Not all mood swings are bipolar disorder

Mood swings: A chart review

We recently completed a retrospective chart review of 100 patients consecutively referred to our pediatric mood disorders clinic for evaluation of “mood swings, rule out BD.” These patients were self-referred, referred by a psychiatrist for a second opinion, or referred by their primary care physician. The mean age of these patients was 8±2.8 years and 68% were male.

Two experienced clinicians (RAK and EM) interviewed each patient and their caregivers and reviewed results of the Conners’ Parent Rating Scale-Revised: Long Form (CPRS-R:L)⁵ and other outside information.
Figure 1 illustrates these patients’ diagnoses. Diagnoses for each of these disorders were made using DSM-IV-TR criteria.³

The most common diagnoses among patients with the chief complaint of mood swings were ADHD (39%); ODD with ADHD (15%); an anxiety disorder, usually generalized anxiety disorder (GAD) (15%); BD (12%); and a secondary mood disorder, usually fetal alcohol spectrum disorder (10%). We were surprised at how often ADHD, ODD, and anxiety disorders were found to be responsible for these patients’ mood swings and how frequently the referring clinician did not recognize these disorders. In the following sections, we discuss each of these disorders and how they differ from BD.

Figure 1 Underlying diagnoses of 100 children/adolescents referred for ‘mood swings’

ADHD: attention-deficit/hyperactivity disorder; BD: bipolar disorder; MDD: major depressive disorder; ODD: oppositional defiant disorder; PDD: pervasive developmental disorder

ADHD and ODD

In our sample, patients with undiagnosed ADHD made up the largest group of those with frequent mood swings. ADHD inattentive type was missed frequently in adolescent girls who still had behavioral aspects of ADHD, including impulsivity and aggression.⁶

The CPRS-R:L is useful for screening and diagnosing children and adolescents with ADHD and ODD. It contains 80 items, can be used in males and females and patients age 3 to 17, and has validated norms by age and sex.⁵ It takes parents approximately 10 minutes to fill out this questionnaire and the results can be scored by hand. The CPRS-R:L includes the following scales: oppositional; cognitive problems/inattention; hyperactivity; anxious-shy; perfectionism; social problems; psychosomatic; Connors’ global index; DSM-IV symptom subscales; and an ADHD index. Patients with mood swings and ADHD combined typically score >2 standard deviations above their age/sex mean on the CPRS-R:L hyperactivity scale, Connors’ Global Index, and ADHD index.⁵

A common childhood disorder, ODD has multiple etiologies.⁷ The first DSM-IV criteria for ODD is “often loses temper”³—essentially mood swings that often are expressed behaviorally as anger and at times as aggressive outbursts.

Dodge and Cole⁸ categorized aggression as reactive (impulsivity with a high affective valence) or proactive (characterized by low arousal and premeditation, ie, predatory conduct disorder). Reactive aggression typically is an angry defensive response to frustration, threat, or provocation, whereas proactive aggression is deliberate, coercive behavior often used to obtain a goal.⁹ Reactive aggression is common among children with ADHD and ODD and typically begins as a mood swing that escalates into reactive aggressive behavior. In a study of 268 consecutively referred children and adolescents with ADHD and 100 community controls, Connor et al¹⁰ found significantly more reactive than proactive forms of aggression in ADHD patients.

It can be difficult to differentiate the moods swings and symptoms of ODD from those of pediatric BD. Mick et al¹¹ found that severe irritability may be a diagnostic indicator of BD in children with ADHD. Using the Kiddie Schedule for Affective Disorders and Schizophrenia (epidemiologic version) structured diagnostic interview,¹² they evaluated 274 children (mean age 10.8±3.2) with ADHD; 37% had no comorbid mood disorder, 36% had ADHD with depression, and 11% had ADHD with BD. Researchers characterized 3 types of irritability in these patients:

• ODD-type irritability characterized by a low frustration tolerance that is seen in ODD
• Mad/cranky irritability found in depressive disorders
• Super-angry/grouchy/cranky irritability with frequent, prolonged, and largely unprovoked anger episodes and characteristics of mania.

ODD-type irritability was common among all ADHD patients, was the least impairing type of irritability, and did not increase the risk of a mood disorder. Mad/cranky irritability was common only in children with ADHD and a mood disorder (depression or BD), was more impairing than ODD-type irritability, and was most predictive of unipolar depression. Super-angry/grouchy/cranky irritability was common only among children with ADHD and BD (77%), was the most impairing, and was predictive of both unipolar depression and BD. The type of irritability and clustering of DSM-IV manic symptoms best differentiated ADHD subjects from those with ADHD and BD. Figure 2 illustrates symptoms that differentiated patients with ADHD from those with ADHD and comorbid BD.¹¹