ADOLESCENT-CHILD BIPOLAR DISORDER
I would like to address aspects of Bipolar Disorder and treatment options. I have done research as
well as have clinical experiences involving patients with Bipolar Disorder. These patients include
children as well as adults who can trace their symptoms to early childhood.
Early diagnosis and treatment of Bipolar Disorder with lithium or valproic acid have proven to have
the effect of repairing both discrete brain circuitry and specific regions of the brain. Deterioration of
the brain continues without complete treatment. The good news is that starting treatment with
lithium or valproic acid can have reparative brain ( neurotropic) effects at any age.
Some clinical experiences are presented in case studies of four patients.
1) Bill
Identification: Patient seen from age 12 to age 17, between the years of 1988 and 2000.
Presenting symptoms: Incredibly disruptive at school, destructive, grandiose, obsessive
compulsive, agitated, and violent. History of thefts. He took things apart incessantly-the refrigerator,
the stove, the toaster. Prior to my care he was admitted fifteen times to psychiatric hospitalizations,
Bill had repeated involvement with juvenile justice system. The school system made numerous
individualized educational plans( IEP) to accommodate his educational needs. Bill came to
appointments in costume: as a businessman, a cowboy, a doctor, a policeman, etc.
Medications: monotherapy with lithium, valproate, carbamazepine, and Zyprexa -- with no success.
The combination of any two mood stabilizers was unsuccessful.
After various combinations of three to five medications at a time, no more than 50% efficacy was
achieved in terms of activities of daily living (ADLS), occupational and social functioning. The patient
was placed on clozapine 75 milligrams twice a day and dextroamphetamine 20 milligrams in the
morning. He had no further hospitalizations, after hours crises, or emergency appointments. The
patient was mainstreamed within three months for the first time since he had entered elementary
school.
2) Cindy
Identification: 40 years old with no known history of Bipolar Disorder in the family.
Presenting symptoms: depression, avoided contact with others, irritable.
Cindy elected to begin treatment with psychotherapy twice a week for the next three years. During the
sessions, she complained of lack of manic periods that she felt fueled her creativity. She was an
artist and musician. She remembers having manic periods as early as third grade as well as
seasonal depression in the midwinter (February and March); even though she was very successful
in high school. By the age of thirty, she had periods of depression more common than manic
periods. At age forty, she started to have periods of irritability.
The patient came to me hoping to recapture periods of manic feelings. I started her on Depakote.
Cindy found that it stabilized her mood, but she also incurred a 40 pound weight gain and Hair
loss(alopecia). So, valproate swapped out for lithium and the patient felt slightly depressed.
Synthroid added for hypothyroidism. After adding Synthroid, I switched back to Depakote ER, the
extended release tablet. The patient stabilized at a mildly depressed state. Lamictal titrated
upwards to 150 milligrams twice a day with excellent results and no breakthrough episodes with the
next six years of follow-up appointments.
3) Jennifer
Identification: nineteen year old Gothic Caucasian, female with few female friends.
Family History: father diagnosed with Bipolar I Disorder and Attention Deficit/Hyperactivity Disorder
Presenting Symptoms: depressed and irritable, dressed in baggy pants and formless sweatshirts,
polysubstance dependence, chain smoking. Jennifer's only activities: playing video games and
promiscuity. Patient combative at home, at school and with lovers. During the psychotherapy process
patient initially diagnosed with Attention Deficit/Hyperactivity Disorder and treated with Dexedrine.
She showed a huge improvement in her appearance and in her aggressive, angry demeanor. She
transformed into a strikingly attractive woman. Patient was intelligent and capable as a computer
technician.
In later psychotherapy sessions she revealed problems maintaining a job and blowing up with
employers. Jennifer misused the Dexedrine and did not take the psychostimulant steadily. The
patient was rediagnosed with Bipolar I Disorder and ADHD. Lithium and Lamictal added to her
Dexedrine with much better coverage of her lingering impulsivity and verbal aggression. Following
this change, the patient had obtained a high level position at a large bank.
4) Sally
Identification: a psychologist well respected as a colleague and a community member.
Presenting symptoms: depression and anxiety, cross-dressing.
After three years in psychotherapy, the patient confessed to horrific and sustained sexual violence by
numerous people including her biological father and mother for whom she maintained the utmost
respect. After revealing details of her parents' ritualistic sexual abuse Sally hospitalized for the first
time and discovered to be a severe alcoholic. One to two weekly psychotherapy sessions with use
of psychodrama and hypnosis for relaxation occurred for the next 5 years.
