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The 10 Dimensions of the Core Phenotype

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Fear Of Harm Trait & Symptoms

Hidden Symptoms of Childhood Bipolar Disorder

Common Symptoms of Childhood Bipolar Disorder

Criteria for Bipolar Disorder Diagnosis

Core Phenotype (Observable Traits) of Childhood Bipolar Disorder

The Juvenile Bipolar Research Foundation (JBRF) Research Consortium and Dr. Demitri Papolos (author of “The Bipolar Child” and director of JBRF) have spent many hours looking into a better way to diagnose bipolar disorder in children than relying upon the criteria for adult bipolar disorder in the Diagnostic and Statistical Manual (DSM-IV). The DSM presents criteria for mental health illnesses in a checklist format with symptoms considered present or absent dependent upon if symptoms meet the established criteria.

The JBRF Research Consortium has developed a better approach which uses phenotypes (observable traits) that are described by ranges of behavior that exist on a continuum. This dimensional approach is more compatible with the currently developing insights into mental health disorders. The symptoms or “traits” that describe the ranges of behavior provided in the Core phenotype are directly related to information that is obtained from the Child Bipolar Disorder Questionnaire. Since professionals and families are more familiar with a checklist format, JBRF has adapted the Core phenotype into a checklist format. To receive a diagnosis of bipolar disorder, a child must meet Criteria A – D in the checklist.

  1. Episodic and abrupt transitions in primary mood states accompanied by rapid alterations in levels of arousal, emotional excitability, sensory sensitivity, and motor activity.
    • The primary mood states are manic/hypomanic, depressed, and mixed. Manic/hypomanic or mixed episode is required for diagnosis. Episodes are defined by DSM-IV symptom criteria but not by DSM-IV duration criteria.
    • Manic or hypomanic episodes are associated with elated/euphoric (silly-goofy-giddy), and/or angry/irritable mood states, and three or more of the following symptoms and behaviors (four or more if irritable mood only):
      • Flight of ideas
      • More talkative than usual, pressured speech
      • Subjective experience of thoughts racing
      • Diminished need for sleep
      • Distractibility
      • Increase in goal-directed activity
      • Excessive involvement in pleasurable activities that have a high potential for painful consequences
      • Heightened interest, enjoyment, and enthusiasm for usual activities
      • Over-estimation of resources and capacities
      • Over-valuation of self and others
      • More argumentative than usual
      • Overbearing, bossy, in pursuit of personal needs or agenda
    • Depressive episodes are associated with dysphoric/sad/irritable and/or anxious/fearful mood states and four or more of the following symptoms and behaviors. (These are accompanied with loss of interest/pleasure in previously enjoyed activities often resulting in expressions of boredom and excessive stimulus seeking behaviors.)
      • Slowed speech
      • Decreased sense of self-esteem
      • Paucity (lack or shortage) of thought
      • Increased need for sleep or disrupted sleep
      • Loss or increase of appetite
      • Decrease or loss of energy
      • Difficulty sustaining attention
      • Diminished ability to concentrate or indecisiveness
      • Psychomotor retardation (slowing of physical and emotional reactions)
      • Loss of motivation and initiative
      • Under-estimation of resources and capacities
      • Devaluation of self and others
      • Negative interpretation of events and misattribution (incorrect/mistaken interpretation) of other’s behaviors
      • Recurrent thoughts of death, recurrent suicidal ideation
    • Mixed episodes are associated with over-lapping features of the primary mood states (euphoric, anger, dysphoric, anxious) accompanied by other associated symptoms of manic/hypomanic and depressive mood states. Presentation may include:
      • Irritability
      • Agitation
      • Insomnia
      • Appetite dysregulation (poor regulation of appetite)
      • Poor control over aggressive impulses – aggression may be directed against self or others or psychotic features
  2. Poor modulation of drives (aggressive, sexual, appetitive, acquisitive) resulting in behaviors that are excessive for age and/or context.
    • Excessive aggressive/fight-based behaviors (critical, sarcastic, demanding, oppositional, overbearing, “bossy”, easily enraged, prone to violent outbursts), and/or self-directed aggression (head-banging, skin-picking, cutting, suicide)
    • Premature and intense sexual feelings and behaviors (precocious curiosity about sex and premature expression of sexual impulses, as well as inappropriate public displays)
    • Appetite dysregulation (excessive craving for carbohydrates and sweets, binge eating, purging, and anorexia)
    • Poor control over acquisitive impulses (relentless pursuit of needs, buying excessively, hoarding)

