Diagnostic Considerations
Upon presentation to health care services, youths with bipolar disorder exhibit behaviors that mimic and overlap those of other diagnoses, particularly attention deficit/hyperactivity disorder (ADHD) and conduct disorder. In the early stages of ADHD and conduct disorder, as in patients with bipolar disorder, activity is increased, and self-esteem may be inflated. Societal and educational responses to the behaviors of ADHD and conduct disorder may ultimately reduce self-esteem in these patients compared with those with bipolar disorder.
Comparison of the characteristic behaviors noted in these 4 important disorders that affect young individuals may help in establishing the diagnosis of bipolar disorder (see the table below). [52] .
Table 1. Characteristic Behaviors Associated With Bipolar Disorder, DMDD, ADHD, and Conduct Disorder (Open Table in a new window)
| Behavior | Bipolar | DMDD | ADHD | Conduct Disorder |
|---|---|---|---|---|
| Self-esteem | Inflated | Deflated/irritable | Inflated and/or deflated | Inflated and/or deflated |
| Pleasure | Euphoric in mania Dyphoric in mixed or depressed state |
Variable | Often dysphoric or euthymic | Pleasure in violating societal norms, especially if not caught |
| Attention | Distractible | Distractible | Distractible | Normal to vigilant |
| Hyperactivity | Goal directed | Variable | Unproductive | Goal directed |
| Sleep | Episodic disturbances such as decreased need in mania | Often poor due to avoiding bedtime | Chronic poor sleep; often late bedtimes | Not known to be disrupted except with substance abuse |
| Speech | Pressured or rapid in mania; slow in depression | Rapid/normal rate | Often rapid; may be pressured | May be normal |
| Impulsivity | Externally driven/reactive | Reactionary | Internally driven | May engage in predatory or reactionary acts |
| Social | Often good | Often poor | Often poor | Often poor |
| Academic | Often good | Varies | Often poor | Often poor |
| Psychomotor activity | Agitated in mania or mixed states; retarded in depressed states | Easily agitated | Chronically agitated | Easily agitated |
| ADHD—attention deficit/hyperactivity disorder |
Additional consideration must be given to the possibility of schizophrenia or schizoaffective disorder, posttraumatic stress disorder (PTSD), substance abuse, or anxiety states (eg, generalized anxiety disorder, social anxiety disorder). Any of these disorders may transiently mimic bipolar disorder. Rarely is dementia an issue in youths, but it may have to be excluded in some patients (particularly after head trauma).
Psychometric instruments can be helpful in diagnosis of bipolar disorder, particularly if coexisting ADHD is possible and if other disorders (eg, schizophrenia, intellectual disability) need to be ruled out. [53]
Comorbid conditions
Biederman et al noted that the combination of conduct disorder and major depression in adolescence could be predictive of bipolar disorder in a 4-year follow-up assessment of those patients. [54] An estimated 10-15% of adolescents who present with recurrent episodes of major depression are later diagnosed with bipolar disorder. In addition, children with ADHD who later develop bipolar disorder have increased rates of other psychiatric conditions, including opposition defiant disorder (ODD).
Overall, the combined symptoms of severe ADHD, unstable affect, and aggression may be predictive of bipolar disorder later in life among children in whom ADHD is already diagnosed.
An important predictor of bipolar disorder in youth was impaired sleep and disruptive behavior disorder (DBD), as well as impaired frustration tolerance. [55, 44]
The data specifically suggested that the combination of ADHD with ODD, correlated with a future onset of bipolar symptoms at a rate of 7%, whereas there was a 5% correlation for ADHD alone. When ADHD was present with ODD that progressed to conduct disorder, the occurrence of bipolar disorder dramatically increased to 44%. That is, approximately 55% of adolescents who have a diagnosis of comorbid ADHD, ODD, and conduct disorder do not have an onset of bipolar symptoms.
