Unspecified Bipolar: Thermoregulatory Sleep Dysregulation Disorder
Information for Providers
Diagnostic & Treatment Tools:
Proposed Diagnostic Criteria
Unique Symptom Checklist
Symptom Tracker
Temperature Questionnaire
Clinician’s Pathway Program (CPP)
Proposed Diagnostic Criteria
Unspecified Bipolar: Thermoregulatory Sleep Dysregulation Disorder
AKA “Fear of Harm”
Criteria A–F are required for diagnosis and must be present most days for at least 6 months, without any symptom free periods that exceed 2 months in duration and cause functional impairment in one or more settings (e.g., significant behavioral problems at home but not necessarily in the school setting).
________________________________________________________________________________
A: Mood Disorder
Typically characterized by episodic and abrupt transitions in mood state accompanied by rapid alternations in levels of arousal, emotional excitability, sensory sensitivity, and motor activity.
Meets DSM-5 criteria for any form of bipolar disorder (bipolar I, bipolar II, mixed episodes, major depression with short duration mania, major depression with insufficient criteria hypomania, hypomania without major depression, cyclothymia). Manic, hypomanic and mixed episodes are defined by DSM-5 symptom criteria but not by DSM-5 duration criteria.
B: Fear of Harm
Fear that physical harm will come to self or others; easily misperceives and experiences neutral stimuli such as tone of voice or facial expression as threatening; obsessive bedtime rituals; fear of the dark; fear of intruders; separation anxiety; contamination fears; hyper-vigilance.
Three (or more) of the following are required:
Obsessive fears that something awful may happen to self or significant others;
Obsessive fears that they will harm themselves or others;
Reacts with excessive anxiety and fearfulness in novel situations or with strangers;
Reacts with excessive anxiety in situations involving separation;
Is self-conscious and feels easily humiliated in social situations;
Easily misjudges other people as threatening, intimidating or critical.
C: Thermoregulatory Disturbance
Experiences thermal discomfort such as feeling hot, or excessively sweating in neutral ambient temperature environments, as well as little or no discomfort during exposure to moderate or extreme cold, and alternates noticeably between being excessively hot in the evening and cold in the morning.
Two (or more) of the following are required:
Feels excessively warm/hot at bedtime or overheats during the night;
Feels cold in the morning having felt hot at bedtime;
Feels excessively warm during day in neutral temperatures;
Has moderate to extreme cold tolerance (able to go out into the cold without a jacket);
Overheats or sweats profusely with exertion.
D: Sleep/Wake Disturbances
Most specifically characterized by highly disturbing nightmares or night terrors resulting in fear of going to sleep and auto-traumatization.
Two (or more) of the following are required:
Frequent night-terrors or nightmares – often containing images of gore and mutilation;
Fear of going to sleep because of disturbing dreams;
Hypnogogic hallucinations;
Excessively restless sleep.
E: Aggression
Territorial and reactive aggression in response to limit setting and perceived threat or loss including aggressive fight-based speech or actions or self-directed aggression such as head banging, cutting or scratching self, suicidal thoughts or actions.
Two (or more) of the following are required:
Excessively aggressive or controlling speech (critical, sarcastic, demanding, “bossy”);
Excessive anger and oppositional/aggressive responses to situations that elicit frustration;
Self-directed aggression (head-banging, skin-picking, cutting, suicidal ideations or actions);
Temper tantrums;
Often threatens or breaks objects, slams doors, smashes walls.
F: Symptoms Are Not Due to a General Medical Condition
(e.g. hypothyroidism) Criteria may overlap with symptomatology from other DSM classifications.
G: A family history of recurrent mood disorder
And/or alcoholism, as well as other bipolar spectrum disorders, lends further support to the diagnosis.
Proposed Diagnostic Criteria (Downloadable PDF)
Unique Symptom Checklist
Parents are asked to select a total of 8 items: spread out amongst whichever 5 categories best represent the most severe symptoms for their child. Must include categories 7 and 8 (Mania/Depression).
1. Sleep disturbance
Difficulty getting to sleep at night
Wakes up in the middle of night
Difficulty getting up in AM
Restlessness during sleep- Always moving around in bed at night
Day for night reversal – goes through periods where he cannot sleep at night and sleeps during the day
2. Arousal disorders of sleep
Nightmares
Night-terrors
Teeth-grinding
Bedwetting
Sleep-walking
3. Temperature disturbance
Complains of body being warm/hot at bedtime and/or that overheats during night
Complains of overheating during the day (hot flashes) in neutral temperatures
Complains of being cold when the ambient temperature is warm
Has moderate to extreme tolerance to the cold – e.g. able to go out into the cold without a jacket
Complains of overheating or sweats profusely on exertion
Becomes highly dysregulated and activated (angry, irritable, explosive, hyperactive) between 3:30-5:30pm in the afternoon/evening on a regular basis.
Appears to be overheating (eg. flushing, complaining of being hot, sweating) between 3:30-5:30pm in the afternoon/evening on a regular basis.
4. Fear of Harm
Afraid that others will hurt, critical, reject or judge them
Afraid of hurting others
Afraid will say something that is embarrassing
Easily misjudges other people’s facial expressions or tone of voice or intent as threatening, intimidating, critical.
