disorder in children and adolescentsdiagnostic 在儿童和adolescentsdiagnostic双相情感障碍课件

Bipolar Disorder in Children and Adolescents:Bipolar Disorder in Children and Adolescents: Diagnostic Issues and Clinical Case Follow-upDiagnostic Issues and Clinical Case Follow-up James H. Johnson, PhD, ABPP/James H. Johnson, PhD, ABPP/CAPCAP University of FloridaUniversity of Florida *Some material for this presentation provided by NIMH Publication No. 00-4778 (2003)*Some material for this presentation provided by NIMH Publication No. 00-4778 (2003) Bipolar Disorder: General IntroductionBipolar Disorder: General Introduction Bipolar disorder is a largely Bipolar disorder is a largely biologically basedbiologically based disorder that causes extreme variations in a disorder that causes extreme variations in a persons persons mood and energymood and energy and impairs their and impairs their ability ability to functionto function. . It causes dramatic It causes dramatic mood swingsmood swings - from an overly - from an overly “high“ and/or irritable mood to sad and hopeless “high“ and/or irritable mood to sad and hopeless mood, and back.mood, and back. In older adolescents and adults there are often In older adolescents and adults there are often periods of normal moodperiods of normal mood in between. in between. Mood related changes are accompanied by severe Mood related changes are accompanied by severe variations in energy and behavior.variations in energy and behavior. The periods of highs and lows are called The periods of highs and lows are called episodesepisodes of of maniamania and and depressiondepression. . Symptoms of Bipolar Disorder: Symptoms of Bipolar Disorder: Mania/Manic EpisodeMania/Manic Episode Increased energy, activity, and restlessness. Increased energy, activity, and restlessness. Excessively “high,“ euphoric mood. Excessively “high,“ euphoric mood. Extreme irritability. Extreme irritability. Racing thoughts, talking very fast, jumping from Racing thoughts, talking very fast, jumping from one idea to another.one idea to another. Distractibility, inability to concentrate. Distractibility, inability to concentrate. Decreased need for sleep. Decreased need for sleep. Unrealistic beliefs in ones abilities and powers Unrealistic beliefs in ones abilities and powers Symptoms of Bipolar Disorder: Symptoms of Bipolar Disorder: Manic EpisodeManic Episode Poor judgment Poor judgment Spending sprees. Spending sprees. Increased sexual drive Increased sexual drive Abuse of drugs, particularly cocaine, alcohol, and Abuse of drugs, particularly cocaine, alcohol, and sleeping medications .sleeping medications . Provocative, intrusive, or aggressive behavior. Provocative, intrusive, or aggressive behavior. Denial that anything is wrong. Denial that anything is wrong. A manic episode is diagnosed A manic episode is diagnosed if elevated mood if elevated mood occurs with three occurs with three or more of the other symptoms or more of the other symptoms most of the daymost of the day, , nearly every daynearly every day, , for 1 week or longer (?). If the mood is irritablefor 1 week or longer (?). If the mood is irritable, four additional , four additional symptoms must be present.symptoms must be present. Symptoms of Bipolar Disorder: Symptoms of Bipolar Disorder: HypomaniaHypomania A mild to moderate level of mania is called A mild to moderate level of mania is called “ “hypomania”hypomania”. . Hypomania may feel good to the person Hypomania may feel good to the person who experiences it and may be associated who experiences it and may be associated with good functioning and enhanced with good functioning and enhanced productivity. productivity. Without proper treatment, however, Without proper treatment, however, hypomania can become more severe or hypomania can become more severe or can switch into depression.can switch into depression. Symptoms of Bipolar Disorder:Symptoms of Bipolar Disorder: Depressive EpisodeDepressive Episode Sad, anxious, or empty mood Sad, anxious, or empty mood Feelings of hopelessness or pessimism Feelings of hopelessness or pessimism Feelings of guilt, worthlessness, or helplessness Feelings of guilt, worthlessness, or helplessness Loss of interest or pleasure in activities once Loss of