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Rasim Somer Diler, MD Professor of Psychiatry, Medical Director/Co-Director, Inpatient/Outpatient
Child and Adolescent Bipolar Services (In-CABS/CABS)University of Pittsburgh Medical Center,
Western Psychiatric Institute & Clinic, Pittsburgh, PA
www.pediatricbipolar.pitt.edu
Thursday October 07, 2021
Differential Diagnosis
in youth with Bipolar Spectrum Disorders
Disclosures
Funding from NIH
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Learning objectives• Importance of comorbidities in differential diagnosis
• Diagnostic criteria & areas of possible confusion
• Key concepts to differentiate bipolar spectrum
• Updates in DSM 5
Why is it important to differentiate
Bipolar Spectrum Disorder in Youth
Actual
BipolarMisdiagnosed
False -
ADHD
Unipolar
Depressed
Stimulant
Antidepressant
No
Antimanic
Very costly> 10 years for BP Dx
Agitation
Psychosis
Mania
Misdiagnosed
False +
Actual
ADHD
Actual
Unipolar
Depressed
Bipolar Antimanic
Costly
Bad Side Effects
Don’t get
better
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Diagnostic difficulties
Difficult, time consuming, & problematic:
• Differentiate from other psychiatric disorders
Moody ADHD/Disruptive Behavior Disorders
Disruptive mood dysregulation disorder
Non-bipolar depression
High functioning autism spectrum disorders
• Differentiate subtle symptoms from developing child
False statement: “Hey, she/he looks normal, she/he
cannot be bipolar!”
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Clinical presentation…
is usually not mania-related
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Comorbid disorders are very common
Mass
GeneralWASH-U
Case
Western
COBY
BP-IAge Adjusted
Attention-Deficit
Hyperactivity D/O87% 87% 70% 69 %
Oppositional
Defiant D/O86% 79% 47% 46%
Conduct D/O 41% 12% 17% 12%
Anxiety D/O 54% 23% 14% 37%
Substance Use
D/O7% 0% 7% 5%
Axelson et al., Arch Gen Psychiatry, 2006
Several mood symptoms are not specific
IrritabilityAnger
Bipolar Disorder
Depression
Autistic Spectrum Disorders
Anxiety Disorders
PTSD / History of
Abuse
Oppositional Defiant Disorder
ADHDSubstance Use
Disorders
DMDD
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DSM decision trees may help ?• In DSM 5
• No perfect fit in real life
Identify episode first & then symptoms
Symptoms must be:
• Concurrent (happen together)
• Present for sufficient duration (be around for long enough time)
• Occur episodically (different than usual self, or baseline pre-existing other
psychopathology such as autism)
• FOCUS ON LONGITUINAL COURSE OF MOOD
• OBTAIN COLLETERAL INFORMATION*
• WHEN IN DOUBT, PROVIDE PSYCHOEDUCATION & KEEP MONITORING..
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Let’s talk about mood episodes..
Mood Episodes and Bipolar Disorder (BD)-I and II
BD-I BD-II
Mania
Hypomania
Normal mood
Mild depression
Major depression
A hypomanic episode: • milder symptoms for four days (vs. 1 week in manic episode)
& have a “distinct change” from the baseline functioning (vs.
impairment in mania)
& patients may like or dislike these changes
❖ How about shorter episodes that looks like manic?
Pearls to help with diagnosis
• Mania-specific symptoms
✓ elation/euphoria
✓ grandiosity
✓ decreased need for sleep
✓ flight of ideas/racing thoughts
✓ hypersexuality (not due to sexual abuse/exposure)
• Distinct episodes within chronic problems
• **Symptoms must cluster together & be abnormal
for child’s level of development and environment
Bipolar
Not
Bipolar
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Bipolar vs ADHD: both can co-exist
Changes in DSM5
for manic/hypomanic episode
• Increased energy or activity level is a “MUST”
• This is in addition to “elated/irritable mood” during the
manic/hypomanic episode
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New DSM 5 mania criteria
Elevated/Expansive mood
or}Irritability
Increased goal-directed activity*or}
Motor hyperactivity*PLUS ≥3 Sx (4 if irritable) Associated with A Elevated/Irritable Mood & Increased
Activity/Energy:Inflated self-esteem, grandiosity
Decreased need for sleep
More talkative, pressured to keep talking
Flight of ideas or racing thoughts
Distractibility
Increased goal-directed activity or psychomotor agitation
Risky/dangerous behaviors done for pleasurable reasons
Other manic symptoms
• Inflated self-esteem, grandiosity
• Decreased need for sleep
• More talkative, pressured to keep talking
• Flight of ideas or racing thoughts
• Distractibility
• Increased goal-directed activity or
psychomotor agitation
• Risky/dangerous behaviors done for
pleasurable reasons
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Disruptive Mood Dysregulation Disorder
DMDD
• Starts before age 10, no later than 18 yo
• Developmental age at least 6
• Chronically irritable for at least 1 year,
without any good mood more than 3 months
• + verbal/physical anger outbursts 3x/ week
• DMDD alone is rare in the clinics, many youth
will have comorbid ADHD, opositonal defiant
(ODD), and conduct diagnoses
• Exclusion: They cannot have mania (>1 day),
ODD, or impulse control disorder
Bipolar Depression vs. Unipolar Depression
• More severe depression
• More hopelessness & more suicidality
• Lower functioning
• More comorbidity (disruptive behavior, anxiety, substance use)
• More inpatient psychiatric treatment
NOT SPECIFIC TO DIFFERENTIATE BP
So, keep asking about past mania!!!!
