Bipolar Disorder & Mood Dysregulation: Neuropsychology

Neuropsychological Studies

• Early-onset bipolar disorder often involves impairments in verbal memory, processing speed, executive function, working memory, and attention
• Children and adolescents who have both bipolar disorder and ADHD show more pronounced impairments in working memory, processing speed, and attention than those who only have ADHD
• Children with bipolar disorder make more errors in recognizing emotions than other children
• These children more frequently identified faces as angry when looking at adult faces, but not when looking at children's faces
• Impaired perception of facial expressions also occurs in adults with bipolar disorder.

Disruptive Mood Dysregulation Disorder

• Disruptive mood dysregulation disorder (DMDD) is a new inclusion in the DSM-5
• DMDD involves severe, developmentally inappropriate, recurrent temper outbursts, occurring three or more times per week
• Individuals with DMDD also exhibit a persistently irritable or angry mood between temper outbursts
• To meet the criteria for DMDD, symptoms must be present for at least a year before the age of 10
• Clinicians often diagnose DMDD in children who have bipolar disorder, oppositional defiant disorder, ADHD, or intermittent explosive disorder
• Data suggests these children do not typically develop bipolar disorder in late adolescence or early adulthood
• Youth with chronic irritability and severe mood dysregulation are at higher risk for future unipolar depressive disorders and anxiety disorders
• Hyperarousal may be a symptom, but it is not included in the DSM-5 diagnostic criteria

Diagnosis and Clinical Features of Disruptive Mood Dysregulation Disorder

• DSM-5 criteria require outbursts that are grossly out of proportion to the situation
• Outbursts may be verbal rages or physical aggression toward people or property
• Outbursts are inappropriate for the child's developmental level
• Outbursts occur on average three or more times per week
• Symptoms must be present before age 10 years
• Symptoms must be present for at least 12 months and present in at least two settings like home and school
• Diagnosing DMDD would not happen in children younger than 6 years or older than 18 years
• Between outbursts, the child's mood is persistently irritable and angry, as noticed by teachers, peers, or parents
• A diagnosis of bipolar disorder would override a diagnosis of DMDD because the symptoms of DMDD cannot occur during a major depressive episode.

Oppositional Defiant Disorder (ODD)

• Oppositional defiant disorder describes enduring patterns of negativity, disobedience, and hostility toward authority figures
• ODD also involves an inability to take responsibility for mistakes, leading to blaming others
• Children with ODD often argue with adults, lose their temper, become easily annoyed, and feel angry and resentful
• Difficulty is present in the classroom and with peer relationships, but generally do not resort to physical aggression or significantly destructive behavior

Diagnosis and Clinical Features of ODD

• Those with ODD often argue with adults, lose their temper, and are angry, resentful, and easily annoyed by others
• The angry reaction happens at a level and frequency that is outside of the expected range for their age and developmental level.
• Youth with ODD actively defy adults' requests or rules and deliberately annoy other persons
• Blaming others for their misbehavior is very common
• Manifestations of ODD symptoms are present at home, but they may not be present at school or with other adults or peers
• Symptoms are most evident in interactions with adults or peers whom the child knows well
• May not show signs of ODD when examined clinically but may justify their behavior as responses to unfair or unreasonable circumstances
• The disorder appears to cause more distress to those around the child than to the child

3 types of Oppositional Defiant Disorder

• DSM-5 has divided oppositional defiant disorder into three types:
  • Angry/irritable mood
  • Argumentative/defiant behavior
  • Vindictiveness
• A child may meet diagnostic criteria for ODD with at least four symptoms from the three types over a 6-month timeframe
• Angry/irritable children with ODD often lose their tempers, are easily annoyed, and feel irritable most of the time
• Argumentative/defiant children argue with authority figures/adults (parents, teachers & relatives)
• This type refuses to comply with requests, break rules, and purposely annoy others or blame others for misbehavior
• Vindictive shows spiteful actions at least twice in 6 months to meet the diagnostic criteria
• ODD or irritability interferes with interpersonal relationships and school performance
• Peers often reject these children, leading to isolation and loneliness which results in low self-esteem, poor frustration tolerance, depressed mood, and temper outbursts
• Chronically irritable children often develop mood disorders in adolescence or adulthood

Pathology, Lab Examination and Differential Diagnosis of ODD

• There are no lab tests or pathologic findings to diagnose ODD
• Some with ODD become violent and aggressive or violate others' rights
• Those ODD patients may then share characteristics like those people who have high levels of aggression, like low CNS serotonin
• Distinguish periods of normative negativism from ODD
• ODD not diagnosed in the presence of disruptive mood dysregulation disorder because it should be ruled out
• We can diagnose adjustment disorder in reaction to a stressor, along with ADHD, cognitive disorders, and mental retardation
• The key is on the severity, pervasiveness, and duration of that behavior.

Conduct Disorder

• Conduct disorder is an enduring set of behaviors that evolves
• It is characterized by aggression and violation of the rights of others.
• Youth exhibit behaviors in four categories:
  • Physical Aggression
  • Threats of harm to people
  • Destruction of their property or that of others
  • Theft/acts of deceit
  • Frequent violation of age-appropriate rules
• Conduct disorder is associated with several comorbidities and psychosocial factors
  • ADHD
  • Depression
  • Learning Disorders
  • Childhood Maltreatment
  • Harsh Parenting
  • Family Discord
  • Lack of Parental Supervision etc
• DSM-5 requires 3 conduct disordered symptoms over the past 12 months; 1 must be in the 6 months prior to being diagnosed
• CD includes bullying, threatening, or intimidating others, and staying out at night despite parental prohibition
• CD cannot be diganosed if it it occurs after the age 18 years
• 3 specifiers are also included: Mild, Moderate and Severe.

Conduct Disorder (cont.)

• Symptoms do not always develop overnight; it evolves until the others' rights are violated
• Young children are unlikely to be viable candidates because that have not developed many of the requirements: school age children being the predominant age
• 3 subtypes are defined by age onset of disorder: The age of onset of the disorder -CD emerges repeatedly before are 10 years -No characteristic or persistent symptoms occur until after after age 10
  • Unspecified Onset
• Children with conduct disorder express overt aggressive behavior in different forms
• Conduct disorder is present in males close to to 10-12 years of age
• In females it is approximately 14-16 years of age

Etiology of Conduct Disorder

• Impulsivity, neglect, physical abuse ect are all key contributing factors
• Harsh, Punitive parenting is also a main attribute
• Chaotic home conditions are key attributes to the disorder
• Sociopathy and Alcohol disorder are also key
• Long term longitudinal studies reveal links between long term expression of aggression
• Significant interactions between frequent alcohol use and age indicated that those adolescents with weekly alcohol use at younger ages were most likely to exhibit aggressive behaviors and mood disorders.