Affect regulation in pediatric bipolar disorder

Understanding Pediatric Bipolar Disorder Through the Investigation of Clinical, Neuroanatomic, Neurophysiological and Neurocognitive Dimensions: A Pilot Study

Background: Pathophysiological models of pediatric bipolar disorder (PBD) are lacking. Multimodal approaches may provide a comprehensive description of the complex relationship between the brain and behavior. Aim: To assess behavioral, neuropsychological, neurophysiological, and neuroanatomical alterations in youth with PBD. Methods: Subjects with PBD (n = 23) and healthy controls (HCs, n = 23) underwent (a) clinical assessments encompassing the severity of psychiatric symptoms, (b) neuropsychological evaluation, (c) analyses of event-related potentials (related to the passive viewing of fearful, neutral, and happy faces during electroencephalography recording, and (d) cortical thickness and deep gray matter volume measurement using magnetic resonance imaging. Canonical correlation analyses were used to assess the relationships between these dimensions. Results: Youth with PBD had higher levels of anxiety (p < 0.001) and borderline personality features (p < 0.001), greater commission errors for negative stimuli (p = 0.003), delayed deliberation time (p < 0.001), and smaller risk adjustment scores (p = 0.002) than HCs. Furthermore, they showed cortical thinning in the frontal, parietal, and occipital areas (all p < 0.001) and greater P300 for happy faces (p = 0.29). In youth with PBD, cortical thickening and P300 amplitude positively correlated with more commission errors for negative stimuli, longer deliberation times, reduced risk adjustment, higher levels of panic and separation anxiety, and greater levels of negative relationships, whereas they negatively correlated with levels of depression (overall loadings > or <0.3). Limitations: Small sample size, cross-sectional design, and limited variables investigated. Conclusions: This preliminary work showed that multimodal assessment might be a viable tool for providing a pathophysiological model that unifies brain and behavioral alterations in youth with PBD.

Neuroanatomical Correlates of the Late Positive Potential in Youth with Pediatric Bipolar Disorder

BACKGROUND

The late positive potential (LPP) could be a marker of emotion dysregulation in youth with pediatric bipolar disorder (PBD). However, the neuroanatomical correlates of the LPP are still not clarified.

OBJECTIVE

To provide cortical and deep gray matter correlates of the LPP in youth, specifically, youth with PBD.

METHODS

Twenty-four 7 to 17 years-old children with PBD and 28 healthy controls (HC) underwent cortical thickness and deep gray matter volumes measurements through magnetic resonance imaging and LPP measurement elicited by passively viewing emotional faces through electroencephalography. T-tests compared group differences in LPP, cortical thickness, and deep gray matter volumes. Linear regressions tested the relationship between LPP amplitude and cortical thickness/deep gray matter volumes.

RESULTS

PBD had a more pronounced LPP amplitude for happy faces and a thinner cortex in prefrontal areas than HC. While considering both groups, a higher LPP amplitude was associated with a thicker cortex across occipital and frontal lobes, and with a smaller right globus pallidus volume. In addition, a higher LPP amplitude for happy faces was associated with smaller left caudate and left globus pallidus volumes across both groups. Finally, the LPP amplitude correlated negatively with right precentral gyrus thickness across youth with PBD, but positively across HC.

CONCLUSION

Neural correlates of LPP in youth included fronto-occipital areas that have been associated also with emotion processing and control. The opposite relationship between BPD and HC of LPP amplitude and right precentral gyrus thickness might explain the inefficacy of the emotional control system in PBD.

Neurocognitive Correlates of Cerebellar Volumetric Alterations in Youth with Pediatric Bipolar Spectrum Disorders and Bipolar Offspring

BACKGROUND

Emerging evidence points towards the involvement of the cerebellum in the processing of emotions and pathophysiology of mood disorders. However, cerebellar and related cognitive alterations in youth with pediatric bipolar disorder (PBD) and those at high risk to develop the disorder, such as bipolar offspring (BD-OFF) are not clearly defined.

OBJECTIVE

To investigate cerebellar gray and white matter volumes, cognition, and their relationship in youth with PBD and BD-OFF.

METHODS

Thirty youth (7 to 17 years, inclusive) with PBD, 30 BD-OFF and 40 healthy controls (HC) were recruited. Study participants underwent a computer-based cognitive battery assessing affective processing, executive function, attention, psychomotor speed, and learning. Three-tesla MRI scan was performed to assess cerebellar white and gray matter volumes. Cerebellar segmentation was performed with FreeSurfer. Statistical analyses include between-group differences in cognitive domains, cerebellar gray, and white matter volumes. Relationships between cerebellar volumes and cognitive domains were examined.

RESULTS

Youth with PBD showed greater cerebellar gray matter volumes than both BD-OFF and HC, whereas no differences were present between BD-OFF and HC. Both youth with PBD and BD-OFF showed altered processing of negative emotions and a bias towards positive emotions. In youth with PBD and BD-OFF, greater impairment in the processing of emotions correlated with greater cerebellar gray matter volumes.

