. can be exacerbated by comorbidity with ADHD. Verbal learning and memory has been one of the deficit areas repeatedly indicated. Individuals with BPD typically perform poorer on tasks of new learning as well as recall, even when semantic cues are offered, possibly indicating that there may be problems with the encoding and retrieval of verbal information. Recognition of previously learned verbal information, as well as efficient and fluent retrieval/production of verbal information are also indicated as an area of weakness . Finally, working memory has also been indicated as an area of impairment for individuals with BPD. Sensory-Motor Integration. It has been demonstrated that individuals with bpd have difficulties with the sequencing of motor acts. They may appear clumsy, or have difficulties when required to perform a sequence of physical tasks. Visual processing has been strongly indicated as a trait deficit of bpd individuals. Processing speed and psychomotor speed deficits have also been documented as deficit areas. Particularly rapid visual information processing, fine motor skills, and response latency. Psychomotor speed deficits appear to persist even into recovery… There is some evidence to suggest that individuals with bpd demonstrate difficulties with nonverbal domains as well, particularly concept formation. While these deficits are evident across episodes into recovery, it has been demonstrated that these abilities become more impaired as the severity of the episode increases. (For example, individuals with depression tend to have significantly more impaired ability to sustain attention, as the individual becomes more depressed, he/she performs worse on tasks of attentional set-shifting, problem-solving, decision-making and concept formation). Other research suggests that impairment was correlated with level of psychosocial functioning, chronicity of the disorder, the number of hospitalizations, suicide attempts, and manic episodes. Mathematics deficits have been demonstrated with adolescents in the recovery phase of BPD. Researchers looked at spelling, mathematics and reading (Wide Range Achievement Test-Revised 2 (WRAT-2), Peabody Individual Achievement Test, Bay Area Functional Performance Evaluation Task-Oriented Assessment, Test of Nonverbal Intelligence Test-2nd edition, and self-reports of mathematical performance n=119). Compared with adolescents with unipolar depression and control subjects, BPD adolescents had significantly lower achievement in mathematics. Researchers hypothesized that these mathematics deficits may not simply be due to global deficits in nonverbal intelligence or executive functioning, but may be associated with neuroanatomical abnormalities that result in cognitive deficits, including a slowed response time.

46 Associated ImpairmentsPsychosocial Deficits Relationships Peers Family members Recognition and Regulation of Emotion Social Problem-Solving Self-Esteem Impulse Control In general, impairments in social behaviors and adjustment have been demonstrated, regardless of the state the individual is currently in when compared to control subjects. Over half of early onset BPD had no friends, were teased by other children, and had poor social skills. They also had poor relationships with siblings and high-tension relationships with their parents. Predictors of recovery and relapse are also available from family environment: For example, living in a household with an intact family unit (biologic mother and father) is a significant predictor of recovery for individuals with mania. These individuals were twice as likely to recover as their counterparts. Conversely, individuals with reported low levels of maternal warmth were 4 times more likely to relapse. Studies have suggested that children with BPD have difficulty processing facial affective cues. Not only do individuals have difficulty with recognition, but they also seem to take longer to process this information. Facial cues provide valuable information about another person’s emotions-happiness, irritation, sadness, anger, disgust, etc. Difficulties with this, as well as difficulty with emotion regulation may be some of the reasons why children with BPD have difficulty with relationships, and may not even recognize when interpersonal problems arise. Negative self-esteem has been demonstrated as a strong predictor of relapse for individuals with bpd. Even in symptomatic remission, or recovery, individuals with BPD present with lower self-esteem than their peers. Impulse control is not really a psychosocial deficit, however, it impacts how an individual interacts with his/her environment. Risk-taking behaviors tend to be rather high in individuals in the manic state of BPD. This, obviously, will impact an individuals performance in a classroom or playground setting.

47 Presentation Outline Diagnosis Course Co-existing DisabilitiesAssociated Impairments Etiology, Prevalence & Prognosis Treatment Best Practices for the School Psychologists

48 Etiology Although the etiology of [early onset bipolar spectrum disorder] is not known, substantial evidence in the adult literature and more recent research with children and adolescents suggest a biological basis involving genetics, various neurochemicals, and certain affected brain regions. Lofthouse & Fristad (2006, p. 212); Pavuluri et al. (2005, p. 853)

