By: Marie Huang
The amphitheater at Nassau University Medical Center fills up slowly as Dr. Alan Jay Cohen, a psychiatrist from Oakland, California, makes his way up to the podium to lead a talk about bipolar disorder, specifically differentiating between its presentations in adults versus in developing children.
Among nonprofessionals, bipolar disorder is simply a psychiatric disorder characterized by drastic changes of the mood or “mood swings.” The infamous symptoms of rapid cycling between mania and depression, when viewed in an adult, automatically give physicians and the layperson alike the impression that the patient is bipolar. Oftentimes, this becomes the final diagnosis, and the patient takes a mood stabilizer, like lithium, to modify the reuptake of certain neurotransmitters (causing this constant flux in personality). However, despite popular belief, bipolar disorder is not as easy to diagnose and treat. Other comorbidities often exist alongside, and, like any other disorder or disease, need to meet criteria for diagnosis. It is important to note that the disorder even shares many of the same features as attention-deficit/hyperactivity disorder (ADHD); so, it is essential that psychiatrists perform a differential diagnosis to rule out, or in, alternative personality disorders.
With the publication of the text revision for DSM-IV in 2000, one would expect it to include clear-cut criteria for the diagnosis of mania in children and adolescents. Come DSM-V (expected release is later this year), it is likely that the criteria will still not be included. So, could we apply same adult criteria to children?
Dr. Cohen comments that the characteristics of manic episodes seen in adults may vary widely and even be absent in children and adolescents.
In adults, the disorder has conveniently numbered subtypes, known as Bipolar Disorder I, Bipolar Disorder II, and Bipolar Disorder Not Otherwise Specified (NOS). “Bipolar Disorder I” is known to contain a flux of mixed and manic episodes, where depression may be absent. Bipolar Disorder II presents with a constant cycling between hypomania and depression, where mania may be absent. Bipolar Disorder NOS is a category in which most pediatric patients fall in because they may not always present with the same symptoms that make it easy to categorize them into the other subtypes (more suitable for adults). This subtype is a “subthreshold bipolar disorder,” and requires further mood monitoring.
As mentioned, without formal criteria for mania in children, pediatric psychiatrists utilize the same benchmarks for adults. They somehow tweak these for their young patients. For adults, a manic episode, by definition, is a distinct period of abnormality, where the patient is in “a persistently elevated or irritable mood that lasts at least a week or any duration if hospitalization is necessary.” This elevated mood is “silly” because the patient will appear very jubilant, despite bad news and incidents (which do not typically call for excitement or happiness). If the patient meets three of more of the following symptoms, a diagnosis for mania is proper: inflated self-esteem/grandiosity, decreased need for sleep, distractibility, pressure to keep talking, racing thoughts, excessive involvement in pleasurable activity, and/or increased goal-directed productivity.
One should not confuse manic episodes with those of hypomania, which happens to share many of the same characteristics but with decreased severity. In hypomania, the criteria for adults focus mainly on the duration of the episode and not so much on its mood. It is a distinct period of persistently elevated or irritable mood lasting at least 4 days. Symptoms are very similar to those of a manic episode, but are not “serious enough” to require hospital admission. Here, the euphoric mood does not necessarily interfere with daily performance or productivity. In fact, it may drastically increase goal-directed productivity and focus, which the patient will most likely see as a benefit. As time goes on and the patient is continually hypomanic, hypomania may transform into mania, where racing thoughts suddenly become too much to handle.
On the opposite side of the spectrum lies the major depressive episodes, specifically defined as distinct periods of depression where the patient is “down in the dumps” most of the day and nearly every day. A firm diagnosis of this episode in adults must meet five or more symptoms listed in DSM-IV over a two-week period. These symptoms are, of course, popularly associated with major depressive disorder, and include fatigue, significant weight loss (due to loss of appetite), feelings of guilt and worthlessness, insomnia, loss of interest in pastimes, and suicidal ideations.
