Bipolar disorder in children and adolescents

There is increased recognition that bipolar disorder has an early age of onset. The prevalence of bipolar disorder in prepubertal children has not been determined, however the prevalence in adolescence is approximately 1%. Bipolar disorder in children poses a diagnostic challenge since the symptoms may differ from those in late adolescence and adulthood. Comorbid disorders, such as attention-deficit/hyperactivity disorder, further complicate both the diagnosis and course of the disorder. There is increasing evidence of the chronicity and severity of this disorder in youths. Bipolar disorder significantly disrupts a child's psychosocial development including impairments in academic functioning, family functioning, and relationship with peers. Although this disorder has significant morbidity in children and adolescents, there is a paucity of controlled studies to assess the efficacy and safety of mood stabilizers in the treatment of this disorder in youths. The treatment literature consists largely of case studies, retrospective chart reviews, and open-label studies. There is a compelling need for double-blind, placebo-controlled trials to determine whether commonly used medications to treat this disorder are significantly superior to placebo. Since many children in clinical practice require more than one psychotropic medication to adequately manage this disorder, studies of combination treatments are warranted. This review will provide an overview of the literature of bipolar disorder in children and adolescents, including discussion of the prevalence, diagnosis, epidemiology, course of the illness, and treatment issues.     

The contemporary face of bipolar illness: complex diagnostic and therapeutic challenges

Manic depression, or bipolar disorder, is a multifaceted illness with an inevitably complex treatment. The current article summarizes the current status of our knowledge and practice concerning its diagnosis and treatment. While the prototypic clinical picture concerns the "classic" bipolar disorder, today mixed episodes with incomplete recovery and significant psychosocial impairment are more frequent. The clinical picture of these mixed episodes is variable, eludes contemporary classification systems, and possibly includes a constellation of mental syndromes currently classified elsewhere. Treatment includes the careful combination of lithium, antiepileptics, atypical antipsychotics, and antidepressants, but not all of the agents in these broad categories are effective for the treatment of bipolar disorder.     

The Role of the Family in the Course and Treatment of Bipolar Disorder

ABSTRACT— Bipolar disorder is a highly recurrent and debilitating illness. Research has implicated the role of psychosocial stressors, including high expressed-emotion (EE) attitudes among family members, in the relapse–remission course of the disorder. This article explores the developmental pathways by which EE attitudes originate and predict relapses of bipolar disorder. Levels of EE are correlated with the illness attributions of caregivers and bidirectional patterns of interaction between caregivers and patients during the postepisode period. Although the primary treatments for bipolar disorder are pharmacological, adjunctive psychosocial interventions have additive effects in relapse prevention. Randomized controlled trials demonstrate that the combination of family-focused therapy (FFT) and pharmacotherapy delays relapses and reduces symptom severity among patients followed over the course of 1 to 2 years. The effectiveness of FFT in delaying recurrences among adolescents with bipolar disorder and in delaying the initial onset of the illness among at-risk children is currently being investigated.     

Cognitive-behavioral psychotherapy for pediatric obsessive-compulsive disorder

Discusses the cognitive-behavioral psychotherapy for pediatric obsessive-compulsive disorder (OCD). Over the past 15 years, cognitive-behavioral psychotherapy has emerged as the psychosocial treatment of choice for OCD across lifespan. Unlike other psychotherapies that have been applied usually unsuccessfully to OCD, cognitive-behavioral treatment (CBT) presents a logically consistent and compelling relationship between the disorder, the treatment, and the specified outcome. Nevertheless, despite a consensus that CBT is usually helpful, clinicians routinely complain that patients will not comply with behavioral treatments and parents routinely complain that clinicians are poorly trained in CBT, with the result that many if not most children and adolescents are denied access to effective psychosocial treatment. This unfortunate situation may be avoidable, given an increased understanding regarding the implementation of CBT in children and adolescents with OCD. To this end, we review the principles and the practical aspects of the cognitive-behavioral treatment of OCD in youth, move on to discuss empirical studies supporting the use of CBT in the pediatric age group, and conclude by discussing directions for future research.     

