未成年人双相障碍

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bipolar I disorder, moods swing between mania and depression, sometimes with periods of normal mood between extremes. Some children with this disorder have episodes of mania and are hardly ever depressed.
bipolar II disorder, depression is more prominent than mania, and manic episodes may be less common and less severe.

cyclothymia, the high and low mood swings are not as severe as mania and depression seen in bipolar I or bipolar II disorders.

Bipolar, NOS (not otherwise specified), is diagnosed when symptoms of mania and depression are not frequent or severe enough for the above diagnoses.

In children and younger teens, bipolar disorder tends to be rapid-cycling or mixed cycling:
Rapid-cycling means that the shifts between depression and mania occur quickly, sometimes within the same day. Often the mood shifts are continuous, rarely returning to a normal mood between extremes.

Mixed-cycling means that symptoms of both mania and depression occur at the same time.

Following are some common symptoms of bipolar disorder in children and teens.

Symptoms of depression

1.Continuous sad or irritable mood
2.Loss of interest in activities that the child enjoyed in the past, such as hobbies, sports, games, or friends
3.Significant changes in appetite or body weight (weight loss or gain)
4.Sleeping too much or too little or having trouble falling asleep
5.Slowed body movements or restlessness
6.No energy, or loss of energy
7.Inappropriate feelings of guilt or worthlessness
8.Problems concentrating
9.Recurrent thoughts or talk of death or suicide
10.Headaches, muscle aches, or stomachaches  


Manic symptoms
1.Severe changes in mood from being extremely irritable to overly silly and elated
2.Too much energy, such as the ability to keep going without tiring while the child's peers are tiring
3.Decreased need for sleep, such as going for days with very little sleep and not being tired
4.Talking too much or too fast, changing topics too quickly, and not allowing interruptions
5.Increased distraction and constantly moving from one thing to another
6.Grandiosity, such as inflated self-esteem or a belief in unrealistic abilities or powers
7.Increased sexual thoughts, feelings, activity, and use of sexual language (hypersexuality)
8.Increased obsession with reaching goals or becoming involved in too many activities
9.Risky, wild, thrill-seeking behavior

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Due to concerns that many children are being mistakenly diagnosed with bipolar disorder, many researchers are working to refine the diagnostic criteria. For example, one subset of children whose primary symptom is chronic, severe irritability may instead be better described as having a syndrome called severe mood dysregulation, while another group of children with rapidly changing moods and high energy may not have bipolar disorder at all, despite showing symptoms commonly associated with it.

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The concerns are spurred by reports of a 40-fold increase of the diagnosis of child and adolescent BD between 1994-1995 and 2002-2003.

For example, children with a newly proposed depression-related syndrome called Temper Dysregulation Disorder with Dysphoria (TDD), or the similar severe mood dysregulation (SMD), present with chronic severe irritability rather than the episodic irritability and mania seen in classic BD. Yet they are as severely disabled as their BD peers and share with them features such as impaired recognition of facial emotion, poor frustration tolerance and ADHD symptoms. Children with SMD are more likely to come from families with histories of depression and to develop depression as adults, not BD.


Functional brain imaging studies are turning up circuitry differencesbetween such seemingly overlapping disorders during emotional processing. In one recent fMRI study, while children rated their subjective fearfulness of neutral faces, the amygdala, the brain’s fear hub, over-activated in ADHD, under-activated in SMD and activated normally in BD. Similar results are emerging from studies with other techniques for measuring brain circuits, such as magnetoencephalography (MEG).  These results suggest that we may be able to use the tools of clinical neuroscience to disentangle these various syndromes to help clinicians provide children with the best care.  

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4.治疗考虑

　　1）锂盐：尽管锂盐在儿童/青少年双相障碍中已经使用多年，但近年来的1项RCT研究并未证实其疗效优于安慰剂。或许该研究样本中纳入过多的严重心境失调的患儿，或者是锂盐只是对成人典型的双相障碍有效。另外，需要注意的是，年幼儿童较年长儿童对锂盐的副反应更多见，尤其是过量中毒的风险不可低估。一般而言，在儿童/青少年患者中，血锂浓度需低于1 mmol/L，若高于该水平则不良反应发生率会明显增加，依从性会降低。

　　2）丙戊酸盐和其他抗癫痫药：至少在2项RCTs与安慰剂对照研究中发现，丙戊酸盐单药治疗对急性躁狂是有效的，而奥卡西平与妥泰无效。不过，在青少年女性中使用丙戊酸盐需特别注意男性化和多囊卵巢综合症的发生。有关卡马西平和拉莫三嗪在儿童/青少年双相障碍的疗效至今尚无对照研究证实。

　　3）非典型抗精神病药：利培酮、喹硫平、阿立哌唑和齐拉西酮已在≥10岁的儿童双相障碍急性躁狂发作中使用，并证实是有效的，不过，剂量越高，副反应越多。一般而言，非典型抗精神病药的有效率与安慰剂比较要高出20%~40%，NNT为3~5。单用喹硫平或与丙戊酸盐合用治疗儿童期急性躁狂较单用丙戊酸盐更有效；奥氮平治疗青少年双相障碍的有效率与其他非典型抗精神病药疗效相似。需要注意的是，尽管阿立哌唑和齐拉西酮增加体重不明显，但其他非典型抗精神病药所致体重增加副反应仍是儿童双相障碍治疗中需要关注的一个重要问题。

