Bipolar Disorder: Diagnostic confusion and concerning findings in youth
by Leslie E. Packer, PhD
Last Updated July 2010
PREFACE: DIAGNOSTIC DILEMMA
Bipolar Disorder is a condition in which the individual “swings” or cycles between different types of mood episodes. Bipolar Disorder used to be called “Manic-Depression.”
For some individuals with Bipolar Disorder, there may be relatively long periods of wellness between the different mood cycles. Adults usually do not cycle as frequently as children and adolescents.
At the present time, the diagnosis of Bipolar Disorder in children and teens continues to be somewhat controversial due to how the diagnostic criteria are being applied (or not applied, in some cases) and due to the difficulty in distinguishing between ADHD with severe irritability and Bipolar Disorder. If a child or teen has clear cycles of mood episodes, it is easier to make a diagnosis, but if there are no clear cycles, then it is more difficult.
Galanter and Leibenluft (2008) have an excellent article on the diagnostic dilemma (abstract). Carlson also has an excellent editorial (pdf) pointing out that “rages” are too often being confused with mania resulting in (inappropriate) diagnosis of Bipolar Disorder in some cases. Children and teens with “rages” or “severe mood dysregulation” do not necessarily have Bipolar Disorder. As Carlson points out, the diagnostic dilemma is not really between ADHD and Bipolar Disorder, but between ADHD+Oppositional Defiant Disorder and Bipolar Disorder.
The controversy over the diagnosis of Bipolar Disorder in youth and the justification for a proposal for a new diagnosis, Temper Dysregulation Disorder with Dysphoria, can be found on the DSM-5 web site.
In order to understand the subtypes of Bipolar Disorder, it’s necessary to understand what the different type of mood episodes are. Major Depression (or more simply, “depression”) is covered in its own files on this site. The remaining types of mood episodes are described below.
WHAT ARE MANIA AND HYPOMANIA?
The prefix “hypo” means “under,” so “hypomania” actually translates into “under mania,” or just below the level of (full) mania. An individual who is hypomanic will be sleeping less (or may not sleep at all), will have a burst of energy, feel heightened focus or creativity, a sense of increased confidence, and may be able to accomplish a lot and tackle a number of meaningful and organized projects.
If the individual is able to control the hypomania, it is a state that may actually be very positive and pleasurable. Some of the impulsivity and increased energy may result in spending sprees or other activities that, while not bizarre, are not what the individual would normally do. While some aspects of hypomania are experienced as positive, the individual’s impulsivity can pose genuine problems. Distractibility is often present, and as in mania, speech may be very rapid as the person responds to everything going on around them. About half of the time, hypomania progresses into full-blown mania.
While some people think of mania as the opposite of depression, i.e., as a “high,” it is necessarily that way, although hypomania (and early stages of mania) are associated with feelings of euphoria or exuberance. A person who is in a manic episode may look “mean as a snake” and not euphoric at all. The evolution of a hypomanic episode into mania might look like this:
- Manic episodes generally begin with what is experienced as an improvement or upward shift in mood. This initially euphoric or elated mood, accompanied by decreased need for sleep is usually experienced as an initially increased sense of energy and confidence. This is the hypomanic state.
- As the hypomania progresses into mania, thoughts begin to race and speech becomes rapid (pressured). The individual may laugh often and giggle inappropriately.
- The euphoria is replaced by irritability, and in some cases, assaultiveness.
- The individual becomes more impulsive, disinhibited, and takes more risks.
- Thoughts become more disorganized, and in severe cases, delusional or psychotic.
An individual in a severely manic state is in as much danger as an individual in a major depression. Overly confident (and having grandiose thoughts), there is an excess of what are usually thought of as “approach behaviors.” Anything the individual might seek out while in normal mood (such as sex, alcohol or drugs, or excitement) becomes magnified. Wild spending sprees or impulsive purchases are not uncommon, nor are impulsive marriages or major commitments. Patty Duke, the actress, in describing her manic episodes in her autobiography, “A Brilliant Madness“, gives readers a clear picture of how devastating mania can be. During some of her manic episodes, Ms. Duke invited a stranger and her daughter to come live with her upon hearing that the young woman had no place to live (the woman later stole all her belongings), married a man she had met only four hours earlier, threw tantrums on the set while working on her show, abused drugs, and would impulsively decide to move and buy a different home.
As with depression, in severe mania, the individual may experience hallucinations. With or without hallucinations, however, individuals in severely manic states had a significant mortality rate until lithium started being prescribed. In some cases, death was accidental, but related to the risk-taking or impulsive behaviors. In other cases, patients died of dehydration (they might neglect to eat and drink in their manic state) or cardiovascular collapse as the body couldn’t keep up with increased psychomotor agitation and ‘racing.’
