Stephanie E. Meyer, Ph.D., and Gabrielle A. Carlson, M.D.
Correspondence: Address correspondence to Stephanie E. Meyer, Ph.D., Division of Child and Adolescent Psychiatry, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians W101, Los Angeles, CA 90048; e-mail: Stephanie.Meyer@cshs.org
….Distinguishing between mania and other conditions of childhood is complicated by overlapping symptoms and by the confounding influences of development itself. At the center of the debate regarding symptom overlap has been a focus on differentiating between symptoms of ADHD and mania (41, 42).
At this point, several studies have shown that these two conditions are distinct and separable (32, 43). However, in practice, mental health professionals may continue to struggle with the question of how to categorize certain behaviors. Indeed, a detailed history and symptom ascertainment are often required to distinguish between the disinhibited silliness of a child with ADHD and the euphoric mood associated with mania. Similarly, impulsivity can closely resemble the pleasure-seeking behaviors of mania, and resistance to bedtime must be distinguished from decreased need for sleep (see reference 4 for a review).
There is some question as to whether rage episodes may be diagnostic of bipolar disorder in youth (15). Although it is true that rages can occur in manic individuals of any age, as an isolated symptom explosive irritability (presumably the affect underlying rage episodes) is common in a variety of childhood conditions and thus has poor discriminatory power (32).
Therefore, although parents often refer to rages as “mood swings,” these should not be interpreted as sufficient evidence of a manic episode. Indeed, Mick et al. (16) found that although extreme explosiveness or “super” angry/grouchy/cranky irritability was common among children with mania, the majority of youth exhibiting these behaviors did not meet the full diagnostic criteria for a bipolar spectrum condition. Similarly, G. A. Carlson et al. (unpublished 2008 data) conducted a pilot study of children referred specifically to “rule out bipolar disorder” (N=33) and found that those youth with the most severe rage episodes (N=8) were a diagnostically heterogeneous group, with 25% meeting the criteria for mania with comorbid ADHD, 25% meeting the criteria for major depressive disorder with comorbid ADHD, 25% with pervasive developmental disorder not otherwise specified and ADHD, and 25% with pervasive developmental disorder not otherwise specified and major depressive disorder.
The issue of differential diagnosis of pediatric bipolar disorder is further complicated by the fact that affective and behavioral symptoms may be exacerbated by the emergence of new developmental demands and changing circumstances. Indeed, children with attention or learning challenges may begin to look increasingly dysregulated with the heightened demands of late elementary or middle school.
Similarly, irritability may intensify in conjunction with increasing environmental challenges, such as difficulties with family and peer relationships. Moreover, symptoms similar to pediatric mania have been found among maltreated children (reviewed in reference 4), and therefore clinicians may struggle to determine whether presenting behaviors are sequelae of the abuse, symptoms of an emerging bipolar disorder, or both. In adolescents with severe psychotic symptoms, schizophrenia and substance-induced psychosis must be considered.
Detailed information regarding history and longitudinal course of symptoms is necessary to distinguish such behavioral changes from the onset of a true mood disorder. In many instances, diagnostic clarity may only come with extended longitudinal follow-up.
The DSM-IV-TR distinguishes among four bipolar phenotypes.
Bipolar I disorder is the most severe, requiring the presence of at least one manic or mixed episode. Depressive episodes are not required for a diagnosis of bipolar I disorder but are usually present.
Bipolar II disorder is defined by a history of one or more major depressive episodes and at least one hypomanic episode.
Cyclothymic disorder involves chronic and variable symptoms of hypomania and depression and is believed to represent a “temperamental predisposition” to more severe forms of bipolar disorder.
Bipolar disorder not otherwise specified is diagnosed when mood symptoms are insufficient in number and/or duration to meet full criteria. The DSM-IV-TR also provides a series of specifiers for making a diagnosis of bipolar disorder, which characterize the illness in terms of severity and chronicity, seasonal patterns, and rapid cycling.
Symptom patterns in youth with bipolar disorder often do not resemble the episodic nature of bipolar disorder in adults as it has been classically described (13). According to McClellan et al. (14), the most common presentation among youth with bipolar disorder in community settings is characterized by “outbursts of mood lability, irritability, reckless behavior, and aggression.” Shifts in mood state are short-lived (15), and irritability, rather than euphoria, tends to be the predominant and most impairing mood state (16).