    Episodic and abrupt transitions in mood states (Criteria A) and poor modulation of drive (Criteria B) are currently present most days and have been present for at least the past 12 months without any symptom free periods exceeding 2 months in duration, and cause functional impairment in 1 or more settings (e.g., significant behavioral problems at home but not necessarily in the school setting).
  3. Four (or more) of the following disturbances have been present during the same 12-month period:
    1. Excessive anger and oppositional/aggressive responses to situations that elicit frustration.

      Compared to his/her peers, the child exhibits difficulties in the postponement of immediate gratification when parents set limits. In particular, when answered “no” to expressed wishes, when having to wait his/her turn, or when there are changes in planned activities or routines.

      This deficit results in maladaptive responses, such as seeming not to listen (purposeful), the display of disruptive, intrusive, and overbearing behaviors, or, in the extreme, temper tantrums and aggressive attacks, often followed by sullen withdrawal and expressions of remorse.
    2. Poor self-esteem regulation.

      At times is overly-optimistic, defiant arrogant, filled with bravado, and prone to self-aggrandizement, exaggeration of abilities, and has feelings of omnipotence, or, alternatively, is overly-pessimistic, self-critical, and overly sensitive to criticism or rejection, often responding to criticism with intense feelings of humiliation and shame. The child often expresses feelings of insecurity, worthlessness, and is capable of rapid and intense idealization and/or devaluation of self and others.
    3. Sleep/wake cycle disturbances.

      At least one of the following is present:
      • Sleep discontinuity (initial insomnia; middle insomnia; early morning awakening; hypersomnia)
      • Sleep arousal disorders (sleep inertia; night terrors and nightmares – often containing images of gore and mutilation, and themes of pursuit, bodily threat and parental abandonment; sleep-walking; bruxism (grinding/clenching of teeth); enuresis (inability to control urination); and confusional arousals)
      • Sleep/wake reversals (a tendency toward periodic lengthening or shortening of sleep duration, often dependent on circadian (daily) and circannual (yearly) changes in light/dark and temperature cycles, as well as, the availability of regular social zeitgebers (events or cues in the environment))
    4. Low threshold for anxiety.

      A tendency to react with excessive anxiety and fearfulness in response to:
      • novel (new) or stressful situations
      • transitions of context, loss, separation
      • the anticipation of loss/separation from attachment objects
      • loss of social status

      Anxiety often arises from fear of harm to self or, alternatively, from the fear that he/she will harm others or self, and expresses itself in the form of anger, rejection, criticism, ostracism (esclusion/isolation).

      This deficit can predispose to (cause or lead to) behavioral inhibition, or flight-based behaviors such as separation anxiety disorder, social phobias, and other anxiety disorders including panic-disorder, obsessive compulsive disorder and post-traumatic stress syndrome.
    5. Disturbance in the capacity to habituate to sensory stimuli often when exposed to novel, repetitive or monotonous sensory stimulation.

      A tendency to over-react to environmental stimuli and to become over-aroused, easily excited, irritated, angry, anxious or fearful when exposed to novel sensory experiences, e.g., crowds, loud or unexpected sounds, (e.g., vacuum cleaners, ticking clocks, thunder and lightning), and dissonant sensations (e.g., shirt tags, fit of clothes or shoes, perceived foul odors).
    6. Executive Function Deficits.