Some individuals may experience both depression and mania at the same time, giving rise to the notion of a “mixed episode.” Indeed, if the predominant symptom is irritability, it may be difficult to know whether it is from depression or mania. An individual in a mixed episode may exhibit signs of agitation, suffer from insomnia, experience changes in appetite, have some psychotic features, and experience suicidal thinking. Janice Papalos, co-author of The Bipolar Child, believes that mixed episodes are actually the most dangerous type of mood episode because the individual may have the suicidal thoughts of depression combined with the increased impulsivity and energy of mania that enables them to act on the suicidal thoughts.
SUBTYPES OF MANIA
When Kraepelin first described mania, several subtypes were described, including hypomania, acute mania, delusional mania, and depressive or anxious mania. Cassidy et al. (2001) attempted to validate the different subtypes using a multivariate structural analysis. They found five subtypes with good validity, and validated the major Kraepelinian subtypes noted above, but they also identified two other subtypes involving mixed mania presentations characterized by significant mood variability. The first of these subtypes is quite different than what we normally think of as mania, as the dominant mood was severely depressive with labile periods of pressured, irritable hostility and paranoia and the complete absence of any euphoria or humor. The second new mixed mania subtype they identified involved a mixture of affects: periods of classical manic symptoms (euphoria, elevated mood, humor, grandiosity, psychosis, and psychomotor activation), switching frequently to depressed mood accompanied by anxiety and irritability.
SUBTYPES OF BIPOLAR DISORDER
Now that we’ve defined the different types of mood episodes, we can talk about the different subtypes of Bipolar Disorder (BPD). BPD is generally classified according to the type of mood episodes the individual swings between. Simply put, the designations simply tell us how high are the highs and how low are the lows.
- Bipolar I Disorder is characterized by at least one manic episode or mixed episode, with or without major depression or hypomania. Most people who are hospitalized for the first time for Bipolar Disorder are hospitalized because of mania.
- Bipolar Disorder type II is characterized by at least one episode of hypomania and at least one episode of major depression. Some children or teens who are initially diagnosed as Bipolar I seem to resolve into Bipolar II. Bipolar II is the most common subtype of Bipolar Disorder in teens.
- Cyclothymic Disorder is not as severe as either Bipolar Disorder II or I, but the condition is more chronic. The disorder lasts at least two years, with single episodes persisting for more than two months (in adults; the criterion is 1 year for youth). Cyclothymic disorder may be a precursor to full-blown bipolar disorder in some people or it may continue as a low-grade chronic condition.
- Bipolar – NOS is a diagnosis that is reserved for when the individual has a cycling mood disorder that does not meet the other subtypes’ criteria.
To Bipolar Disorder subtypes and criteria may be changing when the DSM-5 comes out in a few years. To see all the proposed changes, follow the links from the Mood Disorders page on the DSM-5 site.
SOME FINDINGS OF CONCERN IN BIPOLAR YOUTH
In a study of 300 children and adolescents, Dr. Boris Birmhauer and his colleagues found that 2.5 years after diagnosis of Bipolar Disorder:
- Nearly 1/3 had recovered
- The remaining 2/3 took about 17 months to recover
- About 80% had at least one recurrence
- Children experienced serious symptoms about 2/3 of the time
- Children averaged 16 cycles of mood changes a year (compared to 3.5 cycles per year for adults)
Other studies have also reported data that suggest the enormous challenges that parents, their parents and educators face:
- In a longer-term study of 25 children and adolescents who had presented with mania, Jairam et al. (2004) found that although all of the children recovered from the episode, 16 of them (64%) relapsed after a mean period of 18 +/- 16.4 months. A majority of the relapses (72.4%) occurred while they were adhering to their treatment.
- Geller et al. (2004) followed 86 children over a 4-year period. They found that manic episodes persisted for 79.2 +/- 66.7 consecutive weeks, and that children were symptomatic (met criteria for any mood episode such as depression, mixed, hypomania, or mania) 1/3 – 2/3 of time during the 4-year period.
OTHER FINDINGS AND IMPLICATIONS
It is only within the past 15 years that clinicians and researchers have begun to recognize that Bipolar Disorder may emerge in childhood. Hence, there is relatively little long-term research on treatment strategies or educational interventions. To keep current on developments in this area, see the Child and Adolescent Bipolar Foundation. For a different research approach to juvenile BPD, see the Juvenile Bipolar Research Foundation.
Of particular importance to parents and educators, research on Bipolar Disorder in children and teens suggests that regardless of the child’s medication status or mood state, children and teens with Bipolar Disorder are significantly more likely to experience attentional, executive function, verbal learning, and working memory deficits compared to their peers (Pavuluri et al., 2006), and that some problems persist even when the child or teen is in a “normal” (euthymic) mood state . As part of psychoeducational assessment, children and teens with Bipolar Disorder may need a complete neuropsychological evaluation.
Parents also need to know that many children and teens with Bipolar Disorder have one or more anxiety disorders (including Obsessive-Compulsive Disorder). Anxiety disorders often emerge before the Bipolar Disorder, and can complicate both the course of the disorder and treatment of the disorder. When a young child has an anxiety disorder, do not ignore it or think that the child will just “outgrow” it. Early anxiety predicts adult problems, especially if there is a family history of mood disorders.