There was no further substance abuse. Gradually the chaotic presentation cleared so that the
diagnosis of Bipolar Disorder was made. The patient admitted that she knew she was Bipolar from
age 6. She was treated with Risperdal daily; and for nightmares on an as needed basis. Depakote
was used for the accompanying anxiety to her difficulty to internally modulate both her mood and
anxiety.. Lamictal titrated to 200mg twice a day stabilized her mood for perpetuity.
During the last two years that the patient was seen she divorced and remarried.
New Developments in the Study of Bipolar Disorder
It remains to be determined whether the current diagnostic criteria for Bipolar Disorder are useful for
children as well as adolescents. A new set of criteria may especially need to be established to
diagnose Bipolar Disorder in prepubertal children; that is, antecedent symptoms of Bipolar Disorder
may need to re recognized and these symptoms may differ from those of classic Bipolar Disorder,
reflecting an earlier non-isomorphic presentation. To recognize these antecedent symptoms, it
would be useful to study psychiatric symptoms in children at high risk for developing Bipolar
Disorder.
Studies of adult sample have indicated that 20-54% of adults with BPD report onset of illness in
childhood (Lish et al., 1993), suggesting an under diagnosis of mania in juveniles (Carlson, 1995;
Weller et al 1995; Wozniak et al 1995).
Etiology
Mitochondrial DNA mutations may play a role in the pathogenesis of maternally transmitted BPD.
Several children with treatment-resistant BPD have responded well to thiamine, coenzyme Q10, or
other therapies designed to compensate for metabolic defects. Typically these children display a
combination of treatment-refractory affective illness and other paroxysmal symptoms. They
presented with histories of severe valproic acid toxicity that appeared early in the treatment course. A
consensus is coming that Mitochondrial disorders may represent a final common pathway for a
diverse group of neuropsychiatric disorders.
Presentation
Bipolar Disorder in children and early adolescents resembles severe adult-onset disease,
according to Barbara Geller at the Fourth International Conference on BPD. Early-onset Bipolar
Disorder tends to be completely treatment resistant to monotherapy treatment and involves extreme
rapid cycling. Mixed episodes are common. The psychosocial functioning in young bipolar patients
is significantly impaired compared with normal controls or children with ADHD.
As severe as the condition is, it often goes without specific treatment. The presence of suicidality,
24.7% was particularly striking given the age of the patients. Extremely rapid cycling was the rule:
87% of the patients had more than four episodes per year, 9.7% of these displayed an ultra-rapid
pattern (5-365 cycles/yr), and 77.4% had an ultradien cycling (more than 365 cycles/yr). Recovery
rates were low and relapses frequent.
Overall, the usual adult presentation, with discrete episodes of mania or depression, was infrequent
in these young patients, and what was seen more resembled severe, treatment-resistant,
continuously cycling disease. The young bipolar patients showed substantial psychosocial
functional impairment, compared with the ADHD community controls-notably in areas of maternal-
child warmth, parental-child tension, and peer relationships.
Diagnosis
A key to detecting BPD in these age groups and distinguishing it from ADHD is a symptom
assessment that takes age-dependent expressions of cardinal manifestations. In identifying "racing
thoughts", for example, the developmentally apt concreteness of children should be kept in mind.
They may report things like, "I need a stoplight up there," or "I don't know what to think first."
In the National Institute of Mental Health Research Round table on Prepubertal Bipolar Disorder on
April 27, 2000, discussion of existing controversial areas into his diagnosis of BPD in prepubertal
children was convened.
Consensus was found that:
1. A diagnosis of BPD, using DSM criteria, is possible in prepubertal children. Children seen in
clinics fall into two categories:
a. Those that clearly have a bipolar disorder (because they meet DSM-IV criteria for Bipolar I or II)
b. Those may have BPD but do not meet DSM-IV criteria, such as children who do not meet full
criteria suffer from mood disturbances and symptoms of bipolar disorder and are severely impaired.
This group currently receives a diagnosis of BPD not otherwise specified (BP-NOS)
2. BP-NOS phenotype. Several investigators have reported extensively on severely impaired children
with mood disturbance who do not meet full DSM-IV criteria for BP-I or BP-II, characterized mainly as
irritable and aggressive.
3. It was agreed that BP-NOS could be used as a "working diagnosis" as long as the children are
well described (with particular attention to symptoms of anxiety, oppositional defiant disorder and
prepubertal onset of substance abuse).
