EXPERT
DIAGNOSTIC WORKSHOP/ GRAND ROUNDS INTERACTIVE TUTORIAL
Welcome
Welcome to the Expert Diagnostic Workshop sponsored by the Juvenile Bipolar Research Foundation. Thank you for your willingness to join with an international group of clinicians and researchers, all of whom are making a concerted effort to foster the development of a consensus diagnosis for juvenile-onset bipolar disorder.
This tutorial has been designed to rapidly familiarize you with the online diagnostic and navigational procedures that have been developed for this purpose. If you have problems with any aspect of the program please contact us by clicking on the Help button and describing the specific problem. Also, we hope that you will take advantage of the discussion forums that will accompany each case. Information about these forums is available on this tutorial. Again welcome and thank you.
This virtual tour of the website was developed with the aim to demonstrate the navigation and scoring features of the program.
To view the demonstration movies, you will need the capability to play sound through your computer and the Quicktime player. You may download Quicktime free of charge at http://www.quicktime.com.
Accessing the Expert Diagnostic Workshop Tutorial
Each month, you will receive an email with the URL that will take you to the Expert Diagnostic Workshop login page.
Navigating the Expert Diagnostic Workshop Interactive Tutorial
Each time you log on to the workshop with your user name and password you will see a window with a link to one of four separate sets of related diagnostic criteria. These will be used for rating each case. You’ll begin rating using DSM-IV criteria for Mania/and Hypomania and continue rating using criteria sets based on three proposed behavioral phenotypes: Modified DSM-IV criteria – Broad Phenotype, Modified DSM-IV criteria – Narrow Phenotype, and Research Diagnostic Criteria – Core Phenotype. You may download these criteria sets for future reference.
To begin the first rating session, you will click on the light blue Mania/Hypomania link. This will take you to a web page that displays three frames in one window.
Navigating the 3 Frames
Now you are at a window with 3 areas called "frames." The program is designed to allow you to easily navigate between these three divided frames on your screen.
Data is displayed in the top frame, either in narrative or questionnaire format. A brief QuickTime movie description of this procedure can be viewed here.
When you first arrive at the 3 frames, the top frame will display the case history with a title and a narrative. Click on the list in the right column to see the SADS summary or questionnaire data displayed in the top frame.
The bottom left frame has instructions for rating the case (the criteria) and the bottom right frame is the rating or scoring form.
The Top Frame: Case History
The top frame may display the clinical case history, questionnaire or other data, depending on your selection. When you first arrive at the 3 frames the top frame will contain a case history.
Case History
The information available to you in preparation for scoring this case
is a thorough clinical case history that includes the following information:
- identifying data,
- medical history,
- developmental history,
- family history of psychiatric illness, and
- the history of present illness.
The Top Frame: Questionnaires
Once you've reviewed the case history in the top frame you can review data from a set of seven questionnaires by clicking on the appropriate link. These questionnaire links are easily accessible along the right-hand column of the page.
The next page will show you an example of a questionnaire, along with a QuickTime movie.
CBQ: The Bipolar Child Questionnaire
This is a likert scale questionnaire that lists many of the commonly observed symptoms and behaviors described as features of the clinical presentation of JBD, as well as symptoms derived from common comorbid conditions. It is completed by the child’s parent.
CLICK HERE to view a movie showing how to navigate the CBQ. (Opens in new window.)
The Criteria Frame
The bottom left frame displays the criteria for a given diagnostic criteria set. You can read the criteria as you rate them in the bottom right frame. Where possible, we have keyed each criterion to particular items of questionnaire data appearing in parentheses after the criterion. The bottom right frame is the rating frame where you click on each criterion met.
The Rating Frame
Rate the case by clicking on the criteria in the lower right frame.
When you have completed rating the first set of criteria, you may click Submit. You’ll be taken to a summary page where you will be offered a choice to review your ratings by clicking Back or to rate another diagnostic criteria set.
If you do not want to review your ratings, simply click Complete on the summary page. Then, you may continue to rate the case until all diagnostic criteria sets for bipolar disorder and other psychiatric conditions are rated. Or, you may exit and return to work on your ratings at another time. When you return, the ratings you have completed will be listed for you along with the date completed.
CLICK HERE to view a movie demonstrating how to review and submit your ratings. (Opens in new window.)
The Bulletin Board – Colleagial Discussion
A bulletin board is open for discussion with your colleagues and for your comments on each particular case.
