This excerpt is taken from the 2nd addition, 2007 two volume, 1000-page (with additional appendix and references) Manic-Depressive Illness – Bipolar Disorders and Recurrent Depression by Frederick Goodwin and Kay Redfield Jamison.
(Still available on Amazon or your nearest medical school library)
This reference text is an exhaustive review of the psychiatric literature prior to 2007 focused on mood illnesses. It should have been the primary teaching basis for all psychiatric residencies; however, it probably was not. It addresses the long-standing bias in the field of minimizing and discouraging the diagnosis of child and adolescent bipolar illness even when first- or second-degree relatives have that diagnosis.
Subsequently in 2010 a study indicated “Heritability summary estimates were as follows: bipolar disorder (85%), schizophrenia (81%), Alzheimer’s disease (75%), cocaine use disorder (72%), anorexia nervosa (60%), alcohol dependence (56%), sedative use disorder (51%), cannabis use disorder (48%), panic disorder (43%), stimulant use disorder (40%), major depressive disorder (37%), and generalized anxiety disorder (28%).” (O. J. Bienvenu, et.al., Psychiatric ‘diseases’ versus behavioral disorders and degree of genetic influence. Published online by Cambridge University Press: 12 May 2010)
Yet when I review charts for children and adolescents in a hospital setting, if a family history is even documented, and a relative is said to have a bipolar diagnosis, it appears to have no influence on the child’s diagnosis or even a mention in a differential diagnosis. Instead, the various “off ramps” built into the DSM intended to divert clinicians away from a bipolar diagnosis are uses such as Oppositional Disorder, Conduct Disorder, Intermittent Explosive disorder, Unspecified or Other Disruptive, Impulsive-Control and Conduct disorders and the most recent entry in the DSM-5, as if the preceding weren’t enough, of Disruptive Mood Dysregulation Disorder (a mouth full) commonly recorded in chart as DMDD. The overlap in criteria of Bipolar and ADHD and their non-comorbidity were discussed in a prior blog.
Regarding DMDD several articles were published in the run up to the publication of DSM-5 questioning its validity including:
“In this clinical sample, DMDD could not be delimited from oppositional defiant disorder and conduct disorder, had limited diagnostic stability, and was not associated with current, future-onset, or parental history of mood or anxiety disorders. These findings raise concerns about the diagnostic utility of DMDD in clinical populations.” David Axelson et.al. Examining the proposed disruptive mood dysregulation disorder diagnosis in children in the Longitudinal Assessment of Manic Symptoms study, J Clin Psychiatry 2012 Oct;73(10)
“The proposed addition of disruptive mood dysregulation disorder (DMDD) to the DSM-V  could potentially lead to confusion with regard to cyclothymic disorder. DMDD and its predecessors, severe mood dysregulation disorder and temper dysregulation disorder with dysphoria, are based on limited data and have significant symptom overlap with other childhood disorders. Specifically, irritable mood with temper outbursts is the primary criterion for DMDD and irritable mood can be the primary symptom of mania seen in cyclothymic disorder.” Anna R Van Meter and Eric A Youngstrom. Cyclothymic disorder in youth: why is it overlooked, what do we know and where is the field headed? Neuropsychiatry (London). 2012 December 1; 2(6): 509–519.
“In summary, we strongly disagree with the inclusion of TDD as a new formal diagnosis in the DSM-5. The level of scientific evidence to support TDD is too limited to justify a new diagnostic entity.” David A. Axelson, et. al. Concerns Regarding the Inclusion of Temper Dysregulation Disorder with Dysphoria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Clin Psychiatry. 2011 September; 72(9): 1257–1262
A fuller awareness of the literature in this area could, as documented in the following excerpt, could go a long way to clarify misunderstandings and lessening the anti-bipolar bias in children and adolescents.
Chapter 6 – Children and Adolescents
From Goodwin & Jamison
In rare cases the first beginnings can be traced back even to before the 10th year…. The greatest frequency of first attacks falls, however, in the period of development with its increased emotional excitability between the 15th and 20th year.
Emil Kraepelin (1921 p. 167)
(Please take note of the sections regarding age of onset and course, essential diagnostic validators generally not taught in training programs and which were not included in any DSMs to the present as diagnostic criteria. Their absence is another example of how the DSM does not adhere to a medical model).
Bipolar disorder commonly manifests itself in adolescence or young adulthood, but classic descriptions and numerous studies also demonstrate the existence of the disorder in children. In recent years the identification of these earliest forms has been the subject of an explosion of interest among clinicians, scientists, the public and the media. The interest is driven in part by the emerging hypothesis of bipolar disorder as a progressive neurobiological process that may worsen with succeeding episodes, so that early identification and treatment may have important implications fort attenuating the course of illness. Increasing, moreover parents are seeking answers and help for their children who display bewildering or overwhelmingly severe symptoms and are at increased risk for serious behavioral, as well as suicide, (Hellander and Burke 1999, Lewinsohn 2003).
Aside from treatment considerations, childhood-onset bipolar disorder also raises important conceptual and etiological questions:
- Are there differing subtypes with different causes and courses?
- What are the defining distinctions between pediatric Bipolar illness and other psychiatric disorders such as ADHD?
- Is the rate of childhood bipolar disorder increasing and if so, why?
- Is the course of the disorder different from early versions of adult onset?
Although this book is about Manic-Depressive Illness, which includes both bipolar and recurrent unipolar forms, the pediatric literature rarely distinguishes recurrent from nonrecurrent forms of unipolar depression; this chapter limits itself to the bipolar subgroup.