"Current issues in the identification and management of BPD in special populations" (Cassano
et al., 2000). Although BPD occurs rather infrequently in children below the age of 12, it appears to
be frequently under-recognized and inadequately treated. Typically, children with BPD are more likely
to present with sub threshold and atypical forms of the disorder (dysphoria, irritability and/or mixed
states; rapid cycling), that may be more continuous than episodic in course (Carlson, 1990, Faedda
et al., 1995; Beller et al., 1995; Weller et al., 1995; Woziak et al., 1995).
Symptoms may include affective instability, periods of mania and grandiosity, temper outbursts,
depression, withdrawal, appetite and weight changes, sleep problems, periodic changes in energy,
drug or alcohol abuse, hyper sexuality, grandiose delusions and extreme aggressively. Children can
demonstrate full syndromal mania and depression equivalent to that observed in adult BPD.
Failure to diagnose BPD in children either through a reluctance to believe it can present with early
onset or through being obscured by the presence of other psychiatric conditions, has been a
problem for many years (Giannini et al., 1969). BPD in children is frequently mis-diagnosed as
ADHD because 96% of children who meet the criteria for mania also meet the requirement for
ADHD, whereas only 16% of ADHD patients meet the criteria for mania/hypomania (Beiderman et
al., 1996).
It is important to notice differential symptoms specific of BPD such as hypersexuality, psychosis,
periodicity and seasonality. In addition, it is often useful to consider the best behavior/function for
these children that can function well when stable. On the same note, children with ADHD have more
persistent functionally difficulties.
Misdiagnoses such as schizophrenia can also occur if the child has a substantial degree of
psychosis. Risk factors predictive of BPD in juvenile patients include early onset of depression,
psychotic features, family history of BPD and pharmacologically induced hypomania (Strober and
Carlson, 1982; Akiskal et al., 1983). More provocatively, Akiskal (1995) has proposed that all juvenile
depression is at very high risk for bipolar transformation.
Dimensional Scales and Diagnostic Categories
Guest Editors: Peter Jensen, MD, Jeanne Brooks-Gunn, Ph.D, and
Julia A. Graber, Ph.D
A more sophisticated understanding suggests that there are likely to be few if any gold standards in
our current nosological systems of psychopathology. Much more important is our appreciation of the
processes whereby persons become impaired in mental, behavioral, and emotional functioning.
Costello et al. conducted longitudinal analyses of 300 children aged 7 to 11 to examine the
outcomes of those with Bipolar I Disorder: subthreshold versus threshold diagnosis 7 years later.
They found that functional impairment (the effect of symptoms on current role status) was as
important as psychiatric diagnosis in predicting adolescent consequences of childhood disorders.
Angold and colleagues also found that a substantial number of children suffer from V code
relational problems that these difficulties appear to be a significant source of morbidity and
impairment. Given the number of children who are impaired by symptoms, those who did not meet
full diagnostic criteria but meet some of the criteria, they should still be evaluated and treated. The
authors recommend greater use of the category psychiatric disorder NOS (not otherwise specified).
Surprisingly, this diagnostic category is rarely used.
The best methods for assessing depression and related symptomatology at age 10 may not be
linked to the best methods at age 15. The most meaningful cutoff point for treatment of behavioral
disorders would include all children with any level of psychiatric disorder, using the most lenient
possible cutoff point. The data for emotional disorders are less clear-cut but they point in the same
direction.
Studies of adult samples have indicated that 20-54% of adults with bipolar disorder report onset of
illness in childhood (Lish et al. 1993), suggesting an under diagnosis of mania in juveniles
(Carlson 1995; Wellar et al. 1995; Wozniak et al 1995). There is data to support that comorbid ADHD
is an age-dependent manifestation of child mania (Geller et al., 1995, 1998, 2000) and that a
subgroup of cases had a familial diathesis for both child mania and ADHD (Farone et al., 1997).
Treatment
"Bipolar Mood Stabilizer Trial" (Kowatch et al., 2000)
It is important to recognize that more than half of these patients did not respond of monotherapy with
any of the three mood stabilizers: Lithium, Valproate, or Carbamazepine. Our clinical experience is
that they frequently respond to a combination of mood stabilizers, atypical antipsychotic agents ,
and/or stimulants.
Clinicians used to favor non-pharmacological treatment approaches in Bipolar children (Bowden
and Sarabia, 1980). However, growing evidence suggests that Bipolar Disorder in children should
also be treated pharmacologically in a substantial proportion of cases.
Treatment Contraindications
Stimulants and antidepressants may be risk factors for early development of Bipolar disorder in
children whose parents have BPD warned Catrien G. Reichart, MD at Fourth International
Conference on Bipolar Disorder in Pittsburgh. In two similar studies one in the Netherlands and the
other in the Untied States, 0.6 % of children before the age of 20 compared to 39% in the United
States were diagnosed with Bipolar Disorder respectively. Before the age of 12, none of the children
fulfilled this criteria of BPD in this particular study. Compared to the United States, BPD is rarely
diagnosed in Dutch children aged 11 and younger.