Dr. Cohen mentions that many children may not display the common signs of depression, but, instead, exhibit heavily irritable moods with no cause. It is vital not to jump to conclusions to categorize mood episodes, especially the major depressive. Always ask the patient what exactly provoked them to determine whether the child/adolescent (or adult) has a legitimate reason to be dwelling in that mood. Do not assume that the patient has bipolar disorder because he/she has apparent mood swings. Always access the flipside, determine what type of episode the patient cycles between, and determine whether there is a reason for the changes. Doing so may prevent erroneous diagnoses and unnecessary treatment.
In children, causeless, frequent mood changes are the “pediatric bipolar pattern.” Although youngsters who exhibit this pattern have bipolar disorder, they do not exactly meet the criteria for manic/hypomanic/depressive episodes, and do not present with distinct mood swings. Therefore, many are under the Bipolar Disorder NOS subtype. As previously mentioned, it is important that the psychiatrist check for other possible comorbidities and clearly differentiate between symptoms of ADHD and bipolar disorder. Both, ADHD and bipolar patients may display irritability, hyperactivity, and distractibility.
To diagnose bipolar disorder, there are two sets of cardinal symptoms to note. Cardinal symptoms I include extreme mood liability, grandiose behaviors, and mania. Parents often feel as if they are “tiptoeing around their own house” or “walking on egg shells” when it comes to trying not to set off the belligerent and irritable moods of their children. Cardinal symptoms II include sleep disturbances and often-dangerous thrill-seeking behavior.
In order to differentiate between the subtypes and ADHD, parents ought to keep a diary to chart the moods of their child. Tools that also aid in diagnosis involve clinical assessment components. These include patient/parent interviews, school observations, and mood rating scales. The acronym, FIND, which stands for Frequency (How often?), Intensity (How strongly?), Number (How much?), and Duration (How long?), will allow the psychiatrist to obtain a more complete picture of the disorder as it pertains to the child. Like every disease, family history may play a significant role and needs consideration.
Mainstay treatments of bipolar disorder usually include one or two mood stabilizers and a second-generation antipsychotic (with or without the presence of psychosis). Briefly, useful mood stabilizers include lithium, topiramate, lamotrigine, gabapentin, and oxcarbazepine. Atypical antipsychotics, with some evidence in the management of the disorder, include olanzapine, risperidone, and clozapine. Although antipsychotics decrease aggressiveness and agitation, they have sedating properties and may cognitively impair the patient, which proves to be a huge disadvantage in children. There have been no placebo-controlled trials to determine an optimal treatment plan, most likely due to ethical violations that are associated with simply giving a placebo to a child who is quite literally “out of his mind.” Despite promising results, it is common to witness the relapse of bipolar symptoms in a patient who had once been mood stabilized by medication. The fast physiological development of children and adolescents explains these high rates of relapse. Regardless, family support has a positive effect on the child’s condition while these medications take four to eight months to show maximum effect.
Although DSM-IV does not paint a full picture of bipolar disorder in children and adolescents, many psychiatrists utilize other criteria that have been put together to set a suitable benchmark for diagnosis in youngsters.
In conclusion, as with everything else in the medical field, bipolar disorder requires case-by-case assessment. It may present itself very differently in children as opposed to adults, and by close mood monitoring and an eye for key symptoms, one can properly diagnose this disorder in children. This leads to proper management and treatment of, what is undoubtedly, a very complicated disease state.
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: Author.
- Leibenluft, Ellen. (2008). Pediatric Bipolar Disorder. FOCUS: The Journal of Lifelong Learning in Psychiatry, Volume 6, 331-347.
- The Balanced Mind Foundation. (Updated July 18, 2011). About Pediatric Bipolar Disorder. Retrieved March 10, 2012, from http://www.thebalancedmind.org/learn/library/about-pediatric-bipolar-disorder.