Pediatric Bipolar Disorder According to JBRF Sponsored Research : The Approach and Definition

Pediatric Bipolar Disorder According to JBRF Sponsored Research

The Approach and Definition

In an effort to promote a better understanding of pediatric bipolar disorder (PBD), the JBRF funds research by independent investigators who have come together to form a scientific consortium. The insights generated by studies undertaken by this consortium have yielded a novel description of PBD. This new description deserves serious consideration as an alternative to that which is currently accepted.

The foundation of these studies comes from the collection of clinical data generated by the JBRF website. Since 2001, symptom data from over 19,000 children has been collected. This information has provided the investigators with data sets numbering in the thousands from which to explore the parameters of the illness. This is a unique resource and, without question, the largest source of such information in the world.

The studies have produced a novel view of the condition. Unlike the prevailing view, this perspective is neither conceptual nor based on literature reviews or small data sets. The findings of these studies have been published in five peer-reviewed professional articles. We are working hard to bring it to maturity and wide attention.

Much of the research progress is attributable to the fact that the investigators chose to utilize a dimensional approach to their investigation. This type of analysis is one that is gaining recognition for its usefulness in understanding complex illnesses; yet it is at odds with the underlying notions of the Diagnostic and Statistical Manual (DSM). The DSM categorically defines psychiatric diagnoses. That is, it contends that there are clear boundaries between the different disorders. In an effort to clarify those boundaries, it allocates symptoms exclusively to one illness category or another; a symptom goes to whichever illness with which it is most directly associated. In contrast, a dimensional approach rejects this allocation process and instead allows for the overlapping presence of symptoms in multiple conditions.

For illustrative purposes, let’s consider a simple analogy. Imagine trying to understand what an elephant “is” under a categorical approach. It is likely that we would be limited to a consideration of only its trunk and tusks as they are the features most directly associated with elephants. Certainly, an elephant has more than just a trunk and tusks; however, its other features would be allocated to the animal categories for which the trait is most associated. For instance, necks might all be considered under giraffes, tails under kangaroos, and enormous size under blue whales. While this might give us a standard framework to talk about these features, it really doesn’t give us a good way to understand elephants.

The dimensional perspective accepts that animals have common, overlapping characteristics. It accepts that the nose is a common feature of many different animals but that it is the specificity of how that nose relates to other parts of the animal and what features characterize that nose in each particular case that matters. In the case of our analogy, it results in a nose looking and functioning like a trunk. A whale will also have a nose, but it ends up as a blowhole which looks and functions very differently than a trunk. And a fish? Well, it too has a nose, but it takes in water. Each of these identifications teaches us something important and unique about each animal that would have been lost in the categorical method. The whole of the elephant’s features together, not its isolated parts, allow us to say, “Look Billy! There’s an elephant!,” rather than, “Look Billy, there’s something… but I’m not sure what it is because it looks like so many different things together!” (Click here for more on categorical v. dimensional)

While this analogy uses physical traits, psychiatry must focus on behavioral traits. That is just what the investigators did in their dimensional exploration of pediatric bipolar disorder. Since many children with a bipolar diagnosis have so many co-occurring diagnoses, the investigators reasoned that many of those symptoms might actually be important parts and pieces of a single illness. Bringing the whole picture together would create a more comprehensive view of the disorder; it would provide a more realistic representation of how the illness actually presents. Therefore, in addition to symptoms of mania and depression, they also included in their analysis symptoms that currently reside in the diagnoses for separation anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, oppositional defiant disorder, conduct disorder and attention deficit disorder with hyperactivity.

The specific symptoms selected from those other diagnoses came from a study in which parents of children diagnosed with a bipolar condition endorsed the symptoms and degrees of severity most experienced by their children. The final list of 65 symptoms that make up the CBQ (Child Bipolar Questionnaire) reflects this diverse, but specific, range. When taking the CBQ, parents endorse the symptoms by degree: Never, Sometimes, Often or Almost Always. Cutting-edge computational analyses are now able to handle enormous datasets of these kinds of variable answers. They can determine which items “hang” together in statistically significant ways. Those clustered items imply a type of behavior, or “dimension” which investigators then assign an appropriate name. This method allows us to see the whole elephant. By not excluding symptoms, but rather clarifying their participation and association, we are more certain to consider all symptoms that may be of importance for classifying the condition.

Based on the CBQ data submitted on thousands of children with a community diagnosis of bipolar disorder or at risk for the disorder, a dimensional analysis sorted out the behavioral dimensions listed below. (The size of the database reduces the statistical significance of variation caused by medication, age, diagnostic error, etc. The fact that we were able to replicate the results boosts the confidence in them.) The completeness of this description more logically corresponds to human development and biological systems than an isolated focus on mania and depression.

The order in which we list the dimensions is not random. Investigators conducted a heritability study that determined the heritable, or genetic, strength of each of the dimensions. The behavioral dimension of Fear-of-Harm was by far the most heritable. This is not to say that mania and depression are not important features of the disorder; any family living with the disorder can attest to that. However, in our quest to understand the genetic basis of the illness, a focus on Fear-of-Harm will provide a clearer route to that goal. Further, the relative genetic weight of the Fear-of-Harm dimension revealed in this study, combined with the clinical seriousness of the trait, strengthens our view that it is an important dimension of the disorder and should not be overlooked.

Investigators are confident that this dimensional description of the illness more accurately describes the presentation and experience of these children than the fragmented perspective of the DSM. Such fragmentation increases the likelihood for misdiagnosis and the potential for mistreatment. It would be easy to interpret symptoms from the dimensions of Self-Esteem, Mania and Attention/Executive Function as symptoms of unipolar depression or ADHD since they are not currently considered symptoms of a bipolar condition. This interpretation could lead to the recommendation of antidepressant or stimulant medications. Both of these choices can significantly aggravate the bipolar condition and negatively affect the course of the illness.

With further analysis, investigators defined two subtypes of the disorder. The utility of defining subtypes is growing as it is becoming clear that one-size-fits-all descriptions are at odds with our complex biology. These two subtypes are called the Core phenotype and the Fear-of-Harm phenotype. Identification of the Fear-of-Harm phenotype has rapidly led to the proposal of a neuroanatomical model of the illness and the identification of a known neural pathway that ties it together. The work has given us a deeper biological understanding of the illness.

We at JBRF feel that this new understanding brings many details into logical focus and provides a new path to a much needed outcome. The work also represents a major shift in the way we conceptualize psychiatric diagnosis. As with any significant transition, there will be push back and confusion. We are hopeful that the inquiry will continue to be fruitful and that the self-evidence of its strength will soon break through any resistance to its merit. We look forward to more dedicated people with their brilliant minds joining us in this effort to find effective treatment and relief for our children and their children.

To read more about the Core phenotype and the Fear-of-Harm phenotype, click on their names in the menu margin to the right.

This information is based on articles published in The Journal of Affective Disorders as linked below:

The child bipolar questionnaire: A dimensional approach to screening for pediatric bipolar disorder

A strategy for identifying phenotypic subtypes: Concordance of symptom dimensions between sibling pairs who met screening criteria for a genetic linkage study of childhood-onset bipolar disorder using the Child Bipolar Questionnaire

About Juvenile-Onset Bipolar Disorder

According to JBRF Sponsored Research

Approach and Definition
The Core Phenotype
The Fear of Harm Phenotype

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