Some differences may be due to the differences in recruitment, however the recruitment methods
cannot be the whole explanation. The difference, according to Reichart, may be due to the frequent
use of stimulants and antidepressants by US physicians to treat children with hyperactivity and other
disorders while physicians in the Netherlands rely more on psychosocial approaches.
Comorbidity
It is well established that ADHD in children is predictive of significant psychopathological symptoms
and dysfunction in later life (Beiderman et al., 1996). Almost all children with Bipolar features
simultaneously fulfill the diagnostic criteria for ADHD. It is unusual to find high comorbidity of two
independent disorders; however, there is a diagnostic issue that while some children meet the
criteria for ADHD but do not fulfill the criteria for hypomania or mania, some of them respond well to
treatment with a mood stabilizer and a stimulant.
In children with ADHD, a diagnosis of comorbid Bipolar Disorder should be considered if there are
mood symptoms, periodically, diurnal variations seasonality and psychotic symptoms, especially
when these symptoms worsen with stimulant or anti depressant use. In children fulfilling the criteria
of both Bipolar disorder and ADHD, the first priority is to treat the mood disorder. Only after any
features of hypomania/mania have been suppressed can stimulants be used to treat the residual
attention deficit symptoms.
During adolescence, bipolar disorder may also present in non-specific forms. A positive family
history of BPD can be useful as an indicator for the correct diagnosis (Akiskal et al., 1985). Also, as
with children, adolescents who have an initial episode of depression especially if associated with
psychotic features, are at a much higher risk of being Bipolar. Initial presentation with depression in
this age group is also predictive of a protracted index episode, whereas the rates of recovery in
adolescents with initial mania are more rapid (Strober et al, 1995).
Even though Bipolar Disorder in adolescents often presents in forms not dissimilar from those
seen in adults, under-recognition remains a problem in this population. Bipolar disorder in
adolescents is often associated with behavior problem (e.g. anger outburst, and substance abuse)
and misdiagnosed a conduct disorder (Kovacs and Pollack, 1995). Furthermore, the presence of
psychotic features may also lead to an erroneous diagnosis of schizophrenia.
Based on the current availability of data of data from the literature relative to this age group of Bipolar
patients, it is difficult to make treatment recommendations. However, preliminary evidence supports
the use of both lithium and anticonvulsant mood stabilizers. The later agents may also reduce
affective instability and aggression in non-Bipolar adolescents.
Comorbidiity is an important consideration in patients with BPD. Substantial epidemiological and
clinical data indicate that BPD in all age groups is associated with elevated rates of most other Axis I
disorder, including substance use disorders, anxiety disorders [e.g.. panic disorder,
obsessive-compulsive disorder (OCD), and possibly post-traumatic stress disorder), ADHD,
conduct disorder, eating disorders, impulsive control disorder, and possibly Tourette's disorder
(Goodwin and Jamison, 1990; Robins and Regier, 1991; Winokur et al., 1993; Kessler et al., 1994;
Strakowske et al., 1994; Feadda et al., 1995; Wozniak et al., 1995; Beiderman et al., 1996; West et
al.,1996)
The majority (60%) of patients with BPD admitted to psychiatric facilities has at least one Axis I
disorder (Cassano et al., 1998). Studies from the Dutch epidemiological cohort (NEMISIS)(Bijl et al.,
1997), the US National Comorbidity Survey and the Epidemiologic Catchment Area Study all report
high comorbidity rates in BPD (Regier et al., 1990; Kessler et al., 1997).
Panic disorder, Obsessive-Compulsive disorder, social phobia, and substance use/abuse all occur
in vary high rates along with BPD. The novel anti-epileptic drugs such as Gabapentin for panic and
social phobia, and topiramate and Lamictal for Obsessive-Compulsive disorder have had reported
success.
Manic-panic connection has a genetic component. The four site 200-family funded by the NIMH
confirmed about a 50% rate of panic disorder occurring with BPD.
Two large epidemiological studies indicate that, of all Axis I disorders is the most likely to coexist
with alcohol or drug abuse (Regier et al, 1990). Data from other studies showed that 30% of cocaine
users meet the criteria for BPD ( Brady and Somme, 1995). An event higher proportion of
substance-abusing patients is likely to fall within the Bipolar spectrum (e.g. cyclothymia,
hyperthymia and hypomania, reported by Akiskal et al, 1997)
As with the treatment of other comorbid conditions, it is important to begin management of both
disorders simultaneously.
well as have clinical experiences involving patients with Bipolar Disorder. These patients include
children as well as adults who can trace their symptoms to early childhood.
