A comprehensive overview of bipolar disorder in children and adolescents. Bipolar symptoms, diagnosis and treatment.

Bipolar Defined

Bipolar disorder is a mood disorder in which feelings, thoughts, behaviors, and perceptions are altered within the context of episodes of mania and depression. Previously known as manic depression, bipolar disorder once was thought to occur rarely in youth. However, approximately 20% of adults with bipolar disorder had symptoms beginning in adolescence. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV TR), does not distinguish adult onset from childhood or adolescent onset of symptoms of bipolar disorder. Indeed, the diagnostic criterion for bipolar disorder is the same regardless of age of onset of symptoms. Despite clinically important differences in the way mood disorders may present in a child or adolescent, particularly behavioral differences, no diagnostic accommodation has been made based on age differences.

The DSM-IV TR uses universal symptoms to define the diagnostic criteria for mood episodes, including major depressive and manic episodes. One true manic episode, with or without psychotic features, is the necessary and sufficient criterion by which bipolar disorder is defined as type I. A depressive episode is insufficient for making this diagnosis, even in the presence of a strong family history of bipolar disorder. Type II bipolar disorder is diagnosed based on the presence of at least one hypomanic episode. Thus, bipolar disorders are viewed as a spectrum of symptoms that range from mild hypomania to the most extreme forms of mania, which may include life-threatening behaviors, dysphoria, and psychotic features.

The hallmark symptoms of mania include an abnormal, often expansive and elevated mood lasting for at least 1 week. Mania also may include a decreased need for sleep, racing thoughts or a sense that thoughts are "out of control," rapid and often pressured speech, increased goal-directed activities or projects, hypersexuality, reckless behaviors and risk taking, and "delusions of grandeur." Delusions associated with mania frequently center around an expansive sense of self that goes well beyond narcissism, for example, believing oneself to have special powers, such as supernatural powers, or believing oneself to be the chosen leader of the world or universe.

For some, the elevated and elated mood may transform into a state of dysphoria, during which agitated and irritable behaviors may develop. Cognitive impairment in mania may be exhibited as episodes of confusion during which the flight of ideas and disorganization of thought are present. Additionally, increased risk taking may involve endangerment of physical, emotional, or financial integrity. Moreover, poor insight into one's disorder or behaviors and poor judgment accompany mania; thus, financial accounts or important relationships may be in such disarray as to lead to many adverse outcomes, including loss of significant friends and family support or connections, serious financial setbacks, job loss, legal problems, and homelessness.

According to the DSM-IV TR, the criteria for a manic episode are as follows:

• The individual experiences a distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week (or any duration if hospitalization is necessary).
• During the period of mood disturbance, 3 or more of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree:
  • Inflated self-esteem to levels of grandiosity
  • Decreased need for sleep
  • More talkative than usual, often with pressured speech with a sense of necessity to keep talking
  • Flight of ideas or subjective feeling that thoughts are racing
  • Distractibility
  • Increase in goal-directed activity or psychomotor agitation
  • Excessive involvement in pleasurable activity that has a high potential for painful consequences (eg, hypersexuality, excessive spending, impetuous traveling)
• The symptoms do not meet criteria for a mixed episode.
• The mood disturbance is sufficiently severe to cause marked social impairment in occupational functioning, social activities, or relationships with others. Hospitalization may be necessary to prevent harm to self or others or if psychotic features are present.
• The symptoms are not due to the direct physiologic effects of a substance or a general medical condition.

Hypomania is somewhat similar to mania, but it is a much less severe and less debilitating mood state than true mania. As a less extreme mood state, hypomania is defined as an elevated mood during which (1) no hospitalization has ever been necessary and (2) no state of delusional or other psychotic thinking ever coincided with the elevated mood. Hypomanic and manic states must cause impairment of normal functioning to be considered pathologic states.

An abnormal behavioral episode may be designated a bipolar disorder after consideration of the frequency and type of abnormal mood. Thus, an episode may be reported as a bipolar disorder with a single manic episode, with recurrent manic episodes, or by the mood state of the most recent episode (eg, depressed, mixed, hypomanic, manic). Descriptors such as "with psychosis" or "without psychosis" are used to further clarify and reflect the severity of the state of the disorder.

Mood disturbances in children and adolescents are often more difficult to recognize and diagnose than those in adults. Some of the difficulty arises in recognizing atypical symptoms, including irritability, tantrums, physical aggression, and other behavioral problems, as expressions of mood disruptions. Perhaps this difficulty is best demonstrated in symptom recognition and proper, but controversial, diagnosis of bipolar disorder in youths. The classic symptoms of mania, including racing thoughts, pressured speech, hypersexuality, and grandiosity, more often match the presentation of bipolar disorder in late adolescence. In childhood- or prepubertal-onset bipolar disorder, such a classic cluster of symptoms is uncommon. Nonetheless, as early as 1921, Kraepelin reported that 38% of his 900 patients who experienced manic episodes had symptom onset when younger than 20 years, and 0.4% had onset of symptoms when younger than 10 years.

Despite Kraepelin's early observation and description of childhood-onset and adolescent-onset bipolar disorders, the controversy about diagnosing bipolar disorder in young persons persists. This is partially driven by the requirement of discrete episodes of disturbed mood in order to make the diagnosis of bipolar disorder. Unlike what is noted in adults, the presence of well-defined and discrete episodes of abnormal mood is often missing in children and adolescents affected by this disorder. Specifically, by the DSM-IV TR criteria, at least one discrete episode of mania or hypomania is necessary to make any bipolar disorder diagnosis.

Because no distinction is made for symptoms of adult-onset, adolescent-onset, and childhood-onset bipolar disorder, clinicians are challenged to distinguish abnormal mood symptoms in adolescents and children from normal developmental behaviors, oppositional or defiant behaviors, inattention or hyperactivity, and conduct problems. Childhood-onset bipolar disorder frequently has an insidious onset with affective storms that are often associated with the presentation of mental illness.

Frequency of Bipolar Disorder in Adolescents:

• In the US: The overall prevalence of bipolar I disorder in adolescents is approximately 1%, whereas the prevalence in children ranges from 0.2-0.4%.

Age of Onset for Bipolar Disorder:

• Most cases of bipolar disorder present in early adulthood in persons aged 20-30 years, but the second most common age group at presentation is those aged 15-19 years.

• In contrast to Kraepelin's report that 38% of his patients had onset when younger than 20 years, more recent estimates are that 20-30% of adults with bipolar I disorder experienced symptom onset when younger than 20 years. In addition, approximately 20% of youths in whom a major depressive disorder has been previously diagnosed develop symptoms consistent with a manic state at a later age. Thus, an adolescent or child who initially presents with depression may have a hidden bipolar disorder that becomes obvious later in life.

• Childhood onset of bipolar symptoms may have a more severe, chronic, and refractory course of illness than later onset of symptoms of bipolar disorder. In addition, early onset of bipolar symptoms seems to be associated with increased risk of mixed mood states (combined symptoms of depression and mania simultaneously) and rapid cycling (³3 episodes of mania in 1 y).

Source:

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC:. American Psychiatric Association;2000.

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