49 Etiology Genetics Aggregates among family membersFamily Studies Twin Studies MZ = .67; DZ = .20 concordance Adoption Studies Genetic Epidemiology Early onset BD = confers greater risk to relatives Molecular genetic Aggregates among family members Appears highly heritable Environment = a minority of disease risk There is a 4.5% prevalence of bipolar disorder among relatives of bipolar patients, and a 1.5% prevalence among relatives of depressed patients. Concordance rate of .67 for bipolar in MZ twins, and .20 in DZ twins. From these data it has been suggested that the heritability of bipolar disorder is .59. However, the finding of MZ concordance rates lower that 100% underscores the importance of environmental factors. Compared with a control group, the biological parents of bipolar adoptees had an increase prevalence of bipolar disorder, but the adoptive parents of bipolar adoptees did not. These results showed that genetic – not adoptive – relationships mediated the familial aggregation of bipolar disorder. There is an increased life time rate of bipolar disorder among the first-degree relatives of patients who experienced their first affective symptoms before age 12, compared with relatives of those with onset at 13. Among adults, the development of bipolar disorder appears to depend upon the combined small effects of variations in many different genes, none of which is powerful enough to cause the disease by itself. One of the genes the researchers correlated with this disorder is active in a biochemical pathway through which lithium is thought to exert its therapeutic effects. The gene produces and enzyme (diacylglycerol kinase eta) that functions at a point closer to the root of the lithium-sensitive pathway than does the protein that lithium is thought to target. Baum et al. (2007); Faraone et al. (2003); Pavuluri et al. (2005)

50 Etiology Neuroanatomical differences White matter hyperintensities.Small abnormal areas in the white matter of the brain (especially in the frontal lobe). Smaller amygdala Decreased hipocampal volume White matter hyperintensities: small abnormal areas in the white matter of the brain (especially in the frontal lobe) as seen using magnetic resonance imaging. These abnormalities may be caused by the loss of myelin or axons. The evidence for involvement of the amygdala early in the course of the disease is fairly strong. Involvement of the amygdala in BD is consistent with its central role in emotional and social behavior (assigning emotional valence to stimuli and memories, facilitating encoding). The amygdala plays a key role in emotions and forming emotional memories. This almond-shaped structure integrates your senses and links them with your emotions. It also affects basic behaviors such as feeding, sexual arousal, and the “fight-or-flight” reaction to stress. The hippocampus is a horseshoe-shaped brain structure involved in memory, learning, and emotion. It forms new memories and organizes them with related memories and emotions. Images “Partners HealthCare System” Available Hajek et al. (2005); Pavuluri et al. (2005)

51 Etiology Neuroanatomical differencesReduced gray matter volume in the dorsolateral prefrontal cortex (DLPFC) Bilaterally larger basal ganglia Specifically larger putamen DLPFC Basal Ganglia Reduced gray matter volume in the DLPFC The evidence for involvement of the striatum early in the course of illness is strong. These brain areas have been implicated in the modulation of socially appropriate emotional behavior. Increased striatal volume may be compensatory to a deficit in the fermentation from the frontal lobes or to deficits downstream within the circuitry involving the pallidum and thalamus. Images “Partners HealthCare System” Available Hajek et al. (2005); Pavuluri et al. (2005)

52 Prevalence & EpidemiologyNo data on the prevalence of preadolescent bipolar disorder Lifetime prevalence among 14 to 18 year olds, 1% Subsyndromal symptoms, 5.7% Mean age of onset, 10 to 12 years First episode usually depression Adult prevalence is much higher, most studies indicate 3-6% across nations and cultures. Pavuluri et al. (2005)

53 Prognosis With respect to prognosis …, [early onset bipolar spectrum disorder] may include a prolonged and highly relapsing course; significant impairments in home, school, and peer functioning; legal difficulties; multiple hospitalizations and increased rates of substance abuse and suicide In short, children AND adolescents with [early onset bipolar spectrum disorder] have a chronic brain disorder that is biopsychosocial in nature and, at this current time, cannot be cured or grown out of Pediatric bipolar disorder tends to be more debilitating with poorer outcomes. Juvenile BPD is much more chronic & has a very early onset age, with severe impairment, a great deal of emotional lability & impulsivity. They seem to have a more severe and complicated course of their illness. Suicidality (ideation/attempts) is shown to be more frequent in individuals with an onset of the disorder prior to age 18. Adult onset BPD tends to be episodic with shorter, more distinct episodes. Outcomes for individuals with broad phenotype (subsyndromal) also display significant impairment. Negative consequences exist for these individuals in the ability to cope with the demands for their ability to adjustment required during youth. Lofthouse & Fristad (2006, p )