Is self-conscious and feels easily humiliated in social situations
5. Aggressive behaviors towards others, self or objects
Attempts to control and dominate others – eg. is bossy and demands to get their way,
Aggressive in response to limit setting – is angered when parents set limits or use the word “no”
Aggressive behavior towards sibling(s), parents, or other authority figures, and/or curses viciously or threatens others when angry
Aggressive towards self – bangs head, picks scabs, scratches or cuts self, has made suicide attempts
Aggressive in response to requests to transition from one context to another
Often threatens or breaks objects, slams doors, smashes walls
6. Anxiety
Separation anxiety – afraid to be alone, clings to figures of safety
Phobias: fear of germs, bugs, spiders, other
Morbid preoccupation with death and gory themes
Frequently anxious in social situations
Afraid to sleep in own bed at night
7. Manic/hypomanic Behaviors
Rapid abrupt switches of mood – easily shifts from silly, goofy, giddy mood, to anger and irritability, to complaining of extreme boredom or sad or depressed mood
Racing thoughts and or pressured speech
Hyperactivity – frequently unable to sit still, in constant movement
Often feels a sense of urgency – Mission mode; will not yield when wants something
Is easily distracted – goes from one subject to another, cannot stay with one activity very long
8. Depressive symptoms
Withdraws from others, isolates self
Frequently complains of being bored and wants to do something, but nothing seems interesting enough
Energy level is low and/or is easily stressed and frustrated by minimal demands
Complains that parents, siblings or friends do not love or care about them
Has suicidal thoughts – Says I don’t want to live, or I wish I were dead
9. Psychotic symptoms
Grandiose ideas about self, about what others may do to them
Auditory hallucinations – hears voices inside of head
Visual hallucinations – sees things that are not there
Embellishes reality, tells tall tales, lies to others about their experience
Paranoid thought or ideas – believes other may harm them
Unique Subject Checklist (Downloadable PDF)
Symptom Tracker
Each person with Fear of Harm will have slight differences in which symptoms are most salient and which cause the greatest obstacles to successful daily life. These symptoms can be identified through the use of the Unique Subject Checklist (above).
Changes in symptom frequency and intensity can be documented using this symptom tracker. Additionally, this tool will help to document other influential aspects including medication, changes in medication, environmental temperature, and behavioral changes.
Below are links to a sample Symptom Tracker developed in Google Sheets. Use the links to open the sample based on your preferred version.
If you use Google Drive after opening the spreadsheet you can make a copy of it and save the copy to your Drive. You will be able to edit, duplicate (copy), and fill in this saved version.
If you use Microsoft Office you can download the spreadsheet as an Excel file to your computer. You will be able to edit, duplicate (copy), and fill in this saved version.
Symptom Tracker – Sample (Microsoft Excel)
Symptom Tracker – Sample (Google Sheet)
Temperature Questionnaire
Patient:
Gender:
Date of Birth:
Instructions:
Estimate how frequently the behavior has occurred since it was first observed. Select a number using the following key to represent frequency of occurrence.
Temperature Questionnaire
Never or hardly ever | Sometimes | Often | Very often or almost constantly |
1 | 2 | 3 | 4 |
Complains of feeling hot in the late afternoon and evening despite a neutral ambient temperature.
1 | 2 | 3 | 4 |
Walks outside in cold temperatures with very light clothing (short sleeves, shorts) and seems not to feel the cold.
1 | 2 | 3 | 4 |
Overheats easily (complains of feeling too hot, sweats profusely) with mild to moderate exertion.
1 | 2 | 3 | 4 |
Overheats in response to real or perceived stressors.
1 | 2 | 3 | 4 |
Sweats excessively before or during sleep.
1 | 2 | 3 | 4 |
Face easily becomes flushed or tips of ears redden.
1 | 2 | 3 | 4 |
Complains of being cold in the early morning.
1 | 2 | 3 | 4 |
Becomes moody (irritable/angry) with abrupt increases in temperature/humidity (including entering a warm house from a cold outdoor temperature).
1 | 2 | 3 | 4 |
Becomes activated with increased energy and activity level in the late afternoon.
1 | 2 | 3 | 4 |
Temperature Questionnaire (Downloadable PDF)
Clinician’s Pathway Program (CPP)
The Clinician’s Pathway Program is a Diagnostic Assessment Program
The Diagnostic Assessment Program for Juvenile Bipolar Disorder was designed for use in clinical and research settings to screen for bipolar disorder in children from parent and child reports. The program provides preliminary diagnostic and symptom severity measures, as well as scaled scores of other key symptom dimensions (anxiety, sleep/wake disturbance, mania sensory sensitivity and others).
The Child Bipolar Questionnaire
The Child Bipolar Questionnaire (CBQ) is a reliable and sensitive diagnostic indicator for early onset bipolar disorder. It is simple to use and may be self-administered by the child’s primary caretaker or administered by a clinician.
The unique feature of this 65 question screening instrument is that it collects information not only on the symptoms of bipolar disorder, but for many other disorders considered comorbid to bipolar disorder (mania, major depression, separation anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, oppositional defiant disorder, conduct disorder and attention deficit disorder). Further, it allows that information to be reported in degrees of severity rather than simply “present” or “absent”. The development of the CBQ is important as it provides an efficient screening tool that is both reliable and easy to use.
The Jeannie and Jeffrey Illustrative Interview for Children
The Jeannie and Jeffrey Illustrative Interview for Children is a diagnostic indicator for early onset bipolar disorder. It is a simple to use instrument that can be administered by the child’s primary caretaker or administered by a clinician. The unique feature of this screening interview portrays a child as Jeannie or Jeffrey that is easily identifiable to children and facilitates their describing the nature of their symptoms.