interest or pleasure in activities once enjoyed, including sex enjoyed, including sex Decreased energy, a feeling of fatigue or of Decreased energy, a feeling of fatigue or of being “slowed down“ .being “slowed down“ . Difficulty concentrating, remembering, making Difficulty concentrating, remembering, making decisions .decisions . Restlessness or irritability. Restlessness or irritability. Symptoms of Bipolar Disorder: Symptoms of Bipolar Disorder: Depressive EpisodeDepressive Episode Sleeping too much, or cant sleep. Sleeping too much, or cant sleep. Change in appetite and/or unintended weight Change in appetite and/or unintended weight loss or gain loss or gain Chronic pain or other persistent bodily Chronic pain or other persistent bodily symptoms that are not caused by physical symptoms that are not caused by physical illness or injury illness or injury Thoughts of death or suicide, or suicide Thoughts of death or suicide, or suicide attempts. attempts. A depressive episode is diagnosed if A depressive episode is diagnosed if five or more five or more of these of these symptoms last most of the day, symptoms last most of the day, nearly every daynearly every day, for a , for a period of 2 period of 2 weeks or longer (?)weeks or longer (?). . Mood Swings did not report being tired Flat affect through the evaluation Cooperative throughout the testing but not forthcoming when talking about feelings or responding to personality questionnaires (e.g., leaving out items, refusing to answer some questions) Test Results WASI: FSIQ = 107 (Verbal 102; Performance 109) WIAT: Reading GE = 8 3; Math GE = 5 8; Spelling GE = 8 6 (Note. In 7th Grade) Attention Measures Conners CPT (Confidence Index = 99.9) TEA-CH Selective Attention (Above Average) Attentional Control (Low Average); Sustained Attention (Significantly Impaired on 4 or 5 tests) Conners: Clinically significant elevations on: DSM IV Hyperactive/impulsive, DSM IV inattention, DSM IV Total, ADHD index, Social Problems, Oppositional, Restless-Impulsive, and Emotional Lability (High ranging profie) Test Results (Cont) Personality Inventory for Children Clinically significant elevations on multiple scales: Psychosis Withdrawal Hyperactivity Social Skills Deficits Depression Delinquency (Behavioral Problems) Anxiety PIC PROFILE Child Test Measures Administered child anxiety and depression scales as well as the Roberts Apperception Test and the Incomplete Sentence Schedule Due to patients response set and lack of motivation and involvement, this data is of questionable validity DIAGNOSIS ? DIAGNOSES ADHD, Combined type (314.01) Long standing history of hyperactive- impulsive, and inattentive behavior Poorly Controlled with Medication Highly significant elevations of Conners Parent Report Measure Significant Confidence Index on CPT Impairments in Sustained Attention on Tea- Ch Diagnoses Major Depressive Disorder (296.2) Grandparents report of symptoms of depression, including: Highly significant elevations on Personality Inventory for Children Irritable mood Anhedonia Decreased energy Difficulty sleeping Problems concentrating Diagnoses Bipolar Disorder R/O (296) Question? Should this be the superordinate diagnosis? Grandparents describe the patients behavior off of medication as “Crazy, wild, hyperactive” and note that he becomes “silly, elated, and giddy, as if in another world”. Has taken clothes off and run into the street howling on multiple occasions; this behavior has occurred as far back as 6 years of age and as recently as the past year when medications stop working. Patient has a history of depression, decreased need for sleep, irritable mood, and severely disinhibited behavior. This is combined with a paternal grandmother who was hospitalization for “mood swings”, a paternal grandfather who was medicated into his 60 for attention problems and activity level. Taken together it is believed that he should be further evaluated for bipolar disorder. While a definitive diagnosis is difficult at this time because core psychopathology has been clouded over time by multiple doses and combinations of numerous prescription and over-the-counter medications, it appears that this disorder may well account for his erratic and highly impairing and behavior Six Year