　　4）抗抑郁药：在儿童双相障碍治疗中尚无对照研究评估抗抑郁药的疗效和安全性。有关抗抑郁药治疗青少年抑郁症仍存有较大争议，因为部分meta-分析结果提示抗抑郁药会增加自杀企图的风险，同时并未显著减轻患者的抑郁症状。鉴于目前仍缺乏有效证据，因此，在儿童/青少年双相障碍患者中需慎用抗抑郁药，如果使用，必须与心境稳定剂合用。

mal

DSM5标准:

Disruptive Mood Dysregulation Disorder
Childhood bipolar disorder has a new name — “intended to address issues of over-diagnosis and over-treatment of bipolar disorder in children.” This can be diagnosed in children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol (e.g., they are out of control).

The new condition would apply to children who have chronic irritability, as well as recurrent temper outbursts - three or more times a week, on average - that are “grossly out of proportion’’ to the situation the child confronts.
It can be as disabling to a young child as bipolar disorder, but would probably be treated with antidepressants, not antipsychotic drugs. As adults, these children would be more likely to develop anxiety or depression, rather than bipolar disorder.

新增与儿童相关的疾病：破坏性情绪失调障碍

    精神障碍诊断与统计分册-5儿童工作组意识到目前研究证实“典型”的成人双相障碍的临床表型可以清楚地在青少年、青春前期中出现，但是很少在低年龄组出现。而且在儿童精神医学领域近10年出现了一个突出的现象，那就是越来越多的儿童被诊断为成人双相障碍，如从1994年到2003年间关国儿童精神门诊中诊断为成人双相障碍相关疾病的增加了近40倍。因此，精神障碍诊断与统计分册-5儿童工作组提出在精神障碍诊断与统计分册-5中要从发展的角度看待成人双相障碍，那些严重的、非偶发的易怒和脾气爆发、以及高度的易激惹的临床现象，到底是成人双相障碍的一种？还是焦虑、抑郁、注意缺陷/多动障碍的病理生理过程？

    为了回答这个问题，当时研究组将“严重的、非偶发的易怒和脾气爆发、以及高度的易激惹”定义为严重情绪失调并与依据精神障碍诊断与统计分册-4诊断的典型的成人双相障碍比较研究和跟踪随访。
    研究发现严重情绪失调与成人双相障碍在家族史、性别发布、结局以及病理生理机制等方而都存在着不同。如：严重情绪失调的父母与成人双相障碍患儿的相比有更多的严重情绪失调病史，而不是成人双相障碍病史；一般成人双相障碍的男女比应为1:1,但目前儿科成人双相障碍中报告男孩的比例偏高为66.5%,推测偏高的可能原因与严重情绪失调混入有关，因为严重情绪失调的男孩比例为77.6%.功能磁共振的研究表明严重情绪失调与成人双相障碍杏仁核的激活模式不同，同时严重情绪失调的激活模式与注意缺陷/多动障碍患儿也不同。因此，在精神障碍诊断与统计分册-5中新增了一个诊断，并重新命名为：破坏性情绪失调障碍，归属在“抑郁障碍”之中。破坏性情绪失调障碍的诊断要点为：
    A:以严重的、循环发生的、对一般刺激的脾气暴发为特征，脾气暴发表现为言行的紊乱，例如言语冲动，毁物伤人。这些反应显著背离了刺激的强度和持续时间。
    B:这些反应与发展水平不一致。
    C:频率：平均每周脾气暴发3次或3次以上。
    D:在脾气暴发之间的心境，几乎每天，脾气暴发之间的心境都是负性的（易激惹，生气，或/和悲伤），而且负性情绪能被他人发现（包括父母、老师、同伴）。
    E:持续时间：上述A一D标准出现至少12个月，在这段时间里，不出现上述症状的间隔不超过3个月。
    F:上述A-D症状至少在两个不同的地点和环境下脾气暴发（家里、学校、和同学），而且其中一次必须很严重。
    G:实足年龄至少6岁（或者与发育水平相当）。
    H:初始暴发的年龄在10岁前。I:病史反映或临床观察，症状突出的持续时间从未超过1天。
    J:在过去的几年内，患儿情绪异常高涨的时间不会持续超过1天，而且情绪异常高涨是与发病、加重、躁狂三大标准中的“B”标准（夸大、自我膨胀，睡眠要求减少，滔滔不绝，思维奔逸，注意力随境转移，目标指向性活动增强，或过度参与可能造成严重后果的活动）相伴随的。J情绪异常高涨需要与一些生活中正性事件或关好期盼时的高涨心境区分开来。
    K:行为异常不是精神病或情感障碍（严重抑郁障碍、心境恶劣障碍、双相情感障碍）所特有，也不能更好地诊释其他一些精神障碍（例如广泛性发育障碍、创伤后应激障碍，分离性焦虑）（注：这项诊断可以和对立违抗性障碍、注意缺陷多动障碍、品行障碍、物质滥用共存）这些症状不依赖于药物滥用后的生理反应，或者神经病学情况。