• Wozniak et al. J Affective Disord 82 Suppl 1: S59-69, 2004.
• Carlsson et al. Depress Anxiety 23: 1-12., 2006
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What suggests Bipolar
during a depressive episode?
• Psychosis features
• Atypical symptoms such as
✓ psychomotor retardation
✓ fatigue
✓ hypersomnia/hyperphagia
• Medication induced hypomania
• Family history of bipolar disorder (*)
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Changes in DSM5 for depressive & manic/hypomanic episodes
• No “mixed episode” anymore
• New “mixed features for manic episode” (≥3 depressive
symptoms within manic episode)
• New “mixed features for major depressive episode” (≥3
manic symptoms within depressive episode)
• Medication induced mania
= New “Medication/Substance induced bipolar and related
disorder”
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NEW DSM 5 diagnosis:
*Unspecified/Other Specified
Bipolar and Related Disorder
?Formerly “Bipolar Not Otherwise Specified (NOS)”
Differential diagnosis is a continuous process
Unspecified
BP (NOS)Bipolar I/II
Comorbid conditions may change
1. Diler in prep, 2. Yen 2016
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Our novel
“Mood & Energy Thermometer”
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Take-Home Messages
• Difficult to diagnose & differentiate from other conditions
• Differential diagnosis has significant implications for
treatment
• Pay more attention to identify episodes and changes from
baseline
• Increased activity and energy level are now required for
mania episode
• Differential diagnosis is a continuous process with
developmental progression & changes in clinical presentation
• Pay attention to medical conditions
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• All families & youth for their participation
• Course and Outcome of Bipolar Youth (COBY) Study:
➢ Pittsburgh: David Axelson, Boris Birmaher (PI), Renee Clark, Josh Feldmiller, Mary Kay Gill, Ben Goldstein, Tina Goldstein, Heather Kumar, Fangzi Liao, John Merranko, Sharon Nau, Neal Ryan, Raeanne Sylvester, Vicky Tzanakos
➢ Brown: Daniel Dickstein, Heather Hower, Jeff Hunt, Matthew Killam, Martin Keller (PI), Claire Walker, Shirley Yen
➢ UCLA: Michael Strober (PI)
• The Pittsburgh Bipolar Offspring Study (BIOS): David Axelson, Boris Birmaher (PI), David Brent, Renee Clark, Nicholas Curcio, Ronna Currie, Rasim Diler, Tina Goldstein, Danella Hafeman, Mary Beth Hickey, David Kupfer, Cecile Ladouceur, John Merranko, Kelly Monk, Mary Phillips, Brian Rooks, Dara Sakolsky, Rita Scholle, Lindsay Virgin
• Longitudinal Assessment of Manic Symptoms (LAMS) Study: David Axelson, Boris, Birmaher, Rasim Diler, Mary Kay Gill, C.H. Jaquette, Dawn Rice, Leslie Wehman
• Mood and Brain Circuitry in Adolescence Research Study (MBA): Allison Brown, Pat Brosseau, Rasim Somer Diler (mPI), Cecile Ladouceur (mPI), Han-Tsung Marcus Min, Nicole Gonzalez, Kate Thurston-Griswold.
• InCABS Imaging Study: Maria Wolfe, Halimah Abdul-waalee, Michele Bertocci (mPI), Rasim Somer Diler (mPI), Mariah Chobany, Jon Hart, Greeshma Malgireddy.
• Ways for Adolescents to Validate Emotions (WAVE) Study: Rachel Fersch-Podrat, Nina Hotkowski, Tina Goldstein (PI), Matt Garcia, Megan Krantz, Jessica Levenson, Dawn Rice, Sue Wassick, Tim Winbush, Christine Hoover, Stacy Simon, Barbara Pane
• Children and Adolescents Bipolar Services (CABS) (Outpatient and Inpatient): Boris Birmaher, Donna Barham, Sherri Brunner, Rasim Somer Diler, Rachael Fersch-Podrat, Olivia Flood, Tina Goldstein, Danella Hafeman, Christine Hoover, Nina Hotkowski, Tara Krelic, Megan Nase, Mary Kaye, Leslie Phillips, Kevin Rico, Dara Sakolsky, Amy Schlonski, Rita Scholle, Susan Wassick, Tim Winbush
• The National Institute of Mental Health
• The Koplowitz Foundation (Spain) and The Fine Foundation (Pittsburgh)
Thank You
www.pediatricbipolar.pitt.edu
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THANK YOU FOR YOUR ATTENTION!
Rasim Somer Diler, MD Professor of Psychiatry, Medical Director/Co-Director, Inpatient/Outpatient Child and Adolescent Bipolar Services (In-CABS/CABS) Western Psychiatric Institute & Clinic,
Pittsburgh, PA
www.pediatricbipolar.pitt.edu
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