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Diagnosing Bipolar Disorder in Children and Adolescents
Question:
"I need some guidance on how not to miss bipolar disorder in the kids and adolescents I see in my practice. What steps do you recommend I take in order to not miss it? Mind you, I also don’t want to over-diagnose this disorder!"
There are few areas in mental health that are more controversial, and frankly, more in need of an open discussion than childhood and adolescent bipolar disorder. Your question is therefore much appreciated. I will not claim to have all the answers, nor is there a guaranteed approach to differential diagnosis that leads to the correct diagnosis a hundred percent of the time. There simply isn’t. No blood test for bipolar exists, nor any diagnostic imaging studies.
Bummer, huh?! What is true, however, is that this disorder can, and does present in childhood and adolescence, and its incumbent upon us to make the diagnosis as accurately and promptly as we can. Why? Because an accurate diagnosis is often the first step to helping the patient and the family get on the road to recovery.
So what is known? What is the best way to navigate this minefield and do both things well – correctly diagnose, and avoid over diagnosis?
First, let’s recognize that the concept of childhood mood disorders of any kind, including major depression, is new to psychiatry. You and I would perhaps be shocked to hear that as recently as the middle of the last century, it was thought that children and adolescents simply did not possess the cognitive ability to be depressed! Of course today none of us practicing clinicians believe this to be true. Too often we see depressed youngsters in our practice. The concept of pediatric and adolescent bipolar disorder was similarly dismissed, to the extent that some of the earlier texts of psychopharmacology considered bipolar disorder an exceedingly rare condition. Today, our thinking of course has vastly changed.
By the same token, there is considerable worry in the field that clinicians over-diagnose bipolar disorder, and that we inaccurately apply this label when clinicians only detect a few symptoms (particularly severe irritability) in youngsters. This has lead to a huge public and professional backlash against the diagnosis. This creates an even greater urgency to make the diagnosis correctly, and to reject it when not deserved by the patient’s symptomatology.
Ok, here we go! Let’s examine some fundamental issues:
* DSM –IV-TR does not offer separate diagnostic criteria for adult and for pediatric bipolar disorder. This is a problem. We have to screen for bipolar disorder in the context of that particular patient’s developmental age. This is challenging as development occurs throughout childhood and adolescence. Bipolar disorder can present differently in different aged kids
* Irritability is a common symptom in pediatric bipolar disorder. Problem – irritability is also a common symptom in other common pediatric mental health disorders – such a major depression, ADHD, anxiety disorders, oppositional defiant disorder, etc. Therefore, I caution you against making a diagnosis of bipolar disorder just in the presence of irritability alone. More symptoms of bipolar disorder must be present in order to make the diagnosis with confidence
* Rapid and very rapid mood fluctuations, often multiple mood changes occurring in a single day, are common in pediatric bipolar disorder. This often leads to diagnostic confusion and a label of ‘behavior problems’ is often incorrectly applied
* The presence of irritability, no matter how severe, in the absence of any other symptoms of mania or hypomania is not reason enough to justify a diagnosis of bipolar disorder. I recommend you look for other DSM-IV-TR symptoms, keeping in mind the patient’s specific developmental stage in life, before you either include or exclude the bipolar disorder diagnosis
* Bipolar disorder, when missed, is often misdiagnosed with a host of other conditions – mainly major depression and ADHD. This can be quite problematic as the medications often used to treat these conditions (anti-depressants and stimulants), often destabilize the underlying bipolar disorder
* There is true urgency in diagnosing bipolar disorder as early as possible. This disorder appears to remain and creates a sizable negative impact on a youngster’s psychosocial development
In light of these fundamental issues, I have the following suggestions for you in order to make the accurate diagnosis of bipolar disorder in the youngsters:
* Maintain a high index of suspicion when seeing patients under 18 years old, who present with behavioral issues, mood difficulties, irritability and/or conduct problems.
* Be particularly watchful if there is a ‘loaded’ family history for mood and/ or conduct difficulties in first and second-degree relatives.
* Ask questions regarding bipolar symptoms proactively. Bipolar disorder is not a ‘waste basket’ diagnosis to offer when we are not certain of a diagnosis.
* Be familiar with the DSM-IV-TR diagnostic criteria. Ask the questions of both the family (parents, grandparents, care takers, etc.) along with questioning the youngster. More information equals better diagnostic certainty. This formula is a useful way to approach your differential diagnosis process. Expect some disagreement between informants. In my experience this is the rule and not the expectation. It only means we have to sift through the information carefully in order to move towards a correct diagnosis.