Early diagnosis and treatment of Bipolar Disorder with lithium or valproic acid have proven to have
the effect of repairing both discrete brain circuitry and specific regions of the brain. Deterioration of
the brain continues without complete treatment. The good news is that starting treatment with
lithium or valproic acid can have reparative brain ( neurotropic) effects at any age.
Some clinical experiences are presented in case studies of four patients.
1) Bill
Identification: Patient seen from age 12 to age 17, between the years of 1988 and 2000.
Presenting symptoms: Incredibly disruptive at school, destructive, grandiose, obsessive
compulsive, agitated, and violent. History of thefts. He took things apart incessantly-the refrigerator,
the stove, the toaster. Prior to my care he was admitted fifteen times to psychiatric hospitalizations,
Bill had repeated involvement with juvenile justice system. The school system made numerous
individualized educational plans( IEP) to accommodate his educational needs. Bill came to
appointments in costume: as a businessman, a cowboy, a doctor, a policeman, etc.
Medications: monotherapy with lithium, valproate, carbamazepine, and Zyprexa -- with no success.
The combination of any two mood stabilizers was unsuccessful.
After various combinations of three to five medications at a time, no more than 50% efficacy was
achieved in terms of activities of daily living (ADLS), occupational and social functioning. The patient
was placed on clozapine 75 milligrams twice a day and dextroamphetamine 20 milligrams in the
morning. He had no further hospitalizations, after hours crises, or emergency appointments. The
patient was mainstreamed within three months for the first time since he had entered elementary
school.
2) Cindy
Identification: 40 years old with no known history of Bipolar Disorder in the family.
Presenting symptoms: depression, avoided contact with others, irritable.
Cindy elected to begin treatment with psychotherapy twice a week for the next three years. During the
sessions, she complained of lack of manic periods that she felt fueled her creativity. She was an
artist and musician. She remembers having manic periods as early as third grade as well as
seasonal depression in the midwinter (February and March); even though she was very successful
in high school. By the age of thirty, she had periods of depression more common than manic
periods. At age forty, she started to have periods of irritability.
The patient came to me hoping to recapture periods of manic feelings. I started her on Depakote.
Cindy found that it stabilized her mood, but she also incurred a 40 pound weight gain and Hair
loss(alopecia). So, valproate swapped out for lithium and the patient felt slightly depressed.
Synthroid added for hypothyroidism. After adding Synthroid, I switched back to Depakote ER, the
extended release tablet. The patient stabilized at a mildly depressed state. Lamictal titrated
upwards to 150 milligrams twice a day with excellent results and no breakthrough episodes with the
next six years of follow-up appointments.
3) Jennifer
Identification: nineteen year old Gothic Caucasian, female with few female friends.
Family History: father diagnosed with Bipolar I Disorder and Attention Deficit/Hyperactivity Disorder
Presenting Symptoms: depressed and irritable, dressed in baggy pants and formless sweatshirts,
polysubstance dependence, chain smoking. Jennifer's only activities: playing video games and
promiscuity. Patient combative at home, at school and with lovers. During the psychotherapy process
patient initially diagnosed with Attention Deficit/Hyperactivity Disorder and treated with Dexedrine.
She showed a huge improvement in her appearance and in her aggressive, angry demeanor. She
transformed into a strikingly attractive woman. Patient was intelligent and capable as a computer
technician.
In later psychotherapy sessions she revealed problems maintaining a job and blowing up with
employers. Jennifer misused the Dexedrine and did not take the psychostimulant steadily. The
patient was rediagnosed with Bipolar I Disorder and ADHD. Lithium and Lamictal added to her
Dexedrine with much better coverage of her lingering impulsivity and verbal aggression. Following
this change, the patient had obtained a high level position at a large bank.
4) Sally
Identification: a psychologist well respected as a colleague and a community member.
Presenting symptoms: depression and anxiety, cross-dressing.
After three years in psychotherapy, the patient confessed to horrific and sustained sexual violence by
numerous people including her biological father and mother for whom she maintained the utmost
respect. After revealing details of her parents' ritualistic sexual abuse Sally hospitalized for the first
time and discovered to be a severe alcoholic. One to two weekly psychotherapy sessions with use
of psychodrama and hypnosis for relaxation occurred for the next 5 years.
