COMMENTARY

What Is Unique About Bipolar Disorder in Young People?

Stephen M. Strakowski, MD

Disclosures

November 30, 2015

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Hello. I am Steven M. Strakowski, a professor of psychiatry and behavioral neuroscience, biomedical engineering, and psychology at the University of Cincinnati, where I also serve in the UC Health-attached academic health system as senior vice president and chief strategy officer. Today, I want to talk to you about the diagnosis of bipolar disorder in young people. Bipolar disorder in this age group has gained increasing attention in the last 5 years or so. At times, it has been a bit controversial. There have been concerns about it being overdiagnosed, for example. I think that some of the guidelines we will talk about today may help us think about this condition when faced with adolescents and kids who have it in our offices.

To begin, it's important to recognize that bipolar disorder is, in fact, a disorder of young people. The median age of onset is typically in the mid- to late-teens depending on the study to which you refer. Most patients will have the onset of their illness when they are under 21. It's a lifelong illness, so once it starts, we are then dealing with it for many years. It is particularly disruptive because it occurs at such a developmentally critical time. It interferes with the important processes adolescents are passing through of trying to become independent adults, which both confounds diagnosis at times and also makes treatment so very important.

As you can see in this slide that is attached with this discussion, I have compared a couple of studies, one from Kraepelin[1] back in 1921 and another one from Peter Roy-Byrne[2] in 1985. You will notice that they look virtually identical. What the slide is showing is the interval between concurrent episodes of bipolar disorders—so on this slide, 1 is the first interval between the first manic and second manic episodes, and 2 would be the next interval and so forth. Over time, these intervals steadily shorten. It suggests to us that the early course of bipolar disorder is progressive, so getting these kids treated early is probably the best chance we have of disrupting or slowing this progression.

When you think about making a diagnosis of bipolar disorder in a young person, there are several considerations. First of all, we can't diagnose bipolar disorder until there is a manic episode. By definition, bipolar disorder type I requires a manic episode. Bipolar disorder type II requires a hypomanic episode plus depression also. There is also the NOS (not otherwise specified) category of bipolar disorder that is softer and allows some flexibility. We will talk about that a bit later. Nonetheless, the manic episode is the first defining event for a diagnosis of bipolar disorder, but in these kids, it's often preceded by depression, anxiety, and attention-deficit/hyperactivity disorder (ADHD)-type symptoms, which can be really confusing when they finally present with the mania. Additionally, substance abuse might predate this first episode; and, more importantly, the first year after the first manic episode looks like a very high-risk period for the onset of substance abuse, so that is important to monitor over time.

When making the diagnosis, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) criteria—although they have been predominantly developed in adults—are nonetheless still the gold standard that we use in kids. When making a bipolar disorder diagnosis, the kids are expected to meet these criteria. Two big ones are that first there is a distinct mood change. Typically, irritability and euphoria are common. Keep in mind that irritability is a common and recognized symptom for depression in adolescents too, so that differential becomes more complicated, and we will mention that more in a second. The second criterion is that there needs to be a distinct change in activity or energy level. This change can't just be a continuation of underlying hyperactivity from ADHD. In both cases, these symptoms and the other so-called "B" symptoms of changes in sleep, pursuit of specific activities, and flight of ideas, etc., need to be present. It must be episodic in that it has to be a change from an underlying baseline, or a diagnosis of bipolar disorder is not appropriate.

There are differences from adults. For example, kids may present with softer, less-defined syndrome constructs. Kids may be more likely to present with mixed episodes or more depressive symptoms. Again, by definition, because irritability is a depressive symptom in kids, the likelihood of meeting criteria for both depression and mania is naturally increased. There is some disagreement in studies, but kids may have more psychotic symptoms than adults, although developmentally this can often be complicated to discern. Neurovegetative symptoms or signs—specifically sleep disruption—may be less pronounced and may be better protected in childhood or adolescent brains, perhaps, than adult brains. Finally, the onset in youth may be less abrupt or precipitous compared with in adults. There may be more of a gradual lead-in period where the episodes may be less clear, but in the end an episode must occur, or we cannot differentiate bipolar disorder from more chronic conditions. That becomes important when making the diagnosis.

