Prospective Study of Prodromal Features for Bipolarity in Well Amish Children

Department of Psychiatry and Behavioral Sciences, University of Miami School of Medicine, USA.
Journal of the American Academy of Child & Adolescent Psychiatry (Impact Factor: 7.26). 07/2003; 42(7):786-96. DOI: 10.1097/01.CHI.0000046878.27264.12
Source: PubMed


A prospective study of psychiatrically well Amish children to determine differences in the frequency and pattern of clinical features that may be prodromal for bipolar I disorder.
Children with a bipolar I parent (n = 100) and children of well parents in a matched control sample (n = 110) were assessed annually for 7 years with semistructured interviews covering medical/developmental features and symptoms/behaviors that are possibly prodromal for bipolarity. Randomized histories of these 210 children were evaluated blindly by 4 clinicians for independent ratings of risk for bipolarity.
Thirty-eight percent of the children of bipolar parents were rated as at risk compared with 17% of children in the control sample. Most control sample children with risk ratings had well parents with a bipolar sibling (i.e., family history positive). Children with family histories negative for mental illness rarely received even a low risk rating. Clinical features significantly (p <or=.05) more frequent among children of a bipolar parent included mood lability, low energy, anxious/worried, hyper-alert, attention problems/distractible and school role impairment, easily excited, sensitivity, somatic complaints, and stubborn/determined.
Mini-clusters of early possible predictors suggest a natural history of episodic prodromal features rather than the chronic symptom pattern sometimes described for children at risk for bipolar disorder.