Follow-up Patient seen for reevaluation this past year As an adult (18) wanted an evaluation to reconsider the “diagnosis” of bipolar disorder. Was accompanied to the evaluation by his Grandfather and his 25 year old fianc, with whom he lives. Clinical Status Update Significant change in treatment since last evaluation, although still under the care of a psychiatrist Changed from stimulants and antidepressants + to mood stabilizers + Some positive effects of mood stabilizers over the years were described but they seemed to have not helped with continuing “major attention problems”. Clinical Status UpdateClinical Status Update At the time of evaluation was prescribed At the time of evaluation was prescribed 2000 mg of 2000 mg of DepakoteDepakote, 400 mg of , 400 mg of SeroquelSeroquel, 300 mg of , 300 mg of WellbutrinWellbutrin and .01 and .01 mg of mg of synthroidsynthroid. . Had gained weight on Had gained weight on SeroquelSeroquel; up to 250 ; up to 250 pounds.pounds. Said it make him irritable and that he felt Said it make him irritable and that he felt druggeddrugged Quit taking all meds several months and Quit taking all meds several months and has now dropped to 140 pounds.has now dropped to 140 pounds. Interview FindingsInterview Findings Reports currently sleeping 7 8 hours per Reports currently sleeping 7 8 hours per night but reports functioning fine without night but reports functioning fine without any sleep.any sleep. Describes major problem with angerDescribes major problem with anger Frequently extremely irritable small things Frequently extremely irritable small things set him offset him off When angry he yells, hits, and breaks thingsWhen angry he yells, hits, and breaks things Numerous physical altercations in and out of Numerous physical altercations in and out of school over the yearsschool over the years Got drunk and beat fianc “really bad”Got drunk and beat fianc “really bad” Interview FindingsInterview Findings After previous evaluation he had returned After previous evaluation he had returned to school but had rough timeto school but had rough time Frequently suspended and expelled for Frequently suspended and expelled for fighting and arguing with teachersfighting and arguing with teachers Well known to law enforcement in his Well known to law enforcement in his hometown - fighting, drug usehometown - fighting, drug use Feels he cant go back without being hassled Feels he cant go back without being hassled by policeby police Quit high school after middle of 11Quit high school after middle of 11th th grade grade Interview FindingsInterview Findings Describes frequent mood changesDescribes frequent mood changes Reports that a couple of times a month will be Reports that a couple of times a month will be giddy and laughinggiddy and laughing for 2 3 days at a time for 2 3 days at a time Mood is way beyond just being happy; people Mood is way beyond just being happy; people notice and comment on his exaggerated notice and comment on his exaggerated mood.mood. Describes having Describes having extreme racing thoughts extreme racing thoughts which “he cant keep up with” and creates which “he cant keep up with” and creates problems in concentratingproblems in concentrating Describes Describes problems with hyperactivityproblems with hyperactivity, , impulsivity and inattentionimpulsivity and inattention Interview FindingsInterview Findings Grandfather describes him as Grandfather describes him as significantly significantly depressed.depressed. Patient also describes himself as “sometimes sad”.Patient also describes himself as “sometimes sad”. Grandfather says he is Grandfather says he is just like his mother just like his mother “overly “overly happy, manic and then depressed.”happy, manic and then depressed.” Pt describes himself as Pt describes himself as self-medicating almost daily self-medicating almost daily with marijuanawith marijuana to help himself “calm down” to help himself “calm down” Currently has a drug possession charges pending.Currently has a drug possession charges pending. Grandfather concerned over failure to meet with Grandfather concerned over failure to meet with probation officer for drug testing and having legal probation officer for drug testing and having