Transcript HANDOUT Pary

DSM 5 diagnostic criteria for
bipolar and related disorders
in persons with ID
Robert J. Pary
NADD 2016
Acknowledgement
Co-authors
 Lauren Charlot
 Sherman Fox
 Jessica Hellings
 Anne D. Hurley
Disclosures
None
Aim
To update evidence-based
literature pertaining to the
diagnosis of bipolar and related
disorders in persons with ID
Historical context
It is only in the past three plus
decades that clinicians generally
accepted the notion that a person
with ID might be able to
experience a mood disorder such
as a bipolar disorder
Current Goal
Ensure reliable assessments at the
symptom level rather than
developing new sets of criteria
Use clear behaviorally based
descriptions of possible
manifestations of each DSM-5
symptom criterion
Work Group
In the DSM-IV-TR (and in DM-ID),
Bipolar Disorders were included in
the Mood Disorders chapter
In DSM5 and DM-ID2, Bipolar and
Related Disorders comprise a
separate chapter
Potential Bias
To varying degrees, members of
the work group believed that
during the past several years the
diagnosis (and subsequent
pharmacologic treatment) of
bipolar disorders spiked in
persons with IDD
DSM5 CRITERIA Manic Episode
Criterion A
A distinct period of
abnormally and persistently
elevated, expansive, or
irritable mood AND
DSM5 CRITERIA Manic Episode
Criterion A
abnormally and
persistently increased goaldirected activity or energy
DSM5 CRITERIA Manic Episode
Criterion A
lasting at least 1 week and
present most of the day,
nearly every day (or any
duration if hospitalization
is necessary)
DSM5 CRITERIA Manic Episode
Criterion B
During the period of mood
disturbance and increased
energy or activity
DSM5 CRITERIA Manic Episode
Criterion B
three (or more) of the
following symptoms (four if
the mood is only irritable)
are present to a significant
degree AND
DSM5 CRITERIA Manic Episode
Criterion B
represent a noticeable
change from usual behavior:
DSM5 CRITERIA Manic Episode
Criterion B
1.
Inflated self-esteem
or grandiosity
DSM5 CRITERIA Manic Episode
Criterion B
2.
Decreased need
for sleep (e.g., feels
rested after only 3
hours of sleep)
DSM5 CRITERIA Manic Episode
Criterion B
3.
More talkative
than usual or
pressure to keep
talking
DSM5 CRITERIA Manic Episode
Criterion B
4.
Flight of ideas or
subjective
experience that
thoughts are racing
DSM5 CRITERIA Manic Episode
Criterion B
5.
Distractibility (i.e.,
attention too easily
drawn to unimportant
or irrelevant external
stimuli)
DSM5 CRITERIA Manic Episode
Criterion B
6.
Increase in goaldirected activity (either
socially, at work or
school, or sexually) or
psychomotor agitation
DSM5 CRITERIA Manic Episode
Criterion B
 7.
Excessive involvement in
pleasurable activities that have
a high potential for painful
consequences (e.g., engaging
in unrestrained buying sprees,
sexual indiscretions etc.)
DSM5 CRITERIA Manic Episode
Criterion C
The mood disturbance is
sufficiently severe to cause
marked impairment in
social or occupational
functioning OR
DSM5 CRITERIA Manic Episode
Criterion C
to necessitate
hospitalization to
prevent harm to self or
others OR
DSM5 CRITERIA Manic Episode
Criterion C
there are psychotic
features
DSM5 CRITERIA Manic Episode
Criterion D
The episode is not
attributable to the
physiological effects of a
substance (e.g., a drug of
abuse, a medication, other
treatment) OR
DSM5 CRITERIA Manic Episode
Criterion D
a general medical
condition (e.g.,
hyperthyroidism)
DSM5 CRITERIA Manic Episode
Criterion
A full manic episode that
emerges during antidepressant
treatment (e.g., medication,
electroconvulsive therapy) but
persists at a fully syndromal level
beyond the physiological effect
of that treatment
 Note:
DSM5 CRITERIA Manic Episode
Criterion
is sufficient evidence for
a manic episode and,
therefore, a bipolar I
diagnosis
DSM5 Categories
 Bipolar I Disorder
 Bipolar II Disorder
 Cyclothymic Disorder
 Substance/Medication-Induced Bipolar and Related Disorder
 Induced Bipolar and Related Disorder Due to Another
Medical Condition
 Other Specified Bipolar and Related Disorder Unspecified
Bipolar and Related Disorder
Diagnostic Issues between General
Population and Persons with ID
Rapid cycling, 4 or more episodes in
a year, is more common in persons
with ID than in general population
 Cerebral dysfunction is presumed to
be a factor in the increased risk of
rapid cycling
Diagnostic Issues between General
Population and Persons with ID
Developmental stage can affect
cognitive symptoms of mania (i.e.