We begin with a review of research on childhood and adolescent bipolar disorder. We then explain the epidemiology and implication of bipolar disorder in these populations. Finally, we present the findings of studies of high-risk subjects that have attempted to identify characteristics of children of bipolar parents., with particular emphasis on early markers of potential bipolar illness. Unfortunately, many unresolved issues remain. the interest in manifestations of bipolar disorder in children and young adults is far greater than the yield from research addressing the key to the questions involved.
Throughout the discussion we attempt to identify problems with the methods used in existing studies, as well as research needed to address important issues. One of the many pervasive difficulties stems from the failure of many studies to distinguish between childhood and adolescent onset bipolar disorder; this occurs for example when vague terms such as “juvenile onset bipolar disorder” and pediatric bipolar disorder are used or when child and adolescent samples are combined in the same study.
This is a widespread problem in the study of adolescent bipolar disorder, where distinctions are seldom made between child and adolescent onset. some studies of adolescents with bipolar disorder include patients whose symptoms actually first occurs before age 12 or before puberty. As detailed in chapter 4 (Clinical Studies course outcome and epidemiology), age of onset is also defined differentially in various studies–for example, at age at first diagnosable symptoms of mania or at first symptoms of any affective disorder, or age at onset of first actual diagnosis of mania or depression by a mental health professional.
Studies have employed different diagnostic criteria as well, and many have included clinical populations with a mix of Bipolar I and other bipolar spectrum disorders, despite the fact that there is very little information specifically on Bipolar II in children or adolescents. (See chapter 3—Diagnosis). Finally, one of the greatest methodological gaps is the paucity of longitudinal studies of either childhood or adolescent bipolar disorders. Such studies are essential to clarify diagnostic controversies and to map the course of the disorder and the implications of its early onset.
Childhood Onset Bipolar Disorder
Although occurrences of mania and depression in adolescence are well established, the frequency of early childhood onset of bipolar disorder remains controversial. Kraepelin 1921 found 0.4% of his patients had displayed manic features before age 10.
Despite historical records of cases documenting apparent bipolar illness in children however, theorists believed for an extended period of time in the mid-twentieth century, that bipolar disorder in children before puberty was not possible. For instance, Anthony and Scott examined psychiatric literature from 1884 to 1954 and uncovered only 28 cases of alleged manic episodes in young children.
After applying systemic diagnostic criteria to these clinical reports, they dismiss all the cases as misdiagnosed and concludes that a classic presentation on MDI in childhood had yet to be determined.
Recent years have shown a growing acceptance that pubertal forms of mania can be identified. Opinions range from certainty that characteristic patterns of symptoms signal childhood bipolar disorder in substantial numbers, even if in a form that may not precisely follow that of classical forms of the disorder, to more cautious views that prepubertal mania exists, but that many such complex cases may be misinterpreted as bipolar disorder.
Difficulty in applying the adult criteria for bipolar disorder using the DSM to children is at the heart of the controversy. In the following sections we present research on characteristics of bipolar disorder in children and discuss the controversies related to diagnosis.
Symptoms and Clinical Presentation – Manic Features
The appearance and diagnosis of mania is considered to be a distinctive indicator of bipolar disorder in children. However, the diagnosis of mania in children in controversial and fraught with pitfalls. as reviewed below.
Even as young as preschool age, some children appear to present relatively classic manic symptoms, including. DSM defined mania or hypomania with elated mood or grandiosity; flight of ideas or racing thoughts; poor judgment and excessive silliness, uninhibited people seeking, hypersexuality, or dare devil acts, talking fast; and distractibility, with increased energy, activity and agitation. (Geller 2000 and 2002).
In their study of 93 children with prepubertal and early-adolescent onset of bipolar disorder (mean age onset of 7.3 years) Geller and colleagues found that five manic specific symptoms were especially likely to discriminate bipolar children from ADHD or normal comparison groups:
- flight of ideas/racing thoughts
- decreased need for sleep
See table 6.1 p. 189
Geller and colleagues, 2002c also found that 60 % of their sample had symptoms of psychosis, including 50 % with grandiose delusions. In a later follow up study, they found that psychosis predicted more weeks ill with mania or hypomania, 2004.
In their review of psychotic symptoms in pediatric bipolar disorder, Pavuluri 2004, found the prevalence of psychotic features ranges from 16-88%; most common were mood congruent delusions, especially the grandiose type.
Biederman 2004 found that nearly 1 in 4 of the 298 bipolar patients they studied were psychotic or had a history of psychosis. Likewise in their study of 263 bipolar children and adolescents, Birmahr 2005 found one third of their subjects had a history of psychosis.
Geller and colleagues required elation or grandiosity for the diagnosis of mania in children as did Leibenluft 2003. This is an important if sill preliminary, consensus of clinical researchers, although as Carlson 2005 pointed our uncertainty remains as to what constitutes these two symptoms.
Methods of assessment vary widely as so cultural expectations and developmental factors, and all are likely to influence the assessment of euphoria and grandiosity. Some studies have defined mania by the presence of highly labile moods with intense irritability, rage, explosiveness and destructiveness; extreme agitation and behavioral dysregulation.
Irritability and rage are noted as prominent features in many bipolar children.
The children are often aggressive and are frequently described by their parents as “out of control”. Not surprisingly they are often seen in hospital settings, and their overall functioning is marked by severe impairment in social and academic as well as family roles. Suicidal thoughts and behaviors are not uncommon.
In Part II the following will be covered
- Depressive Features
- Diagnostic Controversies
- Comorbidity and Indistinct diagnostic boundaries.
- Questions about the validity of the diagnosis of mania in children