July 17, 2012

Diagnosing Psychiatric Comorbidity in Pediatric Bipolar Disorder

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Robert L. Findling, MD, MBA

University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio


Making an accurate assessment regarding whether or not a
youngster is suffering from a bipolar disorder can be a difficult task. What
makes the diagnostic process even more challenging is the fact that a
substantial number of these patients suffer from psychiatric comorbidity. Thus,
when faced with a young patient who indeed does suffer from a bipolar illness,
it is important to consider the possibility that this youth also suffers from a
comorbid psychiatric condition.

However, I have found that accurately assessing for
psychiatric comorbidity in pediatric patients with bipolar illness can be quite
difficult to do. One reason for this is that many of the symptoms of mood
episodes are also the symptoms of comorbidities. For example, patients in
hypomanic, mixed, or manic states can experience symptoms of restlessness,
distractibility, and impulsivity. These 3 symptoms are also key features of one
of the most commonly reported comorbidities in pediatric bipolar
illness—attention-deficit/hyperactivity disorder (ADHD). So, how does one try
to disentangle comorbidity from juvenile bipolarity?

One approach involves a careful longitudinal assessment. In
the instance of bipolar illness and ADHD, one may be able to ascertain whether
the conditions have separate ages at onset. In my experience, it is not
uncommon to hear about a patient with chronic symptoms consistent with the
diagnosis of ADHD who, several years later, started to develop “worsening” ADHD
that was also characterized by spontaneous mood episodes associated with
psychosocial dysfunction and emotional distress. In such instances, one might
strongly suspect an underlying diagnosis of ADHD upon which a mood disorder is superimposed.
Conversely, if one gets a long-term history that lacks core symptoms of ADHD,
the likelihood of this comorbidity is reduced.

Sometimes, the longitudinal history is not so clear. So,
what other approaches might one take? Another approach that I have found to be
useful is to do a meticulous family history. In many cases, one hears about a
family history of affective illness in one parent and a family history of
another heritable mental health condition in the other. This can help gauge
one’s index of suspicion about a particular psychiatric comorbidity in the
young patient.

In my experience, another key way to try to tease out the
presence or absence of psychiatric comorbidity is to identify recent periods of
euthymia. Since many youths suffering from bipolar illness have sustained mood
episodes, identifying recent epochs when the patient was euthymic can sometimes
be difficult. However, I have found that many parents and guardians can indeed
identify periods of neutral moods in these children. Identifying the presence
or absence of psychiatric symptomatology during these periods can be quite
helpful in either giving or eschewing a comorbid diagnosis.

I have found that identifying the presence or absence of
psychiatric comorbidity in a youngster can be very important. It can give
clinicians, patients, and patients’ families an appropriate perspective about
what to expect during treatment. For example, if faced with a youngster
suffering from a severe manic episode, it might be useful to anticipate what
residual problems might remain after the patient’s mood state has improved. In
addition, it can help patients and parents identify what may and may not be
addressed by thymoleptic medication, so that “treatment failures” in regard to
mood stabilization can be more precisely identified (rather than attributed to
untreated comorbid conditions).

Making an accurate assessment regarding comorbidity when
faced with a young patient with bipolar illness can be a substantive challenge.
However, since the start of an evidence-based treatment plan begins with a
correct diagnosis, it is important to do one’s best to get a precise
perspective of the patient. I have found that the approaches I have described
can be helpful when evaluating these vulnerable youths.

Financial disclosure:Dr Findling,
in the past 12 months, has received research support, acted as a consultant,
and/or served on a speaker’s bureau for Alexza, American Psychiatric Press,
AstraZeneca, Bristol-Myers Squibb, Dainippon Sumitomo Pharma, Forest,
GlaxoSmithKline, Guilford Press, Johns Hopkins University Press, Johnson &
Johnson, KemPharm, Eli Lilly, Lundbeck, Merck, NIH, Novartis, Otsuka, Pfizer,
Physicians Postgraduate Press, Rhodes, Roche, Sage, Shionogi, Shire, Stanley
Medical Research Institute, Sunovion, Supernus, Transcept, and WebMD.

