ADHD and Bipolar Disorder

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1 소아청소년양극성장애의감별진단 전북대학병원 박태원

2 Pediatric Bipolar Disorder (PBD) Prevalence: 0.2-1% in adolescents More likely to show a non-episodic, chronic course continuous rapid cycling patterns mixed mood states Often present with Moodiness impulsivity, hyperactivity, the inability to concentrate Most children with bipolar disorder fit into bipolar disorder NOS

3 Symptoms Kowatch et al. Bipolar Disorders 2005:7:

4 Comorbidity 동반이환의전체양상은성인 BD와유사 Very early onset (11세이전) 은 ADHD와 separation anxiety disorder가흔하며, 청소년기 BD는 substance use 와 eating disorder가비교적흔하다 Youngstrom et al. Bipolar Disorders 2008: 10: Kowatch et al. Bipolar Disorders 2005:7:

5 Red flags that trigger thorough evaluation of possible bipolar disorder Red flag Description references Early onset depression Onset before age 25 or Prepubertal onset Kowatch et al. (2005) Psychotic features True delusions or hallucinations occurring in the context of mood Kowatch et al. (2005) Episodic aggressive behavior Not specific to bipolar disorder, but most bipolar youth show this; more episodic should trigger evaluation to R/O Hodgins et al. (2002) Family history of Bipolar disorder Five-fold increase in risk for first-degree relative; 2.5-fold for second-degree relative Hodgins et al. (2002) Atypical depression Associated with hypersomnia, increased appetite, wt. gain, decreased energy, interpersonal rejection sensitivity Benazzi & Rhimer (2000); Birmaher et al. (1996) Youngstrom (2007). Assessment of Childhood Disorders

6 DSM symptoms that are highly sensitive but not specific to bipolar disorder Irritable mood, poor concentration, high levels of motor activity 이러한증상의부재는 BD를배제하는데유용 Irritable mood: 소아정신건강의 fever 또는 pain 에해당? (Kowatch et al., 2005) Only a small percentage of children with irritability will have mania. 어떤문제가있음을시사하지만무엇이문제인지판단하는데는도움되지않는다. Aggression: a main presenting problem 현저하게 episodic 하고다른 manic 증상이동반되면 BD 고려

7 DSM symptoms that are highly specific to BD Elated, expansive mood Not so sensitive: PBD의 70~80% 에서등장 (Kowatch et al., 2005) Less frequent in ADHD (Geller et al., 2002) Fluctuation of self-esteem ad grandiosity가중요 Chronic grandiosity or an inflated but brittle sense of self-esteem: 행실장애 ( CD) 와관련될가능성 Decreased need for sleep Highly specific to pediatric bipolar disorder (PBD) 환자의보고는정확하지않을수있고부모는잘모를수있다. Unipolar depression의잠들기어려운것과구분

8 Hypersexuality Low sensitivity (31-45%), but high specificity Sexual abuse 나 mood disorder 를제외하고는소아에서드물다. In young children, hypersexuality may manifest as a fascination with private parts an increase in self-stimulatory behaviors a precocious interest in things of a sexual nature language laced with highly sexual words or phrases. Increased energy 심한기복이나변화를보이는경우에는 highly specific 만성적인경우에는 specificity 가낮다. ( ADHD 를더의심 )

9 Episodicity Episodicity 를보이면정동장애가능성이높다 Esp., when mood episodes have recurred. 다른애매한증상을보이는경우, episodicity 나증상의기복에대한평가가특히중요 기질, 발달력평가를통해환자의기본 ( 배경 ) 상태를평가

10 Psychotic symptoms PBD 의약 30% 에서등장 In the context of mood (Kowatch et al., 2005) Delusions and hallucinations are not uncommon. Sometimes the voices and visions are compelling. Often threatening, critical, or instruct the child to act on aggressive impulses towards others or self.

11 Differential Diagnosis ADHD Conduct Disorder (CD) Oppositional Defiant Disorder (ODD) Substance Abuse Psychosis: Schizophrenia, Schizoaffective Disorder Borderline Personality Disorder Anxiety disorder Adjustment disorder Sexual abuse

12 Medical conditions that mimic PBD Neurological Closed or open head injury, stroke CNS infections Temporal lobe epilepsy Multiple sclerosis, brain tumor, Wilson s disease Immunological SLE, HIV Systemic Hyperthyroidism, porphyria Medication induced mania TCA, SSRIs, SNRIs, steroids, aminophylline, corticosteriods, various antibiotics, amphetamines, & cocaine, hallocinogens etc.

13 PBD Vs ADHD Rates of PBD with comorbid ADHD 20~98% of bipolar children or adolescents also have ADHD 11~23% of ADHD children have co-occurring bipolar disorder Co-occurring ADHD may be a marker or prodrome for early-onset BD? Early onset BD have higher rates of ADHD The age at onset of is earlier in BD+ADHD Offspring of adults with BD have high rates of ADHD BD+ADHD have a worse course and higher rates of other comorbid psychiatric disorders than BD w/o ADHD.

