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Not all mood swings are bipolar disorder

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How to evaluate children with mood lability



M, age 13, is referred by her pediatrician with the chief complaint of “severe mood swings, rule out bipolar disorder (BD).” In the past she was treated for attention-deficit/hyperactivity disorder (ADHD) with stimulants with mixed results. M’s parents are concerned about her “flipping out” whenever she is asked to do something she does not want to do. Her mother has a history of depression and anxiety; her father had a “drinking problem.” There is no history of BD in her first- or second-degree relatives. Are M’s rapid mood swings a sign of BD or another disorder?

The differential diagnosis of “mood swings” is important because they are a common presenting symptom of many children and adolescents with mood and behavioral disorders. Mood swings often occur in children and adolescents with ADHD, oppositional defiant disorder (ODD), developmental disorders, depressive disorders, BD, anxiety disorders, and conduct disorders. Mood swings are analogous to a fever in pediatrics—they indicate something potentially is wrong with the patient, but are not diagnostic as an isolated symptom.

Mood swings in children are common, nonspecific symptoms that more often are a sign of anxiety or behavioral disorders than BD. This article discusses the differential diagnosis of mood swings in children and adolescents and how to best screen and diagnose these patients.

What are ‘mood swings’?

Mood swings is a popular term that is nonspecific and not part of DSM-IV-TR diagnostic criteria for BD. The complaint of “mood swings” may reflect severe mood lability of pediatric patients with BD. This mood lability is best described by the Kiddie-Mania Rating Scale (K-MRS) developed by Axelson and colleagues as “rapid mood variation with several mood states within a brief period of time which appears internally driven without regard to the circumstance.”1 On K-MRS mood lability items, children with mania typically score:

  • Moderate—many mood changes throughout the day, can vary from elevated mood to anger to sadness within a few hours; changes in mood are clearly out of proportion to circumstances and cause impairment in functioning
  • Severe—rapid mood swings nearly all of the time, with mood intensity greatly out of proportion to circumstances
  • Extreme—constant, explosive variability in mood, several mood changes occurring within minutes, difficult to identify a particular mood, changes in mood radically out of proportion to circumstances.

Patients with BD typically exhibit what is best described as a “mood cycle”—a pronounced shift in mood and energy from 1 extreme to another.2 An example of this would be a child who wakes up with extreme silliness, high energy, and intrusive behavior that persists for several hours and then later in the day becomes sad, depressed, and suicidal with no precipitant for either mood cycle. BD patients also will exhibit other symptoms of mania during these mood cycling periods.

Rapid cycling is a DSM-IV course specifier that indicates ≥4 mood episodes per year in patients with BD with a typical course of mania or hypomania followed by depression, or vice versa.3 The episodes must be demarcated by full or partial remission that lasts ≥2 months or by a switch to a mood state of opposite polarity. In the past, children with frequent mood swings were described incorrectly as “rapid cycling,” but this term has been dropped because it engenders confusion between adult and pediatric BD phenomenology.2

A more precise method of describing mood symptoms in a child or adolescent is to use the FIND criteria, which include:4

  • Frequency of symptoms per week
  • Intensity of mood symptoms
  • Number of mood cycles per day
  • Duration of symptoms per day.

Visit this article at CurrentPsychiatry.com to view a table that outlines what to look for when using the FIND criteria to evaluate common pediatric psychiatric disorders that include mood swings. Table 1
describes clinical characteristics and tools and resources used to differentiate these and other disorders.4

Table 1

Clinical characteristics of psychiatric disorders that often feature mood swings

DisorderClinical descriptionUseful tools/resources
ADHDChronic symptoms of hyperactivity, distractibility, impulsivity, poor attentional skills, disorganizationConners’ Parent Rating Scale-Revised: Long Form (CPRS-R:L)
ODDChronic symptoms of oppositionality, negativity; short, frequent mood swings in response to being asked to do something they do not want to doCPRS-R:L
Anxiety disordersExcessive ‘worry,’ difficulty with transitions, increased mood swings during stressful periods, psychosomatic symptomsSelf-Report for Childhood Anxiety Related Disorders
ARNDHistory of exposure to alcohol in-utero; mild dysmorphia, attentional, mood, and executive functioning problemsNational Organization on Fetal Alcohol Syndrome
Bipolar disorderIn children: clustering together of episodes or ‘mini-episodes’ (several days) of increased energy, decreased need for sleep, increased mood cycling, pressured speech, etc. In adolescents: depressive episodes with episodes of hypomania or maniaMood Disorders Questionnaire Kiddie Schedule for Affective Disorders and Schizophrenia Mania Rating Scale
ADHD: attention-deficit/hyperactivity disorder; ARND: alcohol-related neurodevelopmental disorder; ODD: oppositional defiant disorder
Source: Reference 4


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