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    • "Energy changes (increased/ decreased) Egeland et al. 2000 (48) c Faedda et al. 2004 (58) Correll et al. 2007 (41) Conus et al. 2010 (39) Akiskal et al. 1995 (65) Egeland et al. 2003 (63) Shaw et al. 2005 (37) Egeland et al. 2012 (49) Anger/ aggressiveness Lish et al. 1994 (50) Hirschfeld et al. 2003 (3) Egeland et al. 2000 (48) c Faedda et al. 2004 (58) Correll et al. 2007 (41) Conus et al. 2010 (39) Skjelstad et al. 2011 (56) Fergus et al. 2003 (54) Findling et al. 2005 (71) Kochman et al. 2005 (59) Sleep disturbances Lish et al. 1994 (50) Hirschfeld et al. 2003 (3) Egeland et al. 2000 (48) c Faedda et al. 2004 (58) Correll et al. 2007 (41) Rucklidge 2008 (55) Luckenbaugh et al. 2009 (57) Skjelstad et al. 2011 (56) Duffy et al. 2010 (51) Shaw et al. 2005 (37) Egeland et al. 2012 (49) "
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    ABSTRACT: Bipolar disorder is a multifaceted illness and there is often a substantial delay between the first onset of symptoms and diagnosis. Early detection has the potential to curtail illness progression and disorder-associated burden but it requires a clear understanding of the initial bipolar prodrome. This article summarizes the phenomenology of bipolar disorder with an emphasis on the initial prodrome, the evolution of the illness, and the implications for prevention and early intervention. A literature review was undertaken using Medline, Web of Science, and a hand search of relevant literature using keywords (e.g., phenomenology, initial or early symptoms, risk factors, and predictors/prediction). Findings from the literature were reviewed and synthesized and have been put into a clinical context. Bipolar disorder is a recurrent, persistent, and disabling illness that typically develops in adolescence or early adulthood. The literature search yielded 28 articles, in which mood lability, nonspecific, non-mood symptoms, and cyclothymic temperament were the most cited prodromal features. A small number of key prospective studies have provided evidence in support of an initial bipolar prodrome; however, methodological differences across studies have prohibited its clear delineation. It is, therefore, not currently possible to anticipate those who will develop bipolar disorder solely on the basis of early phenomenology. Accurate characterization of the bipolar disorder prodrome through high-quality, prospective research studies with adequate control groups will ultimately facilitate prompt and accurate diagnosis.
    Full-text · Article · Oct 2013 · Bipolar Disorders
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    • "''Other'' categories could be tagged if the clinician felt symptoms/behaviors ''hinted'' at future bipolarity. Inter-rater reliability was examined and supported the panel's ''consensus ratings'' assigned during CARE workshops at Years 7, 10 and 16 (Egeland et al., 2003; Shaw et al., 2005). An illustration of a consensus rating was that of a child who received, by panel member's independent scoring, four votes of ''well'' and one vote of ''low risk.'' "
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    ABSTRACT: BACKGROUND: Longitudinal research of well Amish children over 16 years to identify the pattern and frequency of prodromal symptoms/behaviors associated with onset of BPI disorder during childhood or adolescence. Methods: Parental informants were interviewed annually using structured and semi-structured interviews to record medical, developmental and behavioral/symptomatic data for their children in two samples. The bipolar sample had 115 children with a BPI parent. The control sample had 106 children of well parents, with and without a positive family history for mood disorders. A panel of clinicians assigned risk ratings independently and blind to family relations. Results: Eight children, age 13 or older, onset with BPI in the bipolar sample compared with one in the control sub-sample (well parent of a BPI sibling). The specific "pre-school" behaviors/symptoms that most identified children with BPI from well children in control samples were: sensitivity, crying, hyper-alertness, anxiety/worry and somatic complaints. During school years, parents reported mood (sad) and energy changes (low not high) decreased sleep and fearfulness as key symptoms. Limitations: The sample of 9 BPI onsets is small. However, a variable age of onset means many children remain at risk. Although not statistically significant, 34.6% of the bipolar sample youngsters carry risk ratings compared to 15.2% among controls. Conclusions: The miniclusters of prodromal features that emerged pre-school (ages 1-6), were "episodic" through childhood (7-12) and appeared to mimic adult recurrent illness. Prepubertal onset with mania did not occur. The pattern of prodromal symptoms has clinical relevance for its potential predictive value for onset with BPI disorder and early intervention.
    Full-text · Article · Jul 2012 · Journal of Affective Disorders
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    • "51.9% of youth with first episode mania reported predominantly " insidious " (N1 year) onset and additionally 44.2% present with a " subacute " (1–12 months) onset of the episode (Correll et al., 2007). (c) Prospective studies in general population samples (Eckbald and Chapman, 1986; Depue et al., 1989; Kwapil et al., 2000; Meyer and Hautzinger, 2003), in off-spring of patients with bipolar disorders (Duffy et al., 2010 Egeland et al., 2003; Shaw et al., 2005 ) in people with " unipolar " depression (Akiskal et al., 1995; Angst et al., 2003) and in people at ultra-high risk of psychosis (Thompson et al., 2003) reported on a number of psychopathological and behavioral disturbances prior to the onset of first episode mania including anxiety, depression, racing thoughts and concentration difficulties , episodic mood swings or lability and a diversity of comorbid diagnoses prior to the onset of first episode mania. Moreover 25% of children or adolescents diagnosed with BPAD not otherwise specified (NOS) or cyclothymic disorder according to DSM IV develop BPAD I or II in a follow-up period of 2 years on average (Birmaher et al., 2006). "
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    ABSTRACT: We have developed ultra-high risk criteria for bipolar affective disorder (bipolar at-risk - BAR) which include general criteria such as being in the peak age range of the onset of the disorder and a combination of specific criteria including sub-threshold mania, depressive symptoms, cyclothymic features and genetic risk. In the current study, the predictive validity of these criteria were tested in help-seeking adolescents and young adults. This medical file-audit study was conducted at ORYGEN Youth Health (OYH), a public mental health program for young people aged between 15 and 24years and living in metropolitan Melbourne, Australia. BAR criteria were applied to the intake assessments of all non-psychotic patients who were being treated in OYH on 31 January, 2008. All entries were then checked for conversion criteria. Hypomania/mania related additions or alterations to existing treatments or initiation of new treatment by the treating psychiatrist served as conversion criteria to mania. The BAR criteria were applied to 173 intake assessments. Of these, 22 patients (12.7%) met BAR criteria. The follow-up period of the sample was 265.5days on average (SD 214.7). There were significantly more cases in the BAR group (22.7%, n=5) than in the non-BAR group (0.7%, n=1) who met conversion criteria (p<.001). These findings support the notion that people who develop a first episode of mania can be identified during the prodromal phase. The proposed criteria need further evaluation in prospective clinical trials.
    Full-text · Article · Dec 2010 · Journal of Affective Disorders
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