Is Bipolar Disorder Overdiagnosed in Children and Adolescents: A Virtual Debate

Kiki Chang, MD; Gabrielle Carlson, MD; Stephen M. Strakowski, MD

Disclosures

September 10, 2010

In This Article

The Source of the Confusion

Dr. Carlson: What do you think is the source of the confusion? In your experience, what disorders or circumstances cause the biggest confusion? Let's see if they are similar in kids and adults.

Dr. Chang: For me it is irritability (no news there) and especially explosive reactions. Clearly this is a common problem for children and as you have proposed for many years Gaye, there are many reasons for this besides BD.

I wonder if indeed there is similar confusion in adults. Steve?

Dr. Strakowski: Although certainly there are interface difficulties in adults with mania and with intermittent explosive disorder, as well as other personality (eg, borderline personality disorder) and psychotic disorders, the criteria for DSM-IV and predecessors were specifically developed in adults making them more useful for sorting through these issues. I suspect there are misdiagnoses occurring across the boundaries going both ways, although I don't believe we know much about the details in this regard. The exception may be the recognized problem of blacks with mood disorders generally being overdiagnosed with schizophrenia. It seems to me, being an adult psychiatrist, that a struggle in diagnosing BD in kids is the uncertainty of the specific diagnostic patterns that predict a subsequent course of illness -- the uncertain relationships between pediatric (pre-pubescent) and 'typical' (adolescent or adult) onset BD, and the likelihood that even the same etiologic factor will produce different behaviors in brains at different developmental stages. I would be interested in child psychiatry's view here.

Ultimately, the problem is a lack of objective markers that permit specific distinction among mental illnesses and the likelihood that bipolar disorder, as well as other psychiatric diagnoses, are comprised of multiple etiologies.

Dr. Carlson: I just spent some time with Judy Rapoport (Chief of the National Institute of Mental Health's [NIMH] Child Psychiatry Branch)[1] at an editorial board meeting. We were talking about the strategy she adopted with childhood schizophrenia decades ago. She stuck firmly to adult criteria for schizophrenia, and had another category for what might be called "possible developmental phenotypes." It took her ages to get a sample but what she has, are patients with undeniable adult schizophrenia beginning in childhood. Her alternative forms, it turns out, did not predict schizophrenia. In the sample of kids who were "multidimensionally impaired," one third had mood disorder (half BD, half unipolar depression), one third had behavior disorders, and one third remained "psychosis NOS." Clearly, her sample does not address all of the other kids in whom schizophrenia ultimately develops, and there is certainly no question that in adults, schizophrenia is heterogeneous.

One of the points she made in our conversation was that there is a huge body of work in adult schizophrenia that advises on the kinds of things (in terms of imaging, eye movements, etc) to be done in kids.

I am sorry we did not do the same thing in bipolar disorder, although I realize that the way we have to go about getting grants, with a time-limited period in which to collect a sample, makes that impossible. What we have in child bipolar research is everyone swearing on the DSM-IV bible, but, as I've said before, like the bible, everyone interprets the criteria differently. What Barbara Geller or Joe Biederman, and so on call episodes is not something I would call an episode. People who define euphoria as "silly and giddy" recognized by parents tap into many things that aren't really "euphoria-driven." The way everyone has collected their data with the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS) of one form or another[2,3,4,5,6,7] precludes our being able to look at each other's samples to determine where there are similarities and differences in informant output interpretation. That is, the interview form has check marks for each symptom but unless a good description is written for why a particular symptom endorsement choice was made, and unless there is a good history in which to embed the co-occurring symptoms, it is difficult retrospectively to see how much agreement or disagreement there might be between noncollaborating sites.

Kiki is right in saying that BD in kids is more common than we thought but "Cades disease" (classic manic depressive illness) is still pretty rare, and, because I spent time at NIMH in adult psychiatry many years ago, in my mind, that is the template -- the same way Judy Rapoport's template for childhood schizophrenia mirrors a fairly narrow phenotype of adult schizophrenia. I have been humbled both ways over the years in terms of follow-ups. I've seen more classic-appearing BD develop in adolescence in kids with ADHD-like symptoms,[8] and I have seen kids with what looked like episodes, stop having episodes and stop looking like BD as they have gotten older. But adolescents with classic manic-depression are much less likely to change their stripes.[9]

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