"inflated self-esteem or
grandiosity")
Diagnostic Issues between General
Population and Persons with ID
When cognitive symptoms are
described in people with ID, content
may be simplified
 May believe they possess more
normal abilities they actually have
 Arrange for wedding but no girlfriend
 Try to buy a car but no driver’s license
Diagnostic Issues between General
Population and Persons with ID
Pressured speech can appear
as increased vocalization (rate
or volume) or gesturing in
individuals who have limited
expressive language
Diagnostic Issues between General
Population and Persons with ID
Might be completely silent
during depressive episodes but
vocalizes or babbles almost
continuously during manic
periods
Diagnostic Issues between General
Population and Persons with ID
Distractibility may manifest as
changes in ability level
No longer completing daily
living activities
Skipping from one activity to
another
Diagnostic Issues between General
Population and Persons with ID
Increased energy
 Walking for miles
 Repeatedly changing clothes
 More frenzied baseline behaviors
 Rapidly piling up books or aligning
objects
Diagnostic Issues between General
Population and Persons with ID
Occasionally, one behavior can
capture several manic criteria
 Vigorous masturbation
 LASTING throughout the night
• Knocked mattress off bed
Diagnostic Issues between General
Population and Persons with ID
Recording of challenging
behaviors can fluctutate so that
the pattern suggests bipolar
disorder
Diagnostic Issues between General
Population and Persons with ID
Challenging behaviors may be
consistently under or over-reported
 Relief staff during weekends
 Prolonged substitute coverage
 High staff turnover
 Staff perceived medication change
Diagnostic Issues between General
Population and Persons with ID
Challenging behaviors are accurately
reported, but variations are due to
indirect effects of:
 On-site visits/inspections
 Sporadic family or close friend contact
 Serious illness: housemate, family or
close friend
nd
2
Mania
 Not ALL bipolar-like symptoms
MEAN Bipolar Dx
 Autoimmune
 Endocrine
 Neurologic
 Cerebrovascular
 Metabolic
 Substance withdrawal
nd
2
Mania
The authors of DSM-5 opted not to
include a concrete list of medical
causes because such a list is never
complete
Clinical judgment is critical to
diagnosing bipolar disorder due to a
medical condition
nd
2
Mania
Any medical condition that can
result in bipolar symptoms in the
general population can cause
manic symptoms in persons with
ID
Method
 NADD expert work group examined changes in the Diagnostic
Statistical Manual 5 (DSM 5)
 Reviewed pertinent evidenced-based literature for persons with IDD
 Submitted draft for peer review
 Revised draft
Method – Levels of
Evidence
 Type I: good systematic review and meta-analyses
with at least one randomized control trial (RCT)
 Type II: a RCT
 Type III: well-designed interventional study without
randomization
 Type IV: well-designed observational
 Type V: expert opinion, influential reports and studies
Results
No type I or type II levels of
evidence were found
Vast majority of studies were type
IV or V
Results – DSM5 Modifications
for Bipolar Disorder
Criterion A is revised to include
increased energy or activity as a
core symptom
Results – DSM5 Modifications
for Bipolar Disorder
A person, who meets both the full
criteria for mania and depression, is
diagnosed with bipolar disorder I
The new is “with mixed features”
instead of bipolar disorder I, mixed
episode as in DSM-IV
Results – DSM5 Modifications
for Bipolar Disorder
 The third pertinent change is the
introduction of the diagnostic
category of disruptive mood
dysregulation disorder within the
depressive disorders chapter
Disruptive mood dysregulation
disorder - new DSM5 category
 Chronic irritability - no distinct periods of
mania
 Onset before 10 years. Temper outbursts
inconsistent with developmental level
 Present for at least 12 months; without a threemonth symptom-free period
 Little is known about treatment or outcome
 Often previously diagnosed with pediatric mania
(early onset bipolar disorder)
Results
 In general population, 40-fold
increase in diagnosis of bipolar
disorders in young people over a
decade (Blader & Carlson, Biol
Psychiatry 62:107-14 2007)
 Level V evidence of over-diagnosis of
bipolar disorders in persons with IDD
For a reliable bipolar diagnosis in
a youth with ID
Clear change from previous
functioning
Not merely a worsening of,
or fluctuation in, a condition
present since early childhood
Over-diagnosis of Bipolar
Disorder
Individuals at risk for overdiagnosis of bipolar disorder
include those with persistent
irritability
Over-diagnosis of Bipolar
Disorder
Over-diagnosis of bipolar
disorder can result in
unnecessary exposure and the
subsequent potential adverse
effects of psychotropic
medications
IASSIDD Meeting
Colleagues from Europe and
Australian/New Zealand did not
agree that bipolar disorder was too
frequently diagnosed
 Is over-diagnosis of Bipolar Disorder
more typical of United States? North
America?
DSM5 Bipolar Disorders
Systematic, prospective, wellcontrolled studies have not been
conducted
 Using reliable means of assessing
the presence of full DSM5 criteria
 In representative samples of people
with ID
DSM5 Bipolar Disorders
Bipolar Related Disorders have
RARELY been studied
 Cyclothymia
 Bipolar II
Caution
 Case reports of bipolar
 Chromosome 22.q11.2 deletion
(velocardiofacial or diGeorge syndrome)
 Chromsome 22q13.3 deletion (PhelanMcDermid syndrome)
 Premature to associate any
chromosomal syndromes with an
increased risk for bipolar disorder
Limitation
Data were not kept as to number
of studies reviewed and those that
were excluded from review
involving persons with IDD
Conclusion
Mood dysregulation disorder may
provide greater diagnostic clarity for
pediatric bipolar disorder
The review highlights the potential
over-diagnosis of bipolar and related
for persons with IDD