legal difficulties.difficulties. Patient seemingly not concernedPatient seemingly not concerned. . Interview FindingsInterview Findings Discussed living apart from Grandfather Discussed living apart from Grandfather with fianc.with fianc. Describes good relationship with fianc Describes good relationship with fianc Both unemployedBoth unemployed Got moms inheritance when he turned 18Got moms inheritance when he turned 18 Stated that he had enough money to last a Stated that he had enough money to last a couple of years without workingcouple of years without working Later wants to get GED and learn Later wants to get GED and learn puters. Interview FindingsInterview Findings “Confidential discussion” regarding inheritance“Confidential discussion” regarding inheritance Patient had agreed with grandfather on a Patient had agreed with grandfather on a budget of $2,800 per month to live on.budget of $2,800 per month to live on. Unknown to grandfather - first 6 months after Unknown to grandfather - first 6 months after getting inheritance spent over $100,000.getting inheritance spent over $100,000. Two new carsTwo new cars (both for patient the second car to drive when he was (both for patient the second car to drive when he was tired of driving the first)tired of driving the first) ClothesClothes Jewelry Jewelry Unconcerned about how long money will last!Unconcerned about how long money will last! Test FindingsTest Findings WASIWASI FSIQ = 98;FSIQ = 98; VIQ = 97;VIQ = 97; PIQ = 99PIQ = 99 WIAT IIWIAT II Word Reading 12.9 GEWord Reading 12.9 GE Reading Comp 12.6 GEReading Comp 12.6 GE Math 7.0 (NO) 7.2 (MR) GEsMath 7.0 (NO) 7.2 (MR) GEs Written Expression 3.1 GEWritten Expression 3.1 GE (Low Written Expression due to disinterest and (Low Written Expression due to disinterest and impulsiveness in responding) impulsiveness in responding) Test FindingsTest Findings Parent Report Measures: Conners 3; BASCParent Report Measures: Conners 3; BASC Clinically Significant Elevations on Conners ScalesClinically Significant Elevations on Conners Scales: : ADHD Inattentive; ADHD Hyperactive/Impulsive; ADHD Inattentive; ADHD Hyperactive/Impulsive; Oppositional Defiant; Aggression; Peer Relations; ADHD Oppositional Defiant; Aggression; Peer Relations; ADHD Index; Global Index; and Executive Function ScaleIndex; Global Index; and Executive Function Scale Extreme Elevations on Most ScalesExtreme Elevations on Most Scales Clinically Significant Elevations on the BASCClinically Significant Elevations on the BASC Clinically Significant elevations on Hyperactivity, Conduct Clinically Significant elevations on Hyperactivity, Conduct Problems, Attention Problems; “At Risk elevations on Problems, Attention Problems; “At Risk elevations on Depression, Depression, AtypicalityAtypicality, and Withdrawal, and Withdrawal Also, significant impairment in Daily Living Skills, and Also, significant impairment in Daily Living Skills, and difficulties in social skills and functional communicationdifficulties in social skills and functional communication MMPI 2 MMPI FINDINGS Clinically significant elevations on scales reflecting extremely high levels of manic/hypomanic symptomatology suspiciousness/distrust antisocial features a level of mental confusion that may be reflected in poor judgment in everyday life. Content Scales, composed of critical items associated with depression, suggest significant depressive symptomatology Examples of Critical Items DIAGNOSIS ?DIAGNOSIS ? DiagnosesDiagnoses Attention Deficit Hyperactivity Disorder, Attention Deficit Hyperactivity Disorder, Combined Type (314.01)Combined Type (314.01) Bipolar Disorder, Not Otherwise Specified Bipolar Disorder, Not Otherwise Specified (296.80)(296.80) Are both warranted ?Are both warranted ? RecommendationsRecommendations Given concerns expressed by the patient and his Given concerns expressed by the patient and his Grandfather regarding his current medication regimen, Grandfather regarding his current medication regimen, along with the fact that pt is not taking his medications, along with the fact that pt is not taking his medications, continued consultation with his psychiatrist is continued consultation with his psychiatrist is important.important. This consultation should incl