CONCLUSION

The present findings corroborate hypotheses on cerebellar involvement in the processing of emotions and the pathophysiology of PBD. The presence of cerebellar dysfunction in BD-OFF is unclear.

Cognitive correlates of impulsive aggression in youth with pediatric bipolar disorder and bipolar offspring

BACKGROUND

Youth with bipolar disorder (BD) and offspring of individuals with BD (BD-OFF) are characterized by higher levels of impulsive and overt aggression. The cognitive basis underlying these aggressive behaviors are not clarified in this population. The aim of this study was to investigate the relationship between cognitive alterations and aggressive behavior in youth with BD and BD-OFF.

METHODS

Forty-two youth with BD, 17 BD-OFF and 57 healthy controls (HCs) were administered the Modified Overt Aggression Scale (MOAS), the Cambridge Neuropsychological Test Automated Battery (CANTAB), the Young Mania Rating Scale (YMRS) and the Children's Depression Rating Scale (CDRS). Multiple linear regression analyses were performed in the three groups separately. In each group, tests scores from the CANTAB were predictors. MOAS subscale scores and MOAS total scores were dependent variables. Results are corrected for age, IQ and mood state.

RESULTS

Both youth with BD and BD-OFF showed positive correlations between impairment in executive functions and levels of verbal aggression. In youth with BD, altered processing of either positive and negative stimuli positively correlated with MOAS total scores, whereas in BD-OFF, such relationship was negative.

CONCLUSIONS

Impulsive aggressive behaviors in youth with BD arise from a combination of altered affective processing and executive dysfunction. The negative relationship between affective processing and aggression in BD-OFF suggested the presence of possible mechanisms of resilience in this population.

Early and late cortical reactivity to passively viewed emotional faces in pediatric bipolar disorder

BACKGROUND

We studied emotional information processing in youth with pediatric bipolar disorder (pBD) using the late positive potential (LPP), assessing automatic allocation of attentional resources to emotionally salient stimuli, and the occipital P1, assessing early sensory processing.

METHODS

Participants were 20 youth with pBD and 26 healthy controls (HC). Participants passively viewed faces with a fearful, neutral or happy expressions. Group differences were tested with general linear models. P1 was included to examine modulating effects on LPP. We calculated Bayes factor (BF) values to express strength of evidence for choosing one hypothesis over another.

RESULTS

A significant emotion by group interaction for LPP amplitude was associated with a larger amplitude for happy faces for pBD than HC (F[1,40] = 6.04, p = .018); this was not modulated by P1 amplitude or latency. P1 amplitude did not differ between groups, although P1 peaked earlier for HC (F[1,40] = 5.45, p = .025). BF for LPP was 2.93, suggesting moderate evidence favoring H₁. BF for P1 latency of 14.58 suggests strong evidence favoring H₁.

LIMITATIONS

Inclusion of children and adolescents prohibited careful control for neurodevelopmental effects.

CONCLUSIONS

Larger LPP amplitude for happy faces without change in P1 suggests enhanced automatic allocation of attentional resources to positive information in pBD. Delayed P1 latency in pBD suggests slower early processing of emotional information.

Face Processing Measures of Social Cognition: A Dimensional Approach to Developmental Psychopathology

BACKGROUND

Social cognition impairments in neurodevelopmental disorders impact functioning. Face processing is the most extensively studied aspect of social cognition, commonly indexing this construct in neuropsychiatric disorders compared with typically developing youths. Applying social cognition measures as a Research Domain Criteria concept in the clinical arena requires establishing cutoffs for intervention and identifying vulnerability for psychopathology across disorders. This can be accomplished by comparing extreme performers across multiple clinical symptom features.

METHODS

The Philadelphia Neurodevelopmental Cohort (N = 9498), a community sample of youths (8-21 years old), was assessed with a structured interview (Kiddie Schedule for Affective Disorders and Schizophrenia). The Penn Computerized Neurocognitive Battery was administered measuring accuracy and response time on Executive, Episodic Memory, Complex Cognition, and Social Cognition domains. We parsed participants by performance on social cognition into tertiles and examined their neurocognitive and clinical profiles.

RESULTS

The top social cognition group outperformed the bottom group in face memory and complex reasoning. Concerning symptoms, the top performing group did not differ from the middle group, but the bottom performing group had higher externalizing and psychosis symptoms. There were sex differences in social cognition and symptom profiles but no sex × performance or sex × diagnosis × domain interactions.

CONCLUSIONS

Social cognition is supported by strong face memory and complex reasoning skills. Poor performance portends more severe externalizing and psychosis symptoms. That average performance is sufficient for normative symptomatology suggests that interventions aimed at ameliorating social cognition deficits, as measured here, could be effective in normalizing level of symptoms.

Facial emotion labeling in unaffected offspring of adults with bipolar I disorder

BACKGROUND

Young people 'at risk' for developing Bipolar Disorder have been shown to have deficits in facial emotion labeling across emotions with some studies reporting deficits for one or more particular emotions. However, these have included a heterogeneous group of young people (siblings of adolescents and offspring of adults with bipolar disorder), who have themselves diagnosed psychopathology (mood disorders and neurodevelopmental disorders including ADHD).