Dimensions and Latent Classes of Episodic Mania-Like Symptoms in Youth: An Empirical Enquiry

The dramatic increase in diagnostic rates of bipolar disorder in children and adolescents in the USA has led to an intense interest in the phenomenology of the disorder. Here we present data from a newly-developed instrument to assess episodic mania-like symptoms in youth in a large population-based sample (N = 5326) using parent- and self-report. We found that a substantial proportion of children screened positive for having episodes of “going high” and were at an increased risk for morbidity and impairment. Using factor analysis, we identified that episodic mania-like symptoms comprised two dimensions: An under-controlled dimension that was associated with significant impairment, and a low-risk exuberant dimension. Using latent class analysis, we identified a small group of children scoring high on a range of manic symptoms and suffering from severe psychosocial impairment and morbidity. Our results carry implications for the nosology and psychosocial impairment associated with episodic mood changes in young people.     

Family psychoeducation as an evidence-based practice

Family psychoeducation programs have emerged as a strongly supported evidence-based practice in the treatment of schizophrenia and bipolar disorder. Over 30 randomized clinical trials demonstrated that psychoeducation programs reduce relapse, improve symptomatic recovery, and enhance psychosocial and family outcomes. Recent work supports family psychoeducation strategies for other disorders, including major depression, obsessive-compulsive disorder, and borderline personality disorder. This review summarizes the research evidence supporting prominent models of family psychoeducation. Professional and peer-led family education programs are also reviewed and differentiated from family psychoeducation. Directions for future research studies to enhance the evidence base and inform treatment recommendations are proposed. Finally, strategies for implementation of family psychoeducation in routine clinical practice are discussed.     

Role of Parenting and Maltreatment Histories in Unipolar and Bipolar Mood Disorders: Mediation by Cognitive Vulnerability to Depression

In this article, we review empirical research on the role of individuals' parenting and maltreatment histories as developmental antecedents for symptoms and diagnosable episodes of unipolar and bipolar spectrum disorders. Our review is focused on the following three overarching questions: (1) Do negative parenting and a history of maltreatment contribute risk to symptoms or diagnosable episodes of unipolar and bipolar disorders? (2) Are the associations of negative parenting and maltreatment histories with bipolar disorders similar to those for unipolar depression? and (3) Are the associations between negative parenting and maltreatment histories and unipolar and bipolar symptoms or disorders mediated by cognitive vulnerability to depression? We begin by discussing the methodological requirements for demonstrating a psychosocial risk factor and the methodological issues that plague the parenting and maltreatment literatures. Next, we review the extant studies on the role of parenting histories in unipolar and bipolar disorders. We consider the specificity and possible moderators of the parenting-mood disorder relationship, as well as cognitive vulnerability to depression as a mediator of this relationship. Then, we review studies on the association of maltreatment histories with unipolar and bipolar disorders and the role of cognitive vulnerability to depression as a mediator of this association. We conclude with an assessment of the state of the parenting and maltreatment literatures in unipolar and bipolar disorder with regard to our guiding questions.     

Psychosocial factors in the course and treatment of bipolar disorder: introduction to the special section

Bipolar disorder is associated with high rates of relapse and high social and economic costs, even when patients are maintained on proper pharmacotherapy. The background and rationale are offered here for a series of articles that address the role of psychosocial agents in the course of bipolar disorder and psychosocial treatments as adjuncts to pharmacotherapy in the disorder's outpatient maintenance. It is argued that stressful life events and disturbances in social-familial support systems affect the cycling of the disorder against the backdrop of genetic, biological and cognitive vulnerabilities. Current models of psychosocial treatment focus on modifying the effects of social or familial risk factors as an avenue for improving the course of the disorder.     

