How can you be sure your child has bipolar disorder? Symptoms of bipolar can overlap with ADHD, Anxiety Disorders, Conduct Disorder, even Schizophrenia.

Symptoms of Bipolar Overlap Other Psychiatric Disorders

On presentation to health care services, children with bipolar disorder exhibit behaviors that mimic and overlap other diagnoses. The overlap of bipolar symptoms with symptoms of ADHD and conduct disorder (CD) is significant. Specifically, as with patients with bipolar disorder, activity is increased and self-esteem may be inflated in the early stages of ADHD and CD. Societal and educational responses to the behaviors of ADHD and Conduct Disorder ultimately may result in reduced self-esteem in these patients compared to those with bipolar disorder. Many other features of bipolar disorder compared to ADHD and CD are further described in Table 2, which may help to compare and contrast the clinical features of these 3 important disorders that impact young individuals.

Table 2. Differential Diagnosis Considerations

Additional consideration must be given to the possibility of the existence of schizophrenia or schizoaffective disorder, posttraumatic stress disorder (PTSD), substance abuse, or anxiety states (eg, generalized anxiety disorder, social anxiety disorder) because any of these disorders may transiently mimic bipolar disorder. Rarely is dementia an issue in youths, but this may need to be excluded in some patients (particularly after head trauma).

Comorbidity

Biederman et al (Biederman, Arch Gen Psychiatry, 1996) noted that the combination of CD and major depression in adolescence could be predictive of bipolar disorder in a 4-year follow-up assessment of those patients. An estimated 10-15% of adolescents who present with recurrent episodes of major depression later are given the diagnosis of bipolar disorder. Also, children with ADHD who later develop bipolar disorder have increased rates of other psychiatric conditions, including opposition defiant disorder (ODD). Overall, the combined symptoms of severe ADHD, unstable affect, and aggression may be predictive of bipolar disorder later in life for children in whom ADHD is already diagnosed.

Biederman reports that an important predictor of bipolar disorder in youth involved in his study is the presence of disruptive behavior disorder (DBD). Specifically, his research suggests that the combination of ADHD with ODD, as compared to ADHD alone, correlates to future onset of bipolar symptoms at rates of 7% and 5%, respectively. However, when ADHD with ODD is present but later ODD progresses to CD, the rate of occurrence of bipolar disorder dramatically increases to 44%. Obviously, this means that approximately 55% of adolescents who have a diagnosis of comorbid ADHD, ODD, and CD do not experience onset of bipolar symptoms. Nonetheless, one potential complication to note in youths who have comorbid ADHD and ODD is the development of bipolar features, including depression and psychosis. Also, the combination of ADHD and ODD increases the risk of involvement in legal activities and incarceration. Thus, bipolar symptoms already exist or may develop in some incarcerated youths.

Kovacs and Polack (1995) performed a prospective study of 26 prepubertal youths with onset of bipolar disorder and CD when aged 8-13 years. In a 12-year follow-up evaluation, they discovered that the lifetime comorbidity for these 2 disorders was 69%. Additional review of the pattern of psychiatric pathology revealed that, of those who had onset of both disorders when younger than 13 years, CD had been diagnosed first in 42%, whereas bipolar disorder had been diagnosed first in 27%.

Because clinicians often are concerned that CD carries an increased risk of development of antisocial personality disorder, the data suggest that careful screening and monitoring for the comorbid conditions of bipolar disorder and CD may be necessary in youth who present with either of these disorders. Such screening may help to identify and treat these youths so they may avoid the risk of incarceration and perhaps erroneous labeling as antisocial adults rather than individuals with coexisting bipolar disorder and CD. Another commonly observed comorbid diagnosis in youths with bipolar disorder is ADHD. Among prepubertal youths presenting with bipolar symptoms, nearly 90% have a diagnosis of ADHD; among adolescents, about 30% have ADHD (Geller, 1997). In summary, sustained symptoms of conduct and impulse control problems may be warning signs of prepubertal onset of bipolar disorder.

Incarcerated youths have a disproportionately higher prevalence of bipolar disorders compared to youths in the general population. Recent studies by Steiner (2000) estimate that 2% of incarcerated juveniles have bipolar I disorder, whereas 4% have bipolar II disorder.

Sources:

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC:. American Psychiatric Association;2000.
• Biederman J, Faraone S, Milberger S, et al. A prospective 4-year follow-up study of attention-deficit hyperactivity and related disorders. Arch Gen Psychiatry. May 1996;53(5):437-46.
• Biederman J, Faraone S, Mick E, et al. Attention-deficit hyperactivity disorder and juvenile mania: an overlooked comorbidity?. J Am Acad Child Adolesc Psychiatry. Aug 1996;35(8):997-1008.
• Faraone SV, Biederman J, Wozniak J, et al. Is comorbidity with ADHD a marker for juvenile-onset mania?. J Am Acad Child Adolesc Psychiatry. Aug 1997;36(8):1046-55.
• Kovacs M, Pollock M. Bipolar disorder and comorbid conduct disorder in childhood and adolescence. J Am Acad Child Adolesc Psychiatry. Jun 1995;34(6):715-23.
• Geller B, Luby J. Child and adolescent bipolar disorder: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. Sep 1997;36(9):1168-76.

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