Treatment Protocol for Fear of Harm

Unspecified Bipolar: Thermoregulatory Sleep Dysregulation Disorder

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).

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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.
  1. 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: 
  1. Obsessive fears that something awful may happen to self or significant others; 
  2. Obsessive fears that they will harm themselves or others;
  3. Reacts with excessive anxiety and fearfulness in novel situations or with strangers;
  4. Reacts with excessive anxiety in situations involving separation;
  5. Is self-conscious and feels easily humiliated in social situations; 
  6. 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:
  1. Feels excessively warm/hot at bedtime or overheats during the night;
  2. Feels cold in the morning having felt hot at bedtime;
  3. Feels excessively warm during day in neutral temperatures;
  4. Has moderate to extreme cold tolerance (able to go out into the cold without a jacket);
  5. 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: 
  1. Frequent night-terrors or nightmares – often containing images of gore and mutilation; 
  2. Fear of going to sleep because of disturbing dreams; 
  3. Hypnogogic hallucinations; 
  4. 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: 
  1. Excessively aggressive or controlling speech (critical, sarcastic, demanding, “bossy”); 
  2. Excessive anger and oppositional/aggressive responses to situations that elicit frustration; 
  3. Self-directed aggression (head-banging, skin-picking, cutting, suicidal ideations or actions); 
  4. Temper tantrums; 
  5. 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.

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.

 

Accessing the CPP

Link: CPP: Diagnostic Assessment Program
Link: Establish a New Clinician’s Pathway Account
Link: Login to an Existing Clinician’s Pathway Account
Link: Frequently Asked Questions
Link: Descriptions of Each Instrument
Please note: The web application that provides access to the Clinician’s Pathway Program and the diagnostic tools listed above are not managed by JBRF. They are managed by the private practice of Dr. Demitri Papolos. 
If you have questions or concerns about account set up, account access, or any fees you have paid they must be directed to the program’s administrator at Dr. Papolos’s private practice. 
The administrator can be reached at CCP@drpapolos.com
JBRF does not have access to that system, nor does JBRF collect or retain any of the associated fees.

The Clinician’s Pathway Program (CPP) and its assessment tools, the CBQ and JJ, were developed by Dr. Demitri Papolos. By clicking the links below you will leave www.jbrf.org and be redirected to the research site that contains the CPP and the CBQ & JJ assessments. If you have any questions or concerns regarding these tools please direct them to Dr. Papolos’s system administrator at CPP@drpapolos.com

To Set Up a New CPP Account

To Access an Existing CPP Account

Scoring for assessments within the CPP is a fee-based service offered by the private practice of Demitri Papolos, M.D.; this service is independent of JBRF but may be accessed through the JBRF website. Dr. Papolos developed the CBQ & JJ measures and their automated scoring report with the support of JBRF. Questions and/or concerns with regard to the scored report should be addressed to CPP@drpapolos.com