Nonetheless, a potential complication to note in youths who have comorbid ADHD and ODD is the development of bipolar features, including depression and psychosis. In addition, the combination of ADHD and ODD increases the likelihood that the patient will become involved in illegal activities and incarceration. Therefore, bipolar symptoms already exist or may develop in some incarcerated youths. [56, 31]
In a prospective study of 26 prepubertal youths in whom bipolar disorder and conduct disorder manifested at age 8-13 years, Kovacs and Polack found at their 12-year follow-up evaluation that the lifetime comorbidity for these 2 disorders was 69%. Additional review of the pattern of psychiatric pathology revealed that of the patients in whom both disorders began when they were younger than 13 years, 42% were diagnosed first with conduct disorder, whereas 27% were diagnosed first with bipolar disorder. [57]
Because clinicians are often concerned that conduct disorder increases the risk of antisocial personality disorder, careful screening and monitoring for the comorbid conditions of bipolar disorder and conduct disorder may be necessary in youths who present with either of these disorders. Such screening may help to identify and treat these youths so they may avoid incarceration and perhaps erroneous labeling as antisocial adults rather than as individuals with coexisting bipolar disorder and conduct disorder. [56]
Incarcerated youths have a disproportionately high prevalence of bipolar disorders compared with youths in the general population. Steiner estimated that 2% of incarcerated juveniles have bipolar I disorder (BPI), whereas 4% have bipolar II disorder (BPII). [58]
ADHD is a commonly observed comorbid diagnosis in youths with bipolar disorder. Among prepubertal youths presenting with bipolar symptoms, some studies have shown that as many as 90% have a diagnosis of ADHD, although other researchers have found lower comorbid incidences of ADHD. Among adolescents, the highest reported percentage of concurrent ADHD in those with bipolar disorder is 30%. [59, 28]
The most reliable predictor of DMDD is chronic irritability combined with a lack of history of mania along with a family history of ADHD, conduct disorder or oppositional defiant disorder. [52]
Comorbid conditions should be assessed in a timely fashion. Autism spectrum disorder and pediatric anxiety disorder may present with mood disturbances. [55] Comorbid substance abuse, especially nicotine abuse, presents along with ADHD. [40]
In summary, sustained symptoms of conduct and impulse control problems may be warning signs of a prepubertal onset of bipolar disorder.
Other conditions to be considered include the following:
-
Delinquency/truancy
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Oppositional defiant disorder
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School refusal
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Thyrotoxicosis
Differential Diagnoses
Tables
| Behavior | Bipolar | DMDD | ADHD | Conduct Disorder |
|---|---|---|---|---|
| Self-esteem | Inflated | Deflated/irritable | Inflated and/or deflated | Inflated and/or deflated |
| Pleasure | Euphoric in mania Dyphoric in mixed or depressed state |
Variable | Often dysphoric or euthymic | Pleasure in violating societal norms, especially if not caught |
| Attention | Distractible | Distractible | Distractible | Normal to vigilant |
| Hyperactivity | Goal directed | Variable | Unproductive | Goal directed |
| Sleep | Episodic disturbances such as decreased need in mania | Often poor due to avoiding bedtime | Chronic poor sleep; often late bedtimes | Not known to be disrupted except with substance abuse |
| Speech | Pressured or rapid in mania; slow in depression | Rapid/normal rate | Often rapid; may be pressured | May be normal |
| Impulsivity | Externally driven/reactive | Reactionary | Internally driven | May engage in predatory or reactionary acts |
| Social | Often good | Often poor | Often poor | Often poor |
| Academic | Often good | Varies | Often poor | Often poor |
| Psychomotor activity | Agitated in mania or mixed states; retarded in depressed states | Easily agitated | Chronically agitated | Easily agitated |
