Pediatric bipolar disorder: Mood swings, irritability are cues to this diagnosis
Our challenge is to make the diagnosis early and stabilize mood so that these young patients can cope and achieve at home and in school.
- five types of episodes (manic, hypomanic, mixed, depressed, unspecified)
- four severity levels (mild, moderate, severe without psychosis, severe with psychosis)
- and three course specifiers (with or without inter-episode recovery, seasonal pattern, rapid cycling).
Table 2
PEDIATRIC BIPOLAR DISORDER SUBTYPES: DIAGNOSTIC CHARACTERISTICS AND ASSOCIATED FEATURES
| DSM-IV subtype | Minimum duration of manic symptoms | Depression symptoms | Cardinal features |
|---|---|---|---|
| Bipolar I | Pure mixed or manic 1 week (or hospitalization needed) | Major depressive disorder presentation of bipolar may be the first disorder, particularly in adolescents | Multiple daily mood swings with severe irritability (mood lability) Short periods of euphoria Decreased need for sleep Hypersexuality Grandiosity Racing thoughts Pressured speech |
| Bipolar II | Hypomania 4 days | One or more prior episodes of major depressive disorder required, each with a duration of 2 weeks | Noticeable manic symptoms that do not cause significant dysfunction or lead to hospitalization |
| Cyclothymia | Hypomania cycling with depressive symptoms 1 year | Hypomania cycling with depressive symptoms, without manic, mixed, or major depressive episodes (1 year, with symptom-free intervals <2 months) | Chronic, low-level mood cycling |
| Bipolar NOS | < 4 days of bipolar symptoms | Rapid alternation (within days) between manic depressive symptoms without full manic, mixed, or major depressive episodes | May include hypomanic and episodes (but <4 days) without intercurrent depression May also be diagnosed when clinician determines bipolar disorder is present but cannot determine whether it is primary, due to a general medical condition, or substance-induced, such as severe mood lability secondary to fetal alcohol syndrome or alcohol-related neurodevelopmental disorder |
| NOS: not otherwise specified | |||
Table 3
COMPLICATING FACTORS IN PEDIATRIC BIPOLAR DISORDER
| Medical conditions that may mimic bipolar mania |
| Temporal lobe epilepsy |
| Hyperthyroidism |
| Closed or open head injury |
| Multiple sclerosis |
| Systemic lupus erythematosus |
| Alcohol-related neurodevelopmental disorder |
| Wilson’s disease (rare progressive disease caused by defective copper metabolism) |
| Medications that may increase mood cycling |
| Tricyclic antidepressants |
| Selective serotonin reuptake inhibitors |
| Serotonin and norepinephrine reuptake inhibitors |
| Aminophylline |
| Corticosteroids |
| Sympathomimetic amines, such as pseudoephedrine |
DSM-IV criteria for mania—which were developed from data on adults with bipolar disorders—do not take into account developmental differences between bipolar adults and bipolar children and adolescents.
Diagnostic characteristics of the pediatric bipolar disorder subtypes are compared in Table 2. Generally:
- Pediatric patients with bipolar I disorder have multiple daily mood swings, a “mixed” type of episode with short periods of euphoria and longer periods of irritability, and comorbidities such as ADHD, oppositional defiant disorder, or conduct disorder.3,11,12
- Bipolar II disorder presents more typically in adolescence and is usually noticed clinically as a major depressive episode. Past episodes of hypomania may have been missed unless a careful history was taken.
- Cyclothymia is difficult to diagnose because the hypomania and depressive symptoms are not as severe as in bipolar types I or II. Prospective mood charting can help the clinician diagnose cyclothymia (see “Related Resources”).
- Bipolar disorder NOS represents the largest group of patients with bipolar symptoms. This diagnosis is made when bipolar symptoms are present but not of sufficient severity or duration to warrant a diagnosis of bipolar I, II or cyclothymia. Bipolar NOS also can be diagnosed when a bipolar disorder is secondary to a general medical condition, such as fetal alcohol syndrome or alcohol-related neurodevelopmental disorder.
Differential diagnosis. Medications and medical disorders may exacerbate or mimic pediatric bipolar symptoms (Table 3), so it is important to assess these potential confounds before initiating treatment. Psychiatric comorbidities also frequently complicate the presentation of pediatric bipolar disorder and its response to treatment (Table 4). ADHD is the most common comorbidity, with rates as high as 98% in bipolar children.3,13
Outcomes
Long-term outcomes of children and adolescents with bipolar disorders have not been well studied. In the only prospective follow-up investigation of adolescent inpatients with mania, Strober et al found that most of 54 patients (96%) recovered from an index affective episode, but nearly one-half (44%) experienced one or more relapses within 5 years.14 The rate of recovery varied according to the index episode’s polarity. Recovery was faster in patients with pure mania or mixed states, and multiple relapses occurred more frequently in those with mixed or cycling episodes. Twenty percent of the patients attempted suicide.
Recently, Geller et al reported the results of the first large, prospective, follow-up study of children with bipolar disorder.15 In 89 outpatients (mean age 11) with bipolar I disorder, comprehensive assessments at baseline and at 6, 12, 18, and 24 months showed that 65% recovered from mania but 55% relapsed after recovery. Mean time to recovery was 36 weeks, and relapse occurred after a mean of 28.6 weeks. Children living with their intact biological families were twice as likely to recover as those in other living arrangements.
The poor outcomes of these bipolar children highlight the need for earlier recognition and more effective treatments.
Treating acute mania
Many psychotropic medications used to treat adults with bipolar disorders are also used for children and adolescents. To date, only two double-blind, placebo-controlled studies13,16 and one uncontrolled maintenance treatment study17 have examined treatment of acute mania in pediatric bipolar disorder.