There was no further substance abuse. Gradually the chaotic presentation cleared so that the
diagnosis of Bipolar Disorder was made. The patient admitted that she knew she was Bipolar from
age 6. She was treated with Risperdal daily; and for nightmares on an as needed basis. Depakote
was used for the accompanying anxiety to her difficulty to internally modulate both her mood and
anxiety.. Lamictal titrated to 200mg twice a day stabilized her mood for perpetuity.
During the last two years that the patient was seen she divorced and remarried.
New Developments in the Study of Bipolar Disorder
It remains to be determined whether the current diagnostic criteria for Bipolar Disorder are useful for
children as well as adolescents. A new set of criteria may especially need to be established to
diagnose Bipolar Disorder in prepubertal children; that is, antecedent symptoms of Bipolar Disorder
may need to re recognized and these symptoms may differ from those of classic Bipolar Disorder,
reflecting an earlier non-isomorphic presentation. To recognize these antecedent symptoms, it
would be useful to study psychiatric symptoms in children at high risk for developing Bipolar
Disorder.
Studies of adult sample have indicated that 20-54% of adults with BPD report onset of illness in
childhood (Lish et al., 1993), suggesting an under diagnosis of mania in juveniles (Carlson, 1995;
Weller et al 1995; Wozniak et al 1995).
Etiology
Mitochondrial DNA mutations may play a role in the pathogenesis of maternally transmitted BPD.
Several children with treatment-resistant BPD have responded well to thiamine, coenzyme Q10, or
other therapies designed to compensate for metabolic defects. Typically these children display a
combination of treatment-refractory affective illness and other paroxysmal symptoms. They
presented with histories of severe valproic acid toxicity that appeared early in the treatment course. A
consensus is coming that Mitochondrial disorders may represent a final common pathway for a
diverse group of neuropsychiatric disorders.
Presentation
Bipolar Disorder in children and early adolescents resembles severe adult-onset disease,
according to Barbara Geller at the Fourth International Conference on BPD. Early-onset Bipolar
Disorder tends to be completely treatment resistant to monotherapy treatment and involves extreme
rapid cycling. Mixed episodes are common. The psychosocial functioning in young bipolar patients
is significantly impaired compared with normal controls or children with ADHD.
As severe as the condition is, it often goes without specific treatment. The presence of suicidality,
24.7% was particularly striking given the age of the patients. Extremely rapid cycling was the rule:
87% of the patients had more than four episodes per year, 9.7% of these displayed an ultra-rapid
pattern (5-365 cycles/yr), and 77.4% had an ultradien cycling (more than 365 cycles/yr). Recovery
rates were low and relapses frequent.
Overall, the usual adult presentation, with discrete episodes of mania or depression, was infrequent
in these young patients, and what was seen more resembled severe, treatment-resistant,
continuously cycling disease. The young bipolar patients showed substantial psychosocial
functional impairment, compared with the ADHD community controls-notably in areas of maternal-
child warmth, parental-child tension, and peer relationships.
Diagnosis
A key to detecting BPD in these age groups and distinguishing it from ADHD is a symptom
assessment that takes age-dependent expressions of cardinal manifestations. In identifying "racing
thoughts", for example, the developmentally apt concreteness of children should be kept in mind.
They may report things like, "I need a stoplight up there," or "I don't know what to think first."
In the National Institute of Mental Health Research Round table on Prepubertal Bipolar Disorder on
April 27, 2000, discussion of existing controversial areas into his diagnosis of BPD in prepubertal
children was convened.
Consensus was found that:
1. A diagnosis of BPD, using DSM criteria, is possible in prepubertal children. Children seen in
clinics fall into two categories:
a. Those that clearly have a bipolar disorder (because they meet DSM-IV criteria for Bipolar I or II)
b. Those may have BPD but do not meet DSM-IV criteria, such as children who do not meet full
criteria suffer from mood disturbances and symptoms of bipolar disorder and are severely impaired.
This group currently receives a diagnosis of BPD not otherwise specified (BP-NOS)
2. BP-NOS phenotype. Several investigators have reported extensively on severely impaired children
with mood disturbance who do not meet full DSM-IV criteria for BP-I or BP-II, characterized mainly as
irritable and aggressive.
3. It was agreed that BP-NOS could be used as a "working diagnosis" as long as the children are
well described (with particular attention to symptoms of anxiety, oppositional defiant disorder and
prepubertal onset of substance abuse).
"Current issues in the identification and management of BPD in special populations" (Cassano
et al., 2000). Although BPD occurs rather infrequently in children below the age of 12, it appears to
be frequently under-recognized and inadequately treated. Typically, children with BPD are more likely
to present with sub threshold and atypical forms of the disorder (dysphoria, irritability and/or mixed
states; rapid cycling), that may be more continuous than episodic in course (Carlson, 1990, Faedda
et al., 1995; Beller et al., 1995; Weller et al., 1995; Woziak et al., 1995).
