Pediatric Bipolar Disorder: A Valid Condition?

From Medscape Psychiatry

Christoph U. Correll; MD, Marta Hauser, MA

01/04/2011

• Bipolar Disorder in Children and Adolescents: A Valid Condition or an Over-Diagnosed Label?
• Increasing Rates of Bipolar Diagnosis in Youth
• Diagnostic Considerations in Youth With Bipolar Disorder Features
• Enter Severe Mood Dysregulation
• Diagnostic Uncertainties
• DSM-V
• Summary and Conclusions

Bipolar Disorder in Children and Adolescents: A Valid Condition or an Over-Diagnosed Label?

Bipolar (BP) disorder, also referred to as manic depression, is characterized by severe and disabling shifts in mood and energy levels. The symptoms can cause serious impairment in relationships and school/work performance, and are associated with a lifetime risk for completed suicide in 10%-15% of those diagnosed with BP I disorder.
Estimates of lifetime prevalence for adult BP I disorder range from 0.4% to 1.6% and, for BP II disorder, approximately 0.5%
Up until fairly recently, BP disorder was rarely diagnosed in children and adolescents.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), the age of onset of BP disorder is 20 (for men and women), and criteria do not distinguish between adults and children or adolescents.
However, the increased rate of children and adolescents diagnosed with BP disorder over the past 15 years has raised concern and fueled a debate regarding the accuracy and consequences of this diagnosis in developing youth.
The assignment of a BP disorder diagnosis can have serious consequences, both when this diagnosis is wrongly assigned and when it is missed.

Summary and Conclusions

In summary, despite growing evidence for the validity of pediatric BP disorder, more and longer-term prospective research is needed to characterize and demarcate the features of the disorder in youth more thoroughly and enable diagnostic consensus.
Practitioners are advised to inquire about:
(a) distinct, spontaneous periods of mood changes;
(b) family history of mania, depression and other mood disorders; and
(c) symptoms of irritability, reckless behavior, or increased energy.
However, they should bear in mind that the latter symptoms in particular might be part of other emerging psychiatric disorders and, thus, might lack specificity for BP disorder.
Furthermore, although the diagnosis of (hypo)mania should follow diagnostic criteria, attention should be given to the fact that the clinical presentation of pediatric BP disorder may differ somewhat from those of adults.
For the diagnosis, both current and past symptoms, treatment and treatment response, psychosocial stressors, biological triggers (eg menstrual period in females, substance use, sleep deprivation) and family history should be considered.
Structured interviews and questionnaires may provide helpful tools for the assessment of these aspects. Caregivers and families need to be included in the evaluation and treatment, and both the risks of overdiagnosis and underdiagnosis need to be considered when assessing and managing youth with challenging and often quite disabling emotional dysfunction.

DSM-V

The criteria for BP I and II disorder in DSM-V^[41] are virtually unchanged to those in DSM-IV. Exceptions include the renaming of mixed episode to mixed features specifier.
Based on the important work by the NIMH intramural pediatric mood disorder program on patients classified with severe mood dysregulation (see above), a new diagnostic entity is being proposed, currently called temper dysregualtion disorder with dysphoria (TDD) (Table 5).
Table 5. Proposed Criteria for Temper Dysregulation Disorder With Dysphoria

A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.

1. The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property. 2. The reaction is grossly out of proportion in intensity or duration to the situation or provocation. 3. The responses are inconsistent with developmental level.

B. Frequency: The temper outbursts occur, on average, 3 or more times per week.

C. Mood between temper outbursts:

1. Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad). 2. The negative mood is observable by others (eg, parents, teachers, peers).

D. Duration: Criteria A-C have been present for at least 12 months. Throughout that time, the person has never been without the symptoms of criteria A-C for more than 3 months at a time.

E. The temper outbursts and/or negative mood are present in at least 2 settings (at home, at school, or with peers) and must be severe in at least 1 setting.

F. Chronological age is at least 6 years (or equivalent developmental level).

G. The onset is before age 10 years.

H. In the past year, there has never been a distinct period lasting more than 1 day during which abnormally elevated or expansive mood was present most of the day for most days, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of 3 of the "B" criteria of mania (ie, grandiosity or inflated self-esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-directed activity, or excessive involvement in activities with a high potential for painful consequences; see pp. XX). Abnormally elevated mood should be differentiated from developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation.

I. The behaviors do not occur exclusively during the course of a psychotic or mood disorder (eg, major depressive disorder, dysthymic disorder, bipolar disorder) and are not better accounted for by another mental disorder (eg, pervasive developmental disorder, post-traumatic stress disorder, separation anxiety disorder). (Note: This diagnosis can coexist with oppositional defiant disorder, attention deficit hyperactivity disorder, conduct disorder, and substance use disorders.) The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.

Adoption of this new diagnostic entity would enable the diagnosis of youth currently labeled under the BP spectrum diagnosis heading who seem to have a different long-term course and who may very well require different treatment. However, field trials will need to confirm the validity and specificity of this newly proposed condition.