* Use screening/rating instruments. For older adolescents the MDQ is reasonable. For younger kids, I like the use of the pediatric version of YMRS (Young Mania Rating Scale). Both are freely available and underused. I recommend you use them routinely.
* If the clinical presentation is of significant irritability and moodiness, carefully and thoroughly look for other symptoms. For example, grandiosity, elation, elevated mood, decreased need for sleep, racing thoughts, etc.
* If the patient meets full criteria for another DSM IV-TR disorder (such as major depression, ODD) do remember this does not stop our hunt and screening for bipolar disorder! Why? Bipolar disorder, when present, is frequently co-morbid with other conditions.
* And finally, despite all these efforts, at the end of the day, be willing to be unable to make a firm decision of whether patient has bipolar disorder or not. This is the reality of pediatric evaluations. In my experience, very often I will meet kids that even with a thorough evaluation as described above, I am unable to either include or exclude the diagnosis. It’s okay to be in this position, rather than precipitously or prematurely decide one way or another.
In such a situation, I have the following recommendations:
* Frankly discuss your uncertainty with the family
* It’s perfectly reasonable to defer making a firm decision in such situations. The best thing to do is reevaluate (using the process described above) at regular intervals. In other words, do not assume because your first assessment was inconclusive, future ones will be too. Often clarity in either direction develops with the passage of time and repeated assessments conducted over a period of time
* Consider getting second opinion from a colleague.
* Treat the diagnosis you are certain of (such as ADHD or major depression, but do so cautiously. Dose medications slower than usual and see the patients more often than is typical for your proactive.
* Warn patients and family member about symptoms of possible emergent mania and ask them to call if they notice anything untoward.
I fully realize I have offered you a long list of recommendations. I would not fault you for perhaps thinking, “This is too complicated! I would much rather not deal with this!” I would counter that by saying that we as clinicians are often charged with serious and important tasks. Assessing for bipolar disorder is one of these. I can assure you that if you follow my suggestions above, you surely with have greater success in accurately diagnosing bipolar disorder in those kids who have it, and exclude it in those who don’t. Good luck to you, your patients and their families.
Rakesh Jain, MD
Suggested Reading 1-10
1. Hoertel N, Le Strat Y, Angst J, Dubertret C. Subthreshold bipolar disorder in a U.S. national representative sample: Prevalence, correlates and perspectives for psychiatric nosography. Journal of affective disorders. Oct 3 2012.
2. Margulies DM, Weintraub S, Basile J, Grover PJ, Carlson GA. Will disruptive mood dysregulation disorder reduce false diagnosis of bipolar disorder in children? Bipolar disorders. Aug 2012;14(5):488-496.
3. Galanter CA, Hundt SR, Goyal P, Le J, Fisher PW. Variability among research diagnostic interview instruments in the application of DSM-IV-TR criteria for pediatric bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry. Jun 2012;51(6):605-621.
4. Pliszka SR. Tracking the development of bipolar disorder in childhood. The American journal of psychiatry. Jun 2012;169(6):557-559.
5. Favis TL. Screening for pediatric bipolar disorder in primary care. Journal of psychosocial nursing and mental health services. Jun 2012;50(6):17-20.
6. van Zaane J, van den Berg B, Draisma S, Nolen WA, van den Brink W. Screening for bipolar disorders in patients with alcohol or substance use disorders: performance of the mood disorder questionnaire. Drug and alcohol dependence. Aug 1 2012;124(3):235-241.
7. Castelo MS, Hyphantis TN, Macedo DS, et al. Screening for bipolar disorder in the primary care: A Brazilian survey. Journal of affective disorders. Sep 6 2012.
8. Zimmerman M. Misuse of the Mood Disorders Questionnaire as a case-finding measure and a critique of the concept of using a screening scale for bipolar disorder in psychiatric practice. Bipolar disorders. Mar 2012;14(2):127-134.
9. Belmaker RH. Editorial:Pediatric Bipolar Disorder. The Israel journal of psychiatry and related sciences. 2012;49(1):2.
10. Renaud S, Corbalan F, Beaulieu S. Differential diagnosis of bipolar affective disorder type II and borderline personality disorder: analysis of the affective dimension. Comprehensive psychiatry. Oct 2012;53(7):952-961.