If you don't login with your username and password you will only have access to the public discussion forum; the diagnostician forum is hidden from view until you have logged in. The links from the case home page and the top frame will take you to the login page. If you have not yet received a username and password you must request one from the JBRF administrator. Experts weigh in on topics providing a jumping off point for further discussion with colleagues about the issues raised by each case.
By clicking on Expert Diagnostician Workshop Discussion Forum from either the top frame or the case home page, you may enter a discussion on the bulletin board that is linked to individual cases.
Please feel free to make any comments or raise any specific issues about cases that you may have found difficult to score on the workshop forum. The forum is a venue to open a further dialogue with colleagues and to raise any questions that you think pertain to the diagnostic dilemmas that the field currently faces with the diagnosis of bipolar disorder in children. The discussion forum is open to all participants in this workshop and we encourage your participation.
This concludes the interactive tour.
- You may download this description in a printable form at http://jbrf.org/gr_tutorial/tutorial_print.html or at http://jbrf.org/gr_tutorial/tutorial_print.pdf.
- To return to the beginning of the tour, http://jbrf.org/gr_tutorial/index.html.
- To go to the Expert Diagnostic Workshop home/login page, go to http://jbrf.org/grand/diag_home.cfm.
The JBRF thanks you for participating in the Expert Diagnostic Workshop!
Definitions of Proposed Phenotypes
Narrow Phenotype (elated mood)
This phenotype is characterized by abnormal elevated mood states. A distinct episode of hypomania or mania of at least four days duration is required, during which time the child had elevated, elated mood or grandiosity. In addition, at least three other DSM-IV B symptom criteria must be met for diagnosis. In the absence of elated mood, three symptom criteria must be met in addition to grandiosity.
Symptom criteria include all 7 DSM-IV symptom criteria: inflated self-esteem or grandiosity, decreased need for sleep, more talkative than usual or pressure to keep talking, flight of ideas or subjective experience that thoughts are racing, increase in goal-directed activity or psychomotor agitation, and excessive involvement in pleasurable activities that have a high potential for painful consequences. If the child also meets criteria for ADHD, the symptom criteria of distractibility and psychomotor agitation count toward the diagnosis of mania only if in excess of the child’s usual ADHD.
Broad Phenotype (angry, irritable mood, chronic hyperarousal, explosiveness)
This phenotype is designed to capture children who have chronic irritability and hyperarousal. It is also called severe mood and behavioral dysregulation, and it differs from the narrow phenotype in that the child has no euphoria or grandiosity and no discernable episodes.
All of the following are required: 1) Chronic explosiveness, i.e., the child exhibits marked reactivity to negative emotional stimuli at least 3 times a week, on average. For example, the child’s response to frustration is associated with extended temper tantrums, verbal rages, and/or displays of aggression toward people or property; 2) Baseline abnormal mood (i.e., even between outbursts the child is angry or irritable); and 3) Chronic hyperarousal. To meet this last criterion, the child must have three of the following symptoms: distractibility, racing thoughts or flight of ideas, pressured speech, intrusiveness, agitation, and insomnia, nearly every day. In addition to the absence of elated mood or grandiosity, the presence of irritable mood distinguishes the broad phenotype from the narrow phenotype.
Core Phenotype (Episodic and abrupt transitions in mood state, and poor modulation of at least one drive state).
The hallmark features of this phenotype are episodic and abrupt transitions in mood state (mania/hypomania, depression, mixed state) and poor modulation of at least one drive (aggressive, sexual, appetitive, acquisitive). Descriptive definitions of mania/hypomania, depression, and mixed states remain essentially unchanged from DSM-IV. However, specifying daily, abrupt mood fluctuations and eliminating episode duration distinguish this phenotype from the others. These cardinal features must result in behaviors that are excessive or inappropriate for age and/or context and must be present on most days for at least 12 months to make the diagnosis.
Symptoms must not be due to the direct physiological effects of a substance or a general medical condition. In addition, the child must exhibit four or more of the following symptoms;
- Excessive anger and oppositional and aggressive responses to situations that elicit frustration;
- Poor self-esteem regulation (self-aggrandizement, exaggeration of abilities, and feelings of omnipotence, or, alternatively, pessimistic, self-critical, and overly sensitive to criticism or rejection);
- Sleep/wake cycle disturbances as exemplified by sleep discontinuity, sleep arousal disorders, or sleep/wake reversals;
- Excessive anxiety and fearfulness in response to novel or stressful situations;
- A disturbance in the capacity to habituate to novel, loud or unexpected sounds and dissonant sensations;
- Executive function deficits as exemplified by mental, emotional, or motor inflexibility;
- A family history of recurrent mood disorder and/or alcoholism, as well as other bipolar spectrum disorders.