METHODS

24 offspring of adults with bipolar I disorder and 34 offspring of healthy controls were administered the Diagnostic Analysis of Non Verbal Accuracy 2 (DANVA 2) to investigate the ability of participants to correctly label 4 emotions: happy, sad, fear and anger using both child and adult faces as stimuli at low and high intensity.

RESULTS

Mixed effects modelling revealed that the offspring of adults with bipolar I disorder made more errors in both the overall recognition of facial emotions and the specific recognition of fear compared with the offspring of healthy controls. Further more errors were made by offspring that were male, younger in age and also in recognition of emotions using 'child' stimuli.

LIMITATIONS

The sample size, lack of blinding of the study team and the absence of any stimuli that assess subjects' response to a neutral emotional stimulus are limitations of the study.

CONCLUSIONS

Offspring (with no history of current or past psychopathology or psychotropic medication) of adults with bipolar I disorder displayed facial emotion labeling deficits (particularly fear) suggesting facial emotion labeling may be an endophenotype for bipolar disorder.

Psychosocial interventions in the treatment of youth diagnosed or at high-risk for pediatric bipolar disorder: A review of the literature

Pediatric bipolar disorder (PBD) has emerged as a research field in which psychosocial treatments have provided a plethora of empirical findings over the last decade. We addressed this issue through a systematic review aimed of establishing their effectiveness and feasibility as adjunctive therapies for youth with PBD or at high-risk for PBD. A comprehensive search of databases was performed between 1990 and September 2014. Overall, 33 studies were specifically related to the issue and 20 of them were original articles. Evidence suggests that both "multi-family psychoeducational psychotherapy' and "family-focused therapy" are possible effective treatments for PBD. Likewise, "child and family-focused cognitive-behavioral therapy" may be characterized as a treatment in its experimental phase. The remaining therapies fail to obtain enough empirical support due to inconsistent findings among clinical trials or data solely based on case reports. Studies of psychosocial treatments provide concluding results concerning their feasibility and acceptability. Larger sample sizes and more randomized controlled trials are mandatory for diminishing methodological shortcomings encountered in the treatments displayed.

Bipolar disorder in children

Although bipolar disorder historically was thought to only occur rarely in children and adolescents, there has been a significant increase in children and adolescents who are receiving this diagnosis more recently (Carlson, 2005). Nonetheless, the applicability of the current bipolar disorder diagnostic criteria for children, particularly preschool children, remains unclear, even though much work has been focused on this area. As a result, more work needs to be done to further the understanding of bipolar symptoms in children. It is hoped that this paper can assist psychologists and other health service providers in gleaning a snapshot of the literature in this area so that they can gain an understanding of the diagnostic criteria and other behaviors that may be relevant and be informed about potential approaches for assessment and treatment with children who meet bipolar disorder criteria. First, the history of bipolar symptoms and current diagnostic criteria will be discussed. Next, assessment strategies that may prove helpful for identifying bipolar disorder will be discussed. Then, treatments that may have relevance to children and their families will be discussed. Finally, conclusions regarding work with children who may have a bipolar disorder diagnosis will be offered.

Progression of amygdala volumetric abnormalities in adolescents after their first manic episode

OBJECTIVE

Although previous neuroimaging studies suggest that adolescents with bipolar disorder exhibit smaller amygdala volumes compared with healthy adolescents, whether these abnormalities are present at illness onset or instead develop over time remains unclear. The aim of this study was to conduct a prospective longitudinal investigation comparing amygdala neurodevelopment among adolescents after their first manic episode, adolescents with attention-deficit/hyperactivity disorder (ADHD), and healthy adolescents.

METHOD

A total of 30 adolescents hospitalized for their first manic/mixed episode associated with bipolar disorder, 29 adolescents with ADHD, and 24 demographically matched healthy teens underwent magnetic resonance imaging scanning at index assessment and approximately 12 months later. Adolescents with bipolar disorder were prospectively evaluated using diagnostic interviews and with symptom rating scales.

RESULTS

Mixed models examining the group × time effect for both left (p = .005) and right (p = .002) amygdala volumes were statistically significant. Change in left (p = .01) and right (p = .0008) amygdala volumes from baseline to 12 months were significantly different among groups. Specifically, left amygdala volumes increased over time in healthy adolescents (p = .008) and adolescents with ADHD (p = .0009), but not in adolescents with bipolar disorder (p = .3). Right amygdala volume increased over time in adolescents with ADHD (p < .001), but not in healthy adolescents nor in adolescents with bipolar disorder (p = .1 and p = .3, respectively). In adolescents with bipolar disorder, baseline total amygdala volume was significantly greater in those who subsequently achieved symptomatic recovery as compared with those who did not achieve recovery (p = .02).

CONCLUSIONS

Adolescents with mania do not exhibit normal increases in amygdala volume that occur during healthy adolescent neurodevelopment.