14 ADHD DSM-IV criteria Either: 6 symptoms of inattention or hyperactivity/impulsivity And: Onset before age 7 Impairment in at least 2 settings: (work)-school-home-leisure activities Impairment in social-academic-occupational function No other pervasive disorder: PDD, SPR/other psychotic disorder, mood disorder, anxiety disorder, dissociation disorder

15 Symptoms sharing between BD and ADHD Overlapping diagnostic criteria Psychomotor agitation Being more talkative than usual Distractibility Cf.) overlapping features of mania and CD: irritability, hostility, impulsivity Many children with juvenile mania are frequently misdiagnosed as having ADHD + CD Only euphoria and grandiosity appear to be symptoms exclusive to mania (Carlson, 1999) But, these features are relatively rare in bipolar children

16 Distinguishing BD from ADHD 정동삽화동안에존재하는증상과정동삽화가없는동안에존재하는증상을비교 Age of onset: ADHD는 7세이전에시작하여평생지속하는경향 7세이전에발병하는 BD는매우드물다 Consistency of impairment: ADHD는지속적으로존재 BD는삽화형태로등장

17 Mood triggers: ADHD 의경우생활사건 (life event) 와정서불안정간의상관성이 BD 보다높다. Mood Congruency? Rejection sensitive dysphoria Cf.) Borderline personality disorder

18 Rapidity of mood shift ADHD 의경우전형적인 BD 보다 mood switch 가훨씬빠르다. BD 의경우 ADHD 와달리상당기간동안변화된정동상태가유지된다. Duration of moods ADHD mood shifts are usually measured in hours.

19 Family history BD 와 ADHD 의가족력이함께등장하는경우가많지만, BD 는 BD 의가족력을, ADHD 는가족중에많은 ADHD 환자를주로보고한다. BD 가족력를지속적으로업데이트하는것이필수적 Most of the parents are still within the age range of risk of developing a mood disorder. Mania in childhood is associated with greater familial loading for affective illnesses than adolescent bipolar disorder

20 Responses to medication ADHD: 80% 는 stimulant 에반응 BD: Mood stabilizer 에반응 (sodium divalproex: 50%) Mood congruent psychotic feature Rule breaking behavior: Mania: grandiose, oblivious, excitement seeking quality, presence of true guilt or regret CD: more malicious, antisocial ADHD: often accidental

21 Grossly inflated self-esteem 다른소아청소년장애에서는주로 low self esteem 이등장! 우울장애이후에 manic/hypomanic behavior 가시작 Esp., without history of ADHD or hyperactivity prior to the onset of mania PBD 의절반은 depression/dysthymia 로시작 (Faedda et al., 2004) Sudden change in sleep patterns Significant change in sleep patterns, in the presence of other bipolar symptoms

22 CD & ODD Many young people with bipolar disorder are oppositional and aggressive. Aggression is the most common reason manic people are brought to treatment. Oppositional defiant behavior is common in school age patients. Juvenile mania is frequently mixed mood state. 감별진단 Underlying mood state 를파악 문제행동양상 : Children with mania are mischievous rather than vindictive and calculating. The conflict of BD patients with authority usually result from poor judgment and grandiosity. 적절한치료프로그램으로 CD/ODD 증상이호전?

23 Substance abuse Commonly a confounding factor. 정신장애환자들이일반인구보다약물남용가능성이크다. 약물남용으로 BD 와유사한증상이발생 e.g.) cocaine abuse: euphoric effects followed by dysphoria & depression. 약물남용이 manic 증상을악화시키고치료를어렵게만들수있다. 약물남용이먼저인가? 양극성장애가먼저인가? Geller et al. (1998): The onset of manic symptoms predated substance abuse by several years. 어떤것이먼저인지를파악하는것이향후치료에중요.

24 Schizophrenia Greater perceptual distortions in adolescent BD Schizophrenic prodrome in children starts with affective symptoms DDx: BD 또는 Schizophrenia 의가족력유무 Onset pattern: The onset of mania is more sudden Premorbid personality: SPR: schizoid traits or bizarre conduct disorder Mania: symptoms suggestive of ADHD or conduct disorder with significant affective symptomatology 애매한경우 mood disorder 로간주하고치료를시작하는것이유리? (Akiskal 과 Weller, 1989)

25 Summary PBD tend to have less clear cycles of manic behavior. PBD are more prone to have a variety of comorbid diagnoses. PBD may present as cases of extreme ADHD. PBD is associated with a variety of risky behaviors. No single symptom is in itself diagnostic for PBD. Total clinical picture can lead to the diagnosis of PBD.

다문화 가정의 부모

다문화 가정의 부모 영유아아동정신건강연구 Korean Journal for Infant Mental Health 2013, Vol. 6, No. 1, 57-84 영유아기정서및행동문제에대한 부모와일반교사의인식및지원욕구조사 - 57 - 영유아아동정신건강연구 6 권 1 호 - 58 - 영유아기정서및행동문제에대한부모와일반교사의인식및지원욕구조사 - 59 - 영유아아동정신건강연구 6 권