New diagnosis fits third of bipolar teens



SAN FRANCISCO – Thirty-seven percent of 175 hospitalized adolescents diagnosed with bipolar disorder met criteria for a new disorder listed in the DSM-5 – disruptive mood dysregulation disorder.

Nearly all of the patients (96%) had been diagnosed with bipolar I disorder "not otherwise specified" (NOS) at the time of admission, a retrospective study found. Three other bipolar diagnoses were applied to two patients each: bipolar depression, bipolar mania, or mixed-episode bipolar disorder, David L. Pogge, Ph.D., reported at the annual meeting of the American Psychiatric Association.

The findings suggest that a substantial proportion of adolescent inpatients diagnosed with bipolar disorder may instead meet criteria for disruptive mood dysregulation disorder, and that clinicians should be more careful in diagnosing bipolar disorder, especially bipolar NOS, said Dr. Pogge of the department of psychology and counseling at Fairleigh Dickinson University, Teaneck, N.J. He also serves as director of psychology at Four Winds Hospital, which operates four campuses in New York state.

The study included records for all 1,505 patients aged 13-17 years who were admitted to a private psychiatric hospital over a 2-year period. At the time of admission, clinicians rated 1,351 patients as having at least moderate depression and 368 as also having severe symptoms of hostility and explosiveness. They diagnosed bipolar disorder in 259 cases. The investigators analyzed records for 174 patients with complete records or who had at least moderate depression and severe symptoms of hostility and explosiveness but no signs of elation or euphoria at the time of admission.

Disruptive mood dysregulation disorder is marked by intense temper outbursts superimposed on a background of persistent depressed or irritable mood. Temper outbursts and aggression are common reasons for inpatient admissions of children and adolescents, Dr. Pogge noted in his poster presentation.

Compared with the 63% of patients who did not meet criteria for disruptive mood dysregulation disorder (DMDD), patients who met the DMDD criteria were significantly more likely to experience restraint or seclusion while hospitalized (30% vs. 20%), receive a significantly higher number of restraints or seclusions (2.2 vs. 0.8), and remain hospitalized significantly longer (25 days vs. 21 days), he reported. At the time of discharge, clinicians’ ratings on the Global Assessment of Functioning (GAF) scale indicated significantly greater global psychopathology in patients with DMDD (a mean GAF score of 44), compared with patients who did not meet DMDD criteria (a mean GAF score of 50).

The two groups did not differ significantly by age, clinician ratings of depression severity, or clinical ratings of global psychopathology at admission.

The study identified a subgroup of adolescent inpatients diagnosed with bipolar disorder without euphoric symptoms who exhibited explosiveness, hostility, and concurrent depression, comprising roughly a third of bipolar disorder diagnoses in the cohort. The findings suggest that these patients who lack signs of elevated mood and meet DMDD criteria routinely get diagnosed with bipolar I disorder, have a more problematic hospital stay, and have more symptoms at discharge, Dr. Pogge and his coinvestigators concluded.

The bipolar diagnoses might be incorrect, or there might be a substantial rate of comorbidity between DMDD and bipolar disease, he said.

The results also suggest that DMDD might be a common reason for psychiatric hospitalization of adolescents.

The study excluded patients whose records suggested other confounding factors or were missing any data on outcome measures.

Dr. Pogge reported having no relevant financial disclosures.

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