54 Prognosis Outcome by subtype (research with adults) Bipolar Disorder IMore severe; tend to experience more cycling & mixed episodes; experience more substance abuse; tend to recover to premorbid level of functioning between episodes. Bipolar Disorder II More chronic; more episodes with shorter inter-episode intervals; more major depressive episodes; typically present with less intense and often unrecognized manic phases; tend to experience more anxiety. Cyclothymia Can be impairing; often unrecognized; many develop more severe form of Bipolar illness. BP I is the more classic form of BD typically with clearly recognizable and distinguished episodes of depression and mania. BP I= is thought to be more severe: experience more cycling or mixed episodes (significant 51 vs 30%); tend to have significantly more severe affective episodes (as evidenced by more hospitalization, lower Global Assessment Scale scores, and a higher prevalence of psychotic features); experience slightly more substance abuse (50 comp to 40%); tend to recover to their premorbid level of psychosocial functioning between episodes. BP II= thought to be more chronic- experience more major depressive episodes (thought to be the depressive pole of the bp spectrum; significant difference with 74 vs.50%); tend to have more episodes with shorter inter-episode intervals; experience more anxiety (38 comp to 23%) especially social phobias (Judd, et al., 2003). Cyclothymia is characterized by chronic fluctuating moods involving periods of hypomania and depression. The periods of both depressive and hypomanic symptoms are shorter, less severe, and do not occur with regularity as experienced with bipolar II or I. However, these mood swings can impair social interactions and work. Many, but not all, people with cyclothymia develop a more severe form of bipolar illness. BP: NOS-remember this is our catch-all for kids. It is the largest group of BP disorders, because of the variety of individuals with this dx, it is difficult to generalize about outcomes at this point.

55 Presentation Outline Diagnosis Course Co-existing DisabilitiesAssociated Impairments Etiology, Prevalence & Prognosis Treatment Best Practices for School Psychologists

56 Treatment Psychopharmacological DEPRESSION MANIA Mood StabilizersLamictal Anti-Obsessional Paxil Anti-Depressant Wellbutrin Atypical Antipsychotics Zyprexa MANIA Mood Stabillizers Lithium, Depakote, Depacon, Tegretol Atypical Antipsychotics Zyprexa, Seroquel, Risperdal, Geodon, Abilify Anti-Anxiety Benzodiazepines Klonopin, Ativan Psychopharmacological treatment of individuals with bpd has two goals: (a) reduction of current symptoms, and (b) prevention of relapse. IOW, medications are prescribed to treat acute episodes as well as for ongoing maintenance. There is no cure. Medications are needed through out life Mood stabilizers are the first line of treatment for any phase of bpd. A mood stabilizer is a drug that will not “destabilize” the disorder, or cause a switch to the opposite pole (e.g., from depression to mania). Switching is the most relevant problem for many of the treatments of bp depression. Bipolar depression is treated somewhat differently for this reason. This points to the importance of a correct diagnosis. The two states of bpd are treated with different medications. Real briefly, these medications may be prescribed when an individual is in a particular cycle of the disorder… Bipolar depression=Again, first line is a mood stabilizer, Lamictal has been shown to be efficacious without promoting switching. Anti-Obsessional meds, such as Paxil have also demonstrated efficacy with the risk of switching. Antidepressants are a more gray area. Atypical antidepressant Wellbutrin is particularly effective. The more classic antidepressants: such as Tricyclic’s (Tri’s) or MAO’s are not effective with bp depression (MAO’. Tri’s have been shown to more than triple the possibility of triggering a manic episode. SSRI’s reportedly do not cause a switch into mania, but are a second choice after Wellbutrin. Atypical Antipsychotics have also been shown to effectively treat bp depression. Many of the same approaches are used with manic episodes, of course, first line is a mood stabilizers: the infamous lithium, which still demonstrates to be the most effective medication in the treatment of mania. Also depakote, depacon, and tegretol have been used successfully. Atypical antipsychotics are effective in the treatment of mania, zyprexa, seroquel, risperdal, geodon and abilify all have research to back their efficacy. Less used are the benzo’s, due primarily, to their side effects and tolerability issues. Obviously, a very complicated issue. However, I think it’s important to be familiar with these names…

