Robert J. Pary - PowerPoint Presentation

Slide1

Robert J. ParyNADD 2016

DSM 5 diagnostic criteria for bipolar and related disorders in persons with

IDSlide2

Acknowledgement

Co-authors

Lauren

Charlot

Sherman Fox

Jessica

Hellings

Anne D. HurleySlide3

Disclosures

NoneSlide4

Aim

To update evidence-based literature pertaining to the diagnosis of bipolar and related disorders in persons

with IDSlide5

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

Slide6

Current Goal

E

nsure

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

criterionSlide7

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 chapterSlide8

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 IDDSlide9

DSM5 CRITERIA Manic EpisodeCriterion A

A

distinct period

of abnormally and

persistently

elevated, expansive,

or

irritable

mood

AND

Slide10

DSM5 CRITERIA Manic EpisodeCriterion A

abnormally

and

persistently

increased

goal-directed activity or

energy Slide11

DSM5 CRITERIA Manic EpisodeCriterion A

lasting at least 1 week

and present

most

of the day,

nearly every day

(or

any

duration if

hospitalization

is necessary

)Slide12

DSM5 CRITERIA Manic EpisodeCriterion B

During the period of mood disturbance

and

increased energy or activity Slide13

DSM5 CRITERIA Manic EpisodeCriterion B

three (or more) of the following symptoms (four if the mood is

only

irritable) are present to a significant

degree AND Slide14

DSM5 CRITERIA Manic EpisodeCriterion B

represent a noticeable change from usual

behavior

:Slide15

DSM5 CRITERIA Manic EpisodeCriterion B

1. Inflated self-esteem or grandiositySlide16

DSM5 CRITERIA Manic EpisodeCriterion B

2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)Slide17

DSM5 CRITERIA Manic EpisodeCriterion B

3. More talkative than usual or pressure to keep talkingSlide18

DSM5 CRITERIA Manic EpisodeCriterion B

4. Flight of ideas or subjective experience that thoughts are racingSlide19

DSM5 CRITERIA Manic EpisodeCriterion B

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)Slide20

DSM5 CRITERIA Manic EpisodeCriterion B

6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitationSlide21

DSM5 CRITERIA Manic EpisodeCriterion 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.)Slide22

DSM5 CRITERIA Manic EpisodeCriterion C

The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning

ORSlide23

DSM5 CRITERIA Manic EpisodeCriterion C

to necessitate hospitalization to prevent harm to self or others

ORSlide24

DSM5 CRITERIA Manic EpisodeCriterion C

there are psychotic

featuresSlide25

DSM5 CRITERIA Manic EpisodeCriterion D

The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment)

ORSlide26

DSM5 CRITERIA Manic EpisodeCriterion D

a general medical condition (e.g., hyperthyroidism

)Slide27

DSM5 CRITERIA Manic EpisodeCriterion

Note:

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

treatmentSlide28

DSM5 CRITERIA Manic EpisodeCriterion

is sufficient evidence for a manic episode and, therefore, a bipolar I

diagnosisSlide29

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 DisorderSlide30

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

cyclingSlide31

Diagnostic Issues between General Population and Persons with ID

Developmental

stage

can affect

cognitive

symptoms of mania (i.e.

"

inflated self-esteem or grandiosity"

)Slide32

Diagnostic Issues between General Population and Persons with ID

When cognitive symptoms are described in people with ID, content may be

simplified

M

ay 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 Slide33

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 Slide34

Diagnostic Issues between General Population and Persons with ID

M

ight

be completely silent during depressive episodes but

vocalizes

or babbles almost continuously during manic

periods

Slide35

Diagnostic Issues between General Population and Persons with ID

Distractibility may manifest as changes in ability

level

N

o

longer completing daily living activities

S

kipping

from one activity to

another Slide36

Diagnostic Issues between General Population and Persons with ID

I

ncreased

energy

W

alking

for miles

Repeatedly

changing

clothes

M

ore

frenzied

baseline behaviors

R

apidly

piling up books or aligning

objectsSlide37

Diagnostic Issues between General Population and Persons with ID

Occasionally, one behavior can capture several manic

criteria

V

igorous

masturbation

LASTING throughout

the night

K

nocked mattress

off

bed Slide38

Diagnostic Issues between General Population and Persons with ID

R

ecording

of challenging

behaviors can

fluctutate

so that

the pattern

suggests bipolar disorder Slide39

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

H

igh

staff

turnover

Staff perceived medication change Slide40

Diagnostic Issues between General Population and Persons with ID

C

hallenging

behaviors are accurately reported, but variations are due to indirect effects

of:

On-site visits/inspections

Sporadic

family or close friend

contact

S

erious illness:

housemate, family or close

friend Slide41

2nd Mania

Not

ALL bipolar

-like symptoms

MEAN Bipolar

D

x

A

utoimmune

Endocrine

N

eurologic

C

erebrovascular

Metabolic

S

ubstance

withdrawal Slide42

2nd 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

conditionSlide43

2nd Mania

Any

medical condition that can result in bipolar symptoms in the general population can cause manic symptoms in persons with

ID Slide44

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 draftSlide45

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 studiesSlide46

Results

No type I or type II levels of evidence were found

Vast majority of studies were type IV or VSlide47

Results – DSM5 Modifications for Bipolar Disorder

Criterion A is revised to include increased

energy or activity

as a core

symptomSlide48

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 Slide49

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 chapterSlide50

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 three-

month symptom-free period

Little is known about treatment or outcome

Often previously diagnosed with pediatric

mania

(early onset bipolar disorder)Slide51

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 Slide52

For a reliable bipolar diagnosis in a youth with

ID

Clear change from previous functioning

N

ot

merely a worsening of, or fluctuation

in,

a condition present since early

childhood Slide53

Over-diagnosis of Bipolar Disorder

Individuals at risk for

over-diagnosis

of bipolar disorder include those with persistent irritability Slide54

Over-diagnosis of Bipolar Disorder

Over-diagnosis

of bipolar disorder can result in unnecessary exposure and the subsequent potential adverse effects

of

psychotropic medications Slide55

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?Slide56

DSM5 Bipolar Disorders

Systematic, prospective, well-controlled studies have

not

been conducted

Using

reliable means of assessing the presence of full DSM5 criteria

I

n

representative samples of people with ID Slide57

DSM5 Bipolar Disorders

Bipolar Related Disorders have RARELY been studied

Cyclothymia

Bipolar IISlide58

Caution

C

ase reports of bipolar

Chromosome

22.q11.2 deletion (

velocardiofacial

or

diGeorge

syndrome)

Chromsome

22q13.3 deletion (Phelan-

McDermid

syndrome

)

P

remature

to associate any chromosomal syndromes

with

an increased risk for

bipolar

disorder Slide59

Limitation

Data were not kept as to number of studies reviewed and those that were excluded from review involving persons with IDDSlide60

Conclusion

M

ood

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