Bipolar Disorders: Mixed States, Rapid-Cycling, and Atypical Forms

238 B. Birmaher and D. AxelsonTable 10.1 Clinical manifestations of bipolar disorder in children andadolescentsTypical phenotype (DSM-IV) (bipolar I and bipolar II)Many of these children have rapid-cycling and mixed bipolar presentationsTypical phenotype but for a short time (DSM-IV BP NOS)Many have rapid-cycling and mixed episodesBroad phenotypeContinuous mood lability, mood swings, affective storms, irritability,anger, aggressiveness, periodic agitation, explosiveness, recurrent severetemper tantrums, ADHD-like symptomsDSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th edn;BP NOS, bipolar not otherwise specified;ADHD, attention-deficit hyperactivity disorder.subsyndromal BP symptoms, defined in the study as the presence of a distinctperiod of abnormally and persistently elevated, expansive, or irritable mood. Inclinical samples the incidence of BP disorder in children and adolescents hasranged from 2% to 15% depending on the nomenclature system, assessmentinstruments, and methodology used to diagnose patients’ psychiatric disordersand sample origin (e.g., inpatient versus outpatient; Geller et al., 1995; 1998a, b;Wozniak et al., 1995; Axelson et al., 1998).Clinical diagnosesBased on the literature and our clinical experience, the following three types of BPpresentations in youth can be identified (Nottelmann et al., 2001) (Table 10.1):(1) patients with typical DSM-IV BP characteristics(2) patients with DSM-IV BP characteristics but whose symptoms are of shortduration(3) children and adolescents with continuous mood lability, irritability, andsevere temper outburstsPatients with Kraepelinian or DSM-IV classical BP disorder display the cognitive,emotional, and