      One or more of the following:
      • Mental Inflexibility:
        • Difficulty shifting cognitive set, planning ahead, planning strategically as seen in unrealistic estimates of energy resources and time requirements for the accomplishment of tasks (e.g. difficulty adjusting to changes in plans for the day such as planned trips and changes in venue)
        • has difficulty giving up an idea or desire, no matter how unrealistic or unfeasible
        • has difficulty starting and completing school assignments without a great deal of prompting
        • often gets caught up on small details of an assignment and misses the larger picture
        • This executive dysfunction is often associated with working memory deficits, problems making transitions from one context to another, poor organizational skills, distractibility, excessive daydreaming, and performance deficits in school, particularly in the organization of thought for written expression.
      • Emotional Inflexibility:
        • impulsive, acts before thinking
        • over-reacts to small events
        • rapidly shifts emotional state
        • can demonstrate sudden anger, resentment, and/or rage for greater than 15 minutes that is unresponsive to reason, discussion, or soothing
        • can become progressively unrestrained or silly
        • does not appear to gain pleasure from mastering a skill
      • Inflexibility of Motor Activity:
        • initiation of movement directed at the accomplishment of motor tasks is effortful (e.g., has difficulty starting activities in the morning, and requires help in initiating any activity)
        • is often restless and fidgety
        • has trouble initiating and completing written assignments
        • handwriting is poor
    7. A family history of recurrent mood disorder and/or alcoholism, as well as other bipolar spectrum disorders.

      A history of bilineal familial transmission is commonly observed (seen in family members on both mother's and father's side).
  4. Symptoms are not due to a general medical condition (e.g. hypothyroidism).

 

The 10 Dimensions of the Core Phenotype
(from greatest to least inherited)

  • FEAR OF HARM
    • Displays excessive distress when separated
    • Exhibits excessive anxiety or worry
    • Has night terrors and/or nightmares
    • Displays aggressive behavior toward others
    • Has destroyed property intentionally
    • Makes moderate threats to others or self
    • Makes clear threats of violence to others/self
  • AGGRESSION
    • Has difficulty maintaining friendships
    • Displays aggressive behavior towards others
    • Has destroyed property intentionally
    • Makes moderate threats to self or others
    • Makes clear threats of violence to others/self
    • Has made clear threats of suicide
    • Fascinated with gore, blood, violent imagery
  • ANXIETY
    • Displays excessive distress when separated from family
    • Exhibits excessive anxiety and worry
    • Has night terrors and/or nightmares
  • SENSORY SENSITIVITY
    • Is extremely sensitive to textures of clothes
    • Exhibits extreme sensitivity to sound
    • Complains of body temperature extremes
    • Has concern with dirt, germs, contamination
  • SLEEP/WAKE DISTURBANCE
    • Has difficulty arising in the AM
    • Is hyperactive and easily excited in the PM
    • Has difficulty settling at night
    • Has difficulty getting to sleep
    • Sleeps fitfully and/or awakens in the night
    • Has night terrors and/or nightmares
  • ATTENTION/EXECUTIVE FUNCTION
    • Is easily distracted by extraneous stimuli
    • Is easily distracted during repetitive chores
    • Demonstrates inability to concentrate at school
    • Attempts to avoid homework assignments
    • Able to focus well but also easily distractible
    • Has poor handwriting
    • Has difficulty organizing tasks
    • Has difficulty making transitions
    • Has difficulty estimating time
    • Has auditory processing/short-term memory deficit
  • DEPRESSION
    • Complains of being bored
    • Has periods of low energy or withdrawal
    • Has decreased initiative
    • Has periods of self doubt/poor self-esteem
    • Feels easily criticized and/or rejected
    • Feels easily humiliated or shamed
    • Has made clear threats of suicide
  • GRANDIOSE/HYPERSEXUAL
    • Has exaggerated ideas about self or abilities
    • Tells tall tales/embellishes or exaggerates
    • Displays precocious sexual curiosity
    • Exhibits inappropriate sexual behaviors
    • Lies to avoid consequences of actions
  • MANIA
    • Is hyperactive and easily excited in the PM
    • Is easily excitable and has periods of high energy, frenetic activity
    • Has many ideas at once
    • Interrupts or intrudes on others
    • Has periods of excessive and rapid speech
    • Displays abrupt, rapid mood swings
    • Has elated or silly/giddy mood states
  • OPPOSITIONAL/POOR FRUSTRATION
    • Is intolerant of delays
    • Relentlessly pursues needs/demanding of others
    • Is willful, refuses to subordinate to others
    • Argues with adults
    • Is bossy towards others
    • Defies or refuses to comply with rules
    • Blames others for his/her mistakes
    • Is easily angered in response to limit setting
    • Has protracted, explosive temper tantrums

 

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