Category: ADHD , Bipolar Disorder
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Related to "Diagnosing Psychiatric Comorbidity in Pediatric Bipolar Disorder"

7 thoughts on “Diagnosing Psychiatric Comorbidity in Pediatric Bipolar Disorder

  1. I wonder if the author is aware of the pediatric and adolescent versions of the BSDS as devised by Dr. Manuel Mota-Castillo. Any comments?
  2. Does this apply to kids with ADHD who also have a family history of ADHD and bipolar? Also some kids are so prenatally drug impacted, it is very hard to decide on any diagnosis as there are multiple comorbidities. Tracking euthymia is challenging but certainly worth a try.
  3. Co-morbidity with ADHD is quite common and making the diagnosis is sometimes not possible without the use of an instrument such as the Kiddi-SADS. The big problem in the field though is the overdiagnosis. Calling Conduct Disorder and Substance abusing teens to be bipolar often occurs. Bipolar has become much more socially an acceptable diagnosis but using it where it is not appropriate only enables the denial that is practiced by parents who have a Conduct disordered, substance abusing child.
  4. Steven has raised a very important point. I have been involved in treating refractory anxiety disorders for over 2 decades now. The most common presentation for undiagnosed bipolar II patients I have seen is with one or more anxiety disorders (usually OCD, social anxiety, and panic attacks). Most often the anxiety disorders have been present since childhood or adolescence. I was noting a pattern in my practice that the more anxiety disorders a patient had, the greater the likelihood they had bipolar disorder. To look at this in a community sample I did a statistical analysis of the Ontario Health Survey where I believe Ron Kessler was hired to replicate the National Comorbidity Survey. The likelihood of having a bipolar disorder grew with each anxiety disorder, with the largest increase in likelihood being associated with three or more anxiety disorders. No anxiety disorder was associated with 0.3% likelihood of bipolar disorder; one anxiety disorder with 0.6%; two with 6.1%; three with 17.0% and four with 20.0%. Tho odds ratio for having bipolar disorder was 5.80 with two or less anxiety disorders and 71.12 with three or more anxiety disorders (unbublished data). Not uncommonly, my adult patients with bipolar disorder have a history of prepubertal panic attacks which I have not seen in unipolar patients. Early onset anxiety disorders in bipolar disordered patients is in keeping with the work of a fellow Canadian, Anne Duffy.
    In my experience, only once the bipolar disorder is stabilized will the state-dependent anxiety symptoms resolve. Lamotrigine and low doses of atypical antipsychotics have been most successful in treating my patients with bipolar II or bipolar NOS and comorbid anxiety disorders.

    Kevin Kjernisted M.D. FRCPC
    University of British Columbia

  5. I have also observed co-morbid and difficult-to-treat anxiety in some of my patients with Bipolar disorder. One of my patients, age 25, who has had untreated Bipolar disorder type I (manic psychosis as a teen on fluoxetine) has severe ADHD (an inability to read or concentrate even in a euthymic state), and OCD and Social Anxiety disorder, which keep him isolated indoors. He also has a severe form of cystic acne which further complicates the picture because his only remaining hope of treatment for this is Acutane which I’ve advised against for now. He has responded well to risperidone and Na-Divalproex for the mood instability and Vyvanse for ADHD, but his anxiety disorders are raging on. I’ve started a small dose of citalopram but am uneasy about adding it to the mix. Does anyone have suggestions?
  6. If depression and persistent anxiety have continued, I would suggest trying addition of lamotrigine slowly titrating upwards from 25 mg daily to 200-300 mg BID. I have never found risperidone to have significant antidepressant effects. I would try an atypical with antidepressant properties and use low doses e.g., quetiapine XR
  7. Sorry, my last post was submitted prematurely. Lower doses of atypicals tend to be more antidepressant than higher doses. I would suggest, in addition to the lamotrigine, which by decreasing glutamate may help OCD and other anxiety disorders and depression (as well as schizophrenia and schizoaffective disorder- in my experience- if one is patient enough) adding quetiapine XR 300-450 mg, aripiprazole 2-10 mg, or lurasidone 20-80 mg. Hope you try this and it is helpful. Please let me know. Kevin

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