When we are looking at kids and thinking about a bipolar disorder diagnosis, it becomes important to place the symptoms within the developmental context of that child. This is not necessarily the same thing as their chronologic age because people develop at different rates. An imaginary friend in an 11-year-old may be unusual but may be consistent with a kid's developmental age, so that wouldn't be a sign of psychosis, for example.

We need to try to understand where the child fits typically in the developmental line before we decide that some goofy symptoms of just being a kid are actually euphoria or some impulsive symptoms, which again may be just part of being a kid or some new part of a manic episode. It becomes very important to understand the context of that child, and if you are not clear or sure, then a diagnosis should be delayed.

A critical part of diagnosing bipolar disorder in kids is family history. If there are lots of bipolar people in the family—for instance, the mom, dad, and brother are bipolar—then these symptoms are almost certainly likely to be considered bipolar disorder. If there is a complete absence of mood disorders in the family anywhere, however, then you should really challenge this assumption that the kid has bipolar disorder because bipolar disorder is 85% heritable. It is unusual to just show up in a family line where it has never been before. That being said, one of the complicating factors in general when working with families around mental illness histories is that often times they don't talk about mental illness. So there may, in fact, be bipolar family members that the current parents and child are unaware of. Within my own practice, I find that all the time. I work with families, and over time it slowly unravels that, in fact, there are multiple generations of bipolar people that when we started none of us were aware of, so keep that in mind as you look for that symptom. Again, the complete absence of a family history of mood disorder makes a bipolar disorder diagnosis much less likely.

In adults, bipolar disorder I, II, and NOS tend to stay constant over time, and people don't migrate often between them, but in kids that is much less true. An NOS diagnosis or a bipolar II diagnosis in a 14-year-old may go on to progress to a full bipolar disorder I by the time they are an adult. Keep that in mind as you follow and treat the kids over time. When you think about what is the differential of bipolar disorder in an adolescent or child, the first and perhaps most commonly confused diagnosis is depression. Again, irritability is a depressive symptom in children, and agitation is not uncommon during depression in children and adolescents. Those two can make it very difficult to identify whether this is a bipolar child or a unipolar, depressed child. Having an early onset, particularly severe depression, is a predictor of developing bipolar disorder over time, but it's not defining. In fact, most kids who present that way are not going to develop bipolar disorder. Here, again, family history becomes very important in meeting the fuller criteria of mania. Relying on DSM-5 criteria and making sure that they are all present before diagnosing mania becomes critical. It is often not possible to be sure, so following kids over time is the best way to keep a close eye on the evolving bipolar symptoms.

ADHD is another confounding condition because of the hyperactivity and distractibility and other symptoms, but typically a kid with ADHD will have a very chronic course and doesn't have episodic events, so that becomes the defining difference. Also, although depression is relatively common, mania is not, so we would look for those differentiating factors. Substance abuse disorders, particularly in teenagers, can mimic many of the symptoms. Alcohol use, cocaine use, and opiates—which are widely epidemic now—all can mimic mood and even manic and depressed symptoms, so that history becomes very important.

There has been some very nice recent work done by Ellen Leibenluft and her group at the National Institutes of Health, in which they noticed that a lot of kids who are chronically irritable were getting a diagnosis of bipolar disorder, yet follow-up studies suggested that these kids were unlikely to develop bipolar disorder and showed more of a recurrent depressive course of illness. That became a new diagnosis in DSM-5 called disruptive mood dysregulation disorder, which is characterized by chronic irritability rather than episodic mood symptoms. Finally, disruptive and impulsive conduct disorders can have pieces that can look like what a person might be doing in the context of mania, but typically these kids will lack the broader fuller expression of mania that is expected in DSM-5.

Even though there are differences between adults and kids, and that is absolutely true, by placing the DSM-5 criteria for bipolar disorder within the developmental context of the kid, you may be able to be more confident of whether or not it is bipolar disorder in a young person. Ultimately, it is the careful treatment, re-evaluation, and critical assessment of your diagnosis that will be what is most helpful for kids presenting with these types of symptoms. As a reference, we have a book published by Oxford University Press called Bipolar Disorder in Youth: Presentation, Treatment and Neurobiology[3] in which a lot of these ideas are discussed in much more detail, which you might find useful. These are interesting kids. Many of us manage them in our practices. I think that we can really have a major impact in their lives by managing them well. I hope that these guidelines and thoughts today are useful for you as you work with these children. Thank you very much.

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