| ADHD—attention deficit/hyperactivity disorder |
Medication |
Common Adverse Effects |
Pediatric Doses |
Special Concerns |
Lithium carbonate (Lithobid) |
GI distress, lethargy or sedation, tremor, enuresis, weight gain, alopecia, cognitive blunting |
10-30 mg/kg/d; dose must be adjusted by monitoring serum level and patient response; up-titrate on twice-daily schedule |
Hypothyroidism, diabetes insipidus, toxic in dehydration, polyuria, polydipsia, renal disease; drug-drug interactions and sodium intake may alter therapeutic serum levels Approved for patients 12 y and older |
Sodium divalproex/valproic acid (Depakote, Depakene) |
Sedation, platelet dysfunction, liver disease, alopecia, weight gain |
15-30 mg/kg/d; dose must be adjusted by monitoring serum levels; up-titrate on twice- or thrice-daily schedule |
Elevated liver enzymes or liver disease, drug-drug interactions, bone marrow suppression Approved for patients 12 y and older |
Aripiprazole (Abilify, Abilify Discmelt) |
Less likely to cause prolactinemia than risperidone; may cause Stevens-Johnson syndrome; as with other atypical antipsychotics, may cause tardive dyskinesia, dystonia, parkinsonism, hyperglycemia; use with caution in seizure disorders and cardiac disorders, including problems with cardiac contractility and electrical activity |
2 mg once daily can be increased to 5 mg, 10 mg, 15 mg, to a maximum of 30 mg to start titrate upwards at weekly to bimonthly intervals |
levels may need to be adjusted in patients who are concurrently receiving lamotrigine, topiramate, Depakote, lithium, or other serotonin-norepinephrine reuptake, selective serotonin reuptake, or cytochrome P450 inhibitors Do not administer if there is an unstable seizure disorder Approved for patients 12 y and older |
Carbamazepine (Equetro) |
Suppressed WBCs, dizziness, drowsiness, rashes, liver toxicity (rare) |
10-20 mg/kg/d; dose must be adjusted by monitoring serum blood levels; up-titrate on twice-daily schedule |
Drug-drug interactions, bone marrow suppression |
Asenapine (Saphris) |
Somnolence, oral paraesthesia |
2.5 mg SL q12h initially; may increase to 5 mg SL q12hr after 3 days and to 10 mg SL q12hr after 3 additional days |
Pediatric patients are more sensitive to dystonia with initial dosing when recommended escalation schedule not followed Approved for patients 10 y and older |
Risperidone (Risperdal, Risperdal Consta, Risperdal M-Tab) |
Weight gain, sedation, orthostasis |
0.25 mg bid or 0.5 mg at bedtime initially; titrate as tolerated to target dosage of 2-4 mg/d; not to exceed 6 mg/d |
Galactorrhea, extrapyramidal symptoms Approved for patients 10 y and older |
Quetiapine (Seroquel, Seroquel XR) |
Sedation, orthostasis, weight gain |
50 mg bid initially; titrate as tolerated to target dosage of 400-600 mg/d |
Decrease dosage with hepatic impairment, may cause neuroleptic malignant syndrome or hyperglycemia Approved for patients 10 y and older |
Olanzapine (Zyprexa, Zyprexa Zydis, Zyprexa Relprevv) |
Weight gain, dyslipidemia, sedation, or orthostasis |
2.5-5 mg at bedtime initially; titrate as tolerated to target dosage of 10-20 mg/d |
Metabolic syndrome, extrapyramidal symptoms |
Clonazepam (Klonopin) |
Sedation, abnormal coordination, ataxia |
0.01-0.04 mg/kg/d PO at bedtime or divided bid |
Caution with renal/hepatic impairment and asthma |
Fluoxetine (Prozac) |
Headache, nausea, insomnia, anorexia, anxiety, asthenia, diarrhea, somnolence |
10 mg PO qd; may consider increasing to 20 mg/d after 1 wk |
Long half-life; potential to exacerbate manic symptoms when not coadministered with an antimanic or mood-stabilizing agent |
Ziprasidone (Geodon) |
Akathisia, nausea |
Off-label: 20 mg PO at bedtime; can increase to 40 mg (not to exceed 60 mg), usually in 2 divided doses for children |
Risk of sudden cardiac death due to torsades des pointes due to prolonged QT prolongation, which makes this medication undesirable for individuals with a family history of cardiac sudden death related to cardiac conduction abnormalities |
WBC—white blood cell. |
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