    相信临床医生们通过细致的临床观察和对破坏性情绪失调障碍诊断要点的把握，能够逐渐熟悉这个疾病，因为将破坏性情绪失调障碍与成人双相障碍区分开来，是有临床意义的。首次区分开的意义在于，二者的治疗原则不同，一般认为破坏性情绪失调障碍应首先考虑SSRIs类药物治疗，而成人双相障碍则应使用心境稳定剂和非典型抗精神病药物。其次，将破坏性情绪失调障碍单独诊断将有助于我们对于这样一组极端易激惹的症状给予足够的关注和深入的研究。

Prescilla

破环型情绪失调是不是过去常说的那个情绪障碍，它的诊断有无岁数限制？如果超过了那个岁数还是情绪不稳，还是要怀疑是双相，是吗？

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岁数限制: 0~18

初始暴发的年龄在10岁前

mal

破环型情绪失调是不是过去常说的那个情绪障碍，它的诊断有无岁数限制？如果超过了那个岁数还是情绪不稳，还是要怀疑是双相，是吗？
Prescilla 发表于 14-3-6 15:19

你女儿如果１８岁前去诊断，可能是破坏性情绪失调障碍。

但１８岁后可能就诊断成双相了。两者用药方案不一样。真迷惑。
你女儿用药后效果好吗？如果好，那可能双相是对的

Prescilla

你女儿如果１８岁前去诊断，可能是破坏性情绪失调障碍。

但１８岁后可能就诊断成双相了。两者用药方案不一样。真迷惑。
你女儿用药后效果好吗？如果好，那可能双相是对的
mal 发表于 14-3-7 08:48

我在好大夫在线上看到，北京某三甲医院的某某医生就给某些青少年患者诊断为“情绪障碍”而单用SSRI，病情并没有得到控制。加上心境稳定剂后就有好转。

我女儿16.5岁第一次吃西药时就加上了稳定剂，病情有好转，中间因怀疑就找了上面提到的医生，他不认为是双相，只是急躁，情绪障碍，个性问题等....., 就把稳定剂停了。刚停时孩子觉得自己浑身充满了力量，自己的病已经好了，不用再吃药了。再过几天就开始大发脾气十分的暴躁做事情特别迫切，老觉得没机会了，必须立刻马上现在就行动，谁也不能拦，就赶紧又加上了，而且一次性把抗抑郁药全撤了，结果又抑郁了。真心感觉双相的治疗真的很考验医生的水平，特别是再伴有个性问题时。

昨天又看到那个医生给患者的回复，更无语了。一个患者问自己用齐拉西酮和喹硫平特别困，不知道是哪个药引起的。那个医生建议患者把两个药合并，最好把喹硫平加量，把齐拉西酮撤了。天啦，地球人都知道喹硫平的嗜睡作用远高于齐拉西酮啊。

所以要找个好医生，家属就得懂点相关知识。

hunhexiang

未成年人诊断标准和成年人不同，用药物也有区别，经验和研究相对较少

伊犁春风

...那个医生建议患者把两个药合并，最好把喹硫平加量，把齐拉西酮撤了
Prescilla 发表于 14-3-7 10:20

会不会喹硫平的副作用比齐拉西酮的小, 药力比齐拉西酮强？

伊犁春风

...
所以要找个好医生，家属就得懂点相关知识。Prescilla 发表于 14-3-7 10:20

谢谢提醒, 以后还请您多赐教！

mal

我在好大夫在线上看到，北京某三甲医院的某某医生就给某些青少年患者诊断为“情绪障碍”而单用SSRI，病情并没有得到控制。加上心境稳定剂后就有好转。
我女儿16.5岁第一次吃西药时就加上了稳定剂，病情有好转，中间 ...
Prescilla 发表于 14-3-7 10:20

看来当成双相来治疗风险小些

当成双相的话，不加抗抑郁药容易抑郁；
当成破坏性情绪失调障碍，不加心境稳定剂容易躁狂

真是个麻烦的病

伊犁春风

会不会喹硫平的副作用比齐拉西酮的小, 药力比齐拉西酮强？
伊犁春风 发表于 14-3-8 08:57

有没有说

齐拉西酮会改变心脏的电流传导到某种程度，可能引起危险的心律不齐？这边服用此药，要定期作心电图检查。

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双相抑郁首发年龄小，阳性家族史较为明显，理解记忆和执行功能损害较单相抑郁更严重；而单相抑郁焦虑症状明显，经历生活事件较多。这些研究结果有助于双相抑郁的及时和正确诊断。研究者同时也指出，单相、双相抑郁患者在抑郁严重程度方面无统计学差异，提示仅从临床症状上难以区分单相、双相抑郁，这也是二者易被混淆的原因之一。