Symptoms may include affective instability, periods of mania and grandiosity, temper outbursts,
depression, withdrawal, appetite and weight changes, sleep problems, periodic changes in energy,
drug or alcohol abuse, hyper sexuality, grandiose delusions and extreme aggressively. Children can
demonstrate full syndromal mania and depression equivalent to that observed in adult BPD.
Failure to diagnose BPD in children either through a reluctance to believe it can present with early
onset or through being obscured by the presence of other psychiatric conditions, has been a
problem for many years (Giannini et al., 1969). BPD in children is frequently mis-diagnosed as
ADHD because 96% of children who meet the criteria for mania also meet the requirement for
ADHD, whereas only 16% of ADHD patients meet the criteria for mania/hypomania (Beiderman et
al., 1996).
It is important to notice differential symptoms specific of BPD such as hypersexuality, psychosis,
periodicity and seasonality. In addition, it is often useful to consider the best behavior/function for
these children that can function well when stable. On the same note, children with ADHD have more
persistent functionally difficulties.
Misdiagnoses such as schizophrenia can also occur if the child has a substantial degree of
psychosis. Risk factors predictive of BPD in juvenile patients include early onset of depression,
psychotic features, family history of BPD and pharmacologically induced hypomania (Strober and
Carlson, 1982; Akiskal et al., 1983). More provocatively, Akiskal (1995) has proposed that all juvenile
depression is at very high risk for bipolar transformation.
Dimensional Scales and Diagnostic Categories
Guest Editors: Peter Jensen, MD, Jeanne Brooks-Gunn, Ph.D, and
Julia A. Graber, Ph.D
A more sophisticated understanding suggests that there are likely to be few if any gold standards in
our current nosological systems of psychopathology. Much more important is our appreciation of the
processes whereby persons become impaired in mental, behavioral, and emotional functioning.
Costello et al. conducted longitudinal analyses of 300 children aged 7 to 11 to examine the
outcomes of those with Bipolar I Disorder: subthreshold versus threshold diagnosis 7 years later.
They found that functional impairment (the effect of symptoms on current role status) was as
important as psychiatric diagnosis in predicting adolescent consequences of childhood disorders.
Angold and colleagues also found that a substantial number of children suffer from V code
relational problems that these difficulties appear to be a significant source of morbidity and
impairment. Given the number of children who are impaired by symptoms, those who did not meet
full diagnostic criteria but meet some of the criteria, they should still be evaluated and treated. The
authors recommend greater use of the category psychiatric disorder NOS (not otherwise specified).
Surprisingly, this diagnostic category is rarely used.
The best methods for assessing depression and related symptomatology at age 10 may not be
linked to the best methods at age 15. The most meaningful cutoff point for treatment of behavioral
disorders would include all children with any level of psychiatric disorder, using the most lenient
possible cutoff point. The data for emotional disorders are less clear-cut but they point in the same
direction.
Studies of adult samples have indicated that 20-54% of adults with bipolar disorder report onset of
illness in childhood (Lish et al. 1993), suggesting an under diagnosis of mania in juveniles
(Carlson 1995; Wellar et al. 1995; Wozniak et al 1995). There is data to support that comorbid ADHD
is an age-dependent manifestation of child mania (Geller et al., 1995, 1998, 2000) and that a
subgroup of cases had a familial diathesis for both child mania and ADHD (Farone et al., 1997).
Treatment
"Bipolar Mood Stabilizer Trial" (Kowatch et al., 2000)
It is important to recognize that more than half of these patients did not respond of monotherapy with
any of the three mood stabilizers: Lithium, Valproate, or Carbamazepine. Our clinical experience is
that they frequently respond to a combination of mood stabilizers, atypical antipsychotic agents ,
and/or stimulants.
Clinicians used to favor non-pharmacological treatment approaches in Bipolar children (Bowden
and Sarabia, 1980). However, growing evidence suggests that Bipolar Disorder in children should
also be treated pharmacologically in a substantial proportion of cases.
Treatment Contraindications
Stimulants and antidepressants may be risk factors for early development of Bipolar disorder in
children whose parents have BPD warned Catrien G. Reichart, MD at Fourth International
Conference on Bipolar Disorder in Pittsburgh. In two similar studies one in the Netherlands and the
other in the Untied States, 0.6 % of children before the age of 20 compared to 39% in the United
States were diagnosed with Bipolar Disorder respectively. Before the age of 12, none of the children
fulfilled this criteria of BPD in this particular study. Compared to the United States, BPD is rarely
diagnosed in Dutch children aged 11 and younger.