A systematic review of the evidence-based psychosocial risk factors for understanding of borderline personality disorder

Borderline personality disorder (BPD) is a serious personality disorder characterized by affective instability, impulsivity and interpersonal disturbance. Currently, intensive research is being conducted concerning the aetiology of BPD, including research on neurobiological, temperamental, psychosocial and cultural risk factors. This study focuses on psychosocial risk factors while other risk factors are taken into account in the discussion of the development of BPD. To our knowledge, no systematic review of the evidence-based medicine literature concerning this theme has been made thus far. However, understanding psychosocial risk factors of BPD is important in order to develop psychotherapeutic treatment models and methods. We provide a systematic review of the literature focusing on psychosocial risk factors for BPD. Utilizing this knowledge, we discuss how these data may be used when studying the development of borderline personality disorder and the treatment of borderline personality disorder.     

Assessing the specificity of autobiographical memory in individuals at a trait-based vulnerability to bipolar disorder using a sentence completion task

Overgeneral autobiographical memory recall has been associated with the diagnosis of bipolar disorder, but the role of overgenerality in the vulnerability to bipolar disorder remains under-researched. While a previous study suggested that high-risk individuals for bipolar disorder recall emotionally negative memories in specific detail, this is in contrast to memory recall patterns noted in bipolar samples. The Autobiographical Memory Test (AMT) used in previous non-clinical studies has also been criticised for not being sensitive to overgenerality due to its repetition of specificity instructions and practice trials. The traditional AMT format may allow some individuals to override their trait-based tendencies to be overgeneral. The current study used a sentence completion task to assess memory specificity in groups of students at a low and high trait-based vulnerability for bipolar disorder. In contrast to previous research, high-risk individuals recalled fewer specific positive memories and greater numbers of overgeneral negative memories than low-risk individuals. These results support the notion that the vulnerability for bipolar disorder might be associated with similar recall biases as demonstrated in bipolar samples, and that the AMT might not be sufficiently sensitive to detect overgenerality in non-clinical groups. The implications of these findings and directions for future research are discussed.     

Family Focused Treatment for Patients with Bipolar Disorder in Turkey: A Case Series

Family-focused therapy (FFT) is a 9-month, 21-session structured psychoeducational treatment for bipolar disorder. Several US-based studies have documented its efficacy as adjunctive to medication for depression stabilization and relapse prevention. However, FFT has never been applied outside of the United States. The objective of this case series is to explore the applicability of FFT in a non-Western culture. Ten patients with bipolar disorder and their family members attended the 9-month FFT as adjunctive to pharmacotherapy in an outpatient specialty clinic in Izmir, Turkey. Patients improved in Global Assessment of Functioning Scores and Clinical Global Impression Scores from pre- to posttreatment. Case studies are given, which illustrate the differences between Western and non-Western families coping with bipolar disorder. FFT was easily applied to a Turkish sample with few changes in format or focus. Adaptations included substitution of oral for written therapeutic tasks or homework assignments. Randomized controlled trials are needed to test the clinical effectiveness of FFT and other psychosocial interventions in non-Western cultures.     

The Role of the Family in Childhood Obsessive–Compulsive Disorder

While obsessive–compulsive disorder is widely recognized to have a strong genetic component, psychosocial factors are also acknowledged to be important. The primary focus of this paper is on familial factors associated with OCD in children and adolescents. It explores the family context as a possible risk factor in the development and maintenance of the disorder, including parental modeling, expressed emotion, parenting style, and family accommodation of the child's symptoms. The involvement of the family in the treatment of the disorder is also reviewed. Finally, future directions for research investigating familial factors in childhood OCD are presented.     