57 Psychopharmacology Cont.Treatment Psychopharmacology Cont. Lithium: History Side effects/drawbacks Blood levels drawn frequently Weight gain Increased thirst, increased urination, water retention Nausea, diarrhea Tremor Cognitive dulling (mental sluggishness) Dermatologic conditions Hypothyroidism Birth defects Benefits & protective qualities Brain-Derived Neurotropic Factor (BDNF) & Apoptosis Suicide Lithium is a natural occurring element found in springs, one of the best meds for BPD It’s believed that lithium’s benefits were recognized as far back as the 2nd century, when recommended as a Rx for “manic” patients = “natural H20’s, such as from alkaline springs.” These springs are very rich in lithium. It was “discovered” by accident in the 1940’s by an Australian doctor working in a psychiatric hospital, a Danish doctor furthered its reputation, doing empirical research and establishing not only the improvements related to it’s use, but also the protective or maintenance qualities. Because of the benefits, it was tried for many different things, from gout to kidney stones to heart disease & high blood pressure. Unfortunately, it took some time to figure out all the particulars of the drug and it can be toxic in low concentrations. (Blood levels need to be taken frequently, which is annoying, and a big drawback, especially for kids. ) Side effects… Many of these go away after body adjusts to the meds, but need to be aware of potential side effects & things that will impact the absorption (e.g., sweating a lot) Research has also shown us its benefits related to the suicidal behaviors that are so prevalent among individuals with bipolar disorder

58 Treatment Therapy Psycho-Education Family InterventionsMultifamily Psycho-education Groups (MFPG) Cognitive-Behavioral Therapy (CBT) RAINBOW Program Interpersonal and Social Rhythm Therapy (IPSRT) Schema-focused Therapy Much of the research base for psychotherapy for BPD focuses on relapse and medication compliance. Many of the treatments for bpd are psychoeducational in nature, & tend to include 2-9 sessions that are mainly informative about the disease and its pharmacological treatment. Its goal is to define bp illness as a biological disturbance and to focus treatment on pharmacological measures. Family-focused interventions addresses enhancing communication and coping skills, as well as the role of expressed emotion amongst families. Studies seem to indicate some decreases in relapse rates. MFPG. Empirically supported, not empirically validated. Initial findings indicate increase in parental knowledge regarding disorder, improvement in parent-child relationship. Children showed increase in perceived parental support & increase in perceived social peer support. Increase for families in “consumer skills”- ability to access appropriate services. CBT. A short-term psychotherapeutic individual intervention designed for treating depression. It is based on cognitive restructuring and is aimed at decreasing depressive symptoms and improving self-esteem. It includes self-monitoring and self-regulation, by means of managing and dealing with automatic, dysfunctional thoughts, and usually includes behavioral techniques for decreasing environmental stress & promote social adaptation . There is substantial evidence for the effectiveness of CBT for depression. The application of this theory for bpd derives from this research. There is evidence that improvements in mood and social functioning have been made with individual CBT. There have been no studies on group CBT. RAINBOW program. It’s a combination of CBT & Family Intervention. Focuses on Routine; Affect regulation; positive “I” statements; eliminating Negative thoughts; developing social and problem-solving skills; and learning where and how to get support. A recent study has indicated a decrease in symptom severity. IPSRT addresses the impact of biological and social rhythms on life events. Treatment focuses on eliciting and defining the salient problem area, followed by supported processing of emotion, and problem-solving around practical consequences. With unipolar depression, there is much evidence to support this intervention. There is limited research with bpd, with some evidence to support an impact on subsyndromal symptoms, with impact on the stability of social routine and can lead to longer periods of euthymia . Schema-focused therapy is an integration of cognitive therapy with experiential techniques, and was originally developed for personality disorders. Schemas are core beliefs/pervasive themes regarding oneself and others. They are self-perpetuating, with an individual tending to distort information to maintain its validity. The modified schema-focused cognitive therapy incorporates schemas associated with adaptability to illness and adaptability styles. Few studies.

59 Treatment Alternative Treatments Light TherapyElectro-Convulsive Therapy (ECT) & Repeated Transcranial Magnetic Stimulation (r-TMS) Circadian Rhythm Melatonin Nutritional Approaches Omega-3 Fatty Acids Medication are the primary treatments Psychotherapy are secondary Also may consider alternatives ECT as used today is very safe, and very effective especially with someone who is not medication compliant. Not currently used among children rTMS = smaller electrical current no seizure CR to preserve the sleep cycle “…although dietary interventions such as Omega-3 fatty acids and high intensity vitamin-mineral complexes have been tried in children, their efficacy is still being tested, an only case series data are available. As evidence for efficacy in some of the medicines being used for EOBPSD is currently stronger, families are encouraged to begin treatment with those agents first.” (Lofthouse & Fristad, 2006, p. 218)