Some differences may be due to the differences in recruitment, however the recruitment methods
cannot be the whole explanation. The difference, according to Reichart, may be due to the frequent
use of stimulants and antidepressants by US physicians to treat children with hyperactivity and other
disorders while physicians in the Netherlands rely more on psychosocial approaches.
Comorbidity
It is well established that ADHD in children is predictive of significant psychopathological symptoms
and dysfunction in later life (Beiderman et al., 1996). Almost all children with Bipolar features
simultaneously fulfill the diagnostic criteria for ADHD. It is unusual to find high comorbidity of two
independent disorders; however, there is a diagnostic issue that while some children meet the
criteria for ADHD but do not fulfill the criteria for hypomania or mania, some of them respond well to
treatment with a mood stabilizer and a stimulant.
In children with ADHD, a diagnosis of comorbid Bipolar Disorder should be considered if there are
mood symptoms, periodically, diurnal variations seasonality and psychotic symptoms, especially
when these symptoms worsen with stimulant or anti depressant use. In children fulfilling the criteria
of both Bipolar disorder and ADHD, the first priority is to treat the mood disorder. Only after any
features of hypomania/mania have been suppressed can stimulants be used to treat the residual
attention deficit symptoms.
During adolescence, bipolar disorder may also present in non-specific forms. A positive family
history of BPD can be useful as an indicator for the correct diagnosis (Akiskal et al., 1985). Also, as
with children, adolescents who have an initial episode of depression especially if associated with
psychotic features, are at a much higher risk of being Bipolar. Initial presentation with depression in
this age group is also predictive of a protracted index episode, whereas the rates of recovery in
adolescents with initial mania are more rapid (Strober et al, 1995).
Even though Bipolar Disorder in adolescents often presents in forms not dissimilar from those
seen in adults, under-recognition remains a problem in this population. Bipolar disorder in
adolescents is often associated with behavior problem (e.g. anger outburst, and substance abuse)
and misdiagnosed a conduct disorder (Kovacs and Pollack, 1995). Furthermore, the presence of
psychotic features may also lead to an erroneous diagnosis of schizophrenia.
Based on the current availability of data of data from the literature relative to this age group of Bipolar
patients, it is difficult to make treatment recommendations. However, preliminary evidence supports
the use of both lithium and anticonvulsant mood stabilizers. The later agents may also reduce
affective instability and aggression in non-Bipolar adolescents.
Comorbidiity is an important consideration in patients with BPD. Substantial epidemiological and
clinical data indicate that BPD in all age groups is associated with elevated rates of most other Axis I
disorder, including substance use disorders, anxiety disorders [e.g.. panic disorder,
obsessive-compulsive disorder (OCD), and possibly post-traumatic stress disorder), ADHD,
conduct disorder, eating disorders, impulsive control disorder, and possibly Tourette's disorder
(Goodwin and Jamison, 1990; Robins and Regier, 1991; Winokur et al., 1993; Kessler et al., 1994;
Strakowske et al., 1994; Feadda et al., 1995; Wozniak et al., 1995; Beiderman et al., 1996; West et
al.,1996)
The majority (60%) of patients with BPD admitted to psychiatric facilities has at least one Axis I
disorder (Cassano et al., 1998). Studies from the Dutch epidemiological cohort (NEMISIS)(Bijl et al.,
1997), the US National Comorbidity Survey and the Epidemiologic Catchment Area Study all report
high comorbidity rates in BPD (Regier et al., 1990; Kessler et al., 1997).
Panic disorder, Obsessive-Compulsive disorder, social phobia, and substance use/abuse all occur
in vary high rates along with BPD. The novel anti-epileptic drugs such as Gabapentin for panic and
social phobia, and topiramate and Lamictal for Obsessive-Compulsive disorder have had reported
success.
Manic-panic connection has a genetic component. The four site 200-family funded by the NIMH
confirmed about a 50% rate of panic disorder occurring with BPD.
Two large epidemiological studies indicate that, of all Axis I disorders is the most likely to coexist
with alcohol or drug abuse (Regier et al, 1990). Data from other studies showed that 30% of cocaine
users meet the criteria for BPD ( Brady and Somme, 1995). An event higher proportion of
substance-abusing patients is likely to fall within the Bipolar spectrum (e.g. cyclothymia,
hyperthymia and hypomania, reported by Akiskal et al, 1997)
As with the treatment of other comorbid conditions, it is important to begin management of both
disorders simultaneously.
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