Responsiveness to Threat and Incentive in Bipolar Disorder: Relations of the BIS/BAS Scales with Symptoms

Over the past 10 years, theorists have suggested that bipolar disorder symptoms result from increases and decreases in the activity of the Behavioral Activation or Facilitation System (BAS or BFS) and the Behavioral Inhibition System (BIS). These neurobehavioral systems are thought to determine the intensity of affective and behavioral responses to incentives and threats. This study examined cross-sectional and prospective associations of self-reported BIS and BAS with mania and depression in a sample of 59 individuals diagnosed with Bipolar I disorder. Depression was tied to BIS, pointing to the importance of sensitivity to threats in depression. However, links between BIS and depression appeared state-dependent. BAS subscales did not correlate with manic symptoms in a state-dependent manner; however, BAS (total scale and reward responsiveness subscale) predicted relative intensification of manic symptoms over time. Thus, evidence suggests that BAS sensitivity may constitute a vulnerability to mania among persons diagnosed with bipolar disorder. Discussion focuses on the integrative potential of the BIS/BAS constructs for linking psychosocial and biological research on bipolar disorder.     

Family Functioning and the Course of Adolescent Bipolar Disorder

The symptoms of bipolar disorder affect and are affected by the functioning of family environments. Little is known, however, about the stability of family functioning among youth with bipolar disorder as they cycle in and out of mood episodes. This study examined family functioning and its relationship to symptoms of adolescent bipolar disorder, using longitudinal measures of family cohesion, adaptability, and conflict. Parent- and adolescent-reported symptom and family functioning data were collected from 58 families of adolescents with bipolar disorder (mean age = 14.48 ± 1.60; 33 female, 25 male) who participated in a 2-year randomized trial of family-focused treatment for adolescents (FFT-A). Cohesion and adaptability scores did not significantly change over the course of the study. Parent-reported conflict prior to psychosocial treatment moderated the treatment responses of families, such that high-conflict families participating in FFT-A demonstrated greater reductions in conflict over time than low-conflict families. Moreover, adolescent mania symptoms improved more rapidly in low-conflict than in high-conflict families. For all respondents, cohesion, adaptability, and conflict were longitudinally correlated with adolescents’ depression scores. Finally, decreases in parent-reported conflict also predicted decreases in adolescents’ manic symptoms over the 2-year study. Findings suggest that family cohesion, adaptability, and conflict may be useful predictors of the course of adolescent mood symptoms. Family conflict may be an important target for family intervention in early onset bipolar disorder.     

Mental imagery as an emotional amplifier: application to bipolar disorder

Cognitions in the form of mental images have a more powerful impact on emotion than their verbal counterparts. This review synthesizes the cognitive science of imagery and emotion with transdiagnostic clinical research, yielding novel predictions for the basis of emotional volatility in bipolar disorder. Anxiety is extremely common in patients with bipolar disorder and is associated with increased dysfunction and suicidality, yet it is poorly understood and rarely treated. Mental imagery is a neglected aspect of bipolar anxiety although in anxiety disorders such as posttraumatic stress disorder and social phobia focusing on imagery has been crucial for the development of cognitive behavior therapy (CBT).In this review we present a cognitive model of imagery and emotion applied to bipolar disorder. Within this model mental imagery amplifies emotion, drawing on Clark's cyclical panic model [(1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461–470]. We (1) emphasise imagery's amplification of anxiety (cycle one); (2) suggest that imagery amplifies the defining (hypo-) mania of bipolar disorder (cycle two), whereby the overly positive misinterpretation of triggers leads to mood elevation (escalated by imagery), increasing associated beliefs, goals, and action likelihood (all strengthened by imagery).Imagery suggests a unifying explanation for key unexplained features of bipolar disorder: ubiquitous anxiety, mood instability and creativity. Introducing imagery has novel implications for bipolar treatment innovation - an area where CBT improvements are much-needed.     

Pharmacological treatment of childhood obsessive-compulsive disorder: from theory to practice

Discusses pharmacological treatment of childhood obsessive-compulsive disorder (OCD), chronic and underrecognized psychiatric condition that affects up to 2% to 3% of children and adolescents. Research in OCD in children, including neuropharmacology, brain imaging, genetics, and clinical phenomenology, informs current views of OCD pathophysiology. Contemporary research supports the notion of a dysregulation in serotonin subsystems in the central nervous system, with target areas of dysfunction including basal ganglia and orbitofrontal cortex. Pharmacotherapy, along with cognitive-behavioral approaches, constitutes the indicated treatment for childhood OCD. Pharmacological treatment is best guided by a phenomenological understanding of the type of obsessions and compulsions, the intensity and frequency of their presentation with attention to behavioral reinforcements, and psychosocial factors that affect the course of the disease. Serotonin-enhancing agents, such as fluoxetine, fluvoxamine, paroxetine, and sertraline and citalopram (SSRIs) are first-line pharmacological agents, whereas refractory symptoms can be treated by augmentation with neuroleptics or other agents. Clomipramine is as effective as the SSRIs but its use may be accompanied by increased side effects. Genetic factors probably influence susceptibility to OCD as well as response to treatment, and the elucidation of these and other risk factors will be important elements in the future understanding and treatment of this disorder.     

ADHD treatment in the 21st century: pushing the envelope

Required for optimal intervention for attention deficit hyperactivity disorder (ADHD) is evidence-based matching of child, treatment, and situation. The landmark Multimodal Treatment Study (MTA) of Children with ADHD documented the superiority of pharmacotherapy for the vast majority of children with ADHD. Although this study could not address the problem of the match directly, it is generating important leads for research on the use of psychosocial strategies to enhance the scope and durability of treatment gains while decreasing the risks attendant upon long-term use of medication. Given the inherent distinctions between pharmacological and psychosocial treatments, conclusive answers to questions about comparative efficacy will continue to elude scientist-practitioners. Needed next is research examining ways to improve outcomes beyond the effects of medication, using systematically tailored and sequenced psychosocial approaches and exploring new treatment targets, agents, and modalities. To illustrate, some emerging findings from an ongoing experience sampling study and implications for online therapy are discussed.     

Androgyny and its relation to adolescent psychosocial well-being: A review of the literature

The theoretical and empirical literature on androgyny in adolescence is reviewed in this paper. The traditional bipolar view of sex roles and more recent models of sex role development are contrasted. Then the research literature on the relation between sex role orientation and psychosocial well-being in adolescence is reviewed. From a review of several research articles on the topic, it is concluded that it is masculinity and the masculine component of androgyny that is most associated with both male and female adolescents' psychosocial well-being. This conclusion is discussed in light of current issues in the area of sex roles.     

Perceived Genetic Risks for Bipolar Disorder in a Patient Population: An Exploratory Study

Thirty-one subjects with bipolar illness completed a questionnaire about genetic risk for bipolar disorder. Subjects estimated both quantitative and qualitative genetic risk for bipolar disorder for the following categories: general population, siblings, parents, spouses, and children. Results showed that quantitative risks were inflated when compared to qualitative risks and that subjects routinely overestimated the risk for developing bipolar illness. These findings suggest that genetic counseling may be useful for this population.     

Mood stability versus mood instability in bipolar disorder: a possible role for emotional mental imagery

A cognitive model of bipolar disorder suggests that mental imagery acts as an emotional amplifier of mood and may be heightened in bipolar disorder. First, we tested whether patients with bipolar disorder would score higher on mental imagery measures than a matched healthy control group. Second, we examined differences in imagery between patients divided into groups according to their level of mood stability. Mood ratings over approximately 6-months, made using a mobile phone messaging system, were used to divide patients into stable or unstable groups. Clinician decisions of mood stability were corroborated with statistical analysis. Results showed (I) compared to healthy controls, patients with bipolar disorder had significantly higher scores for general mental imagery use, more vivid imagery of future events, higher levels of intrusive prospective imagery, and more extreme imagery-based interpretation bias; (II) compared to patients with stable mood, patients with unstable mood had higher levels of intrusive prospective imagery, and this correlated highly with their current levels of anxiety and depression. The findings were consistent with predictions. Further investigation of imagery in bipolar disorder appears warranted as it may highlight processes that contribute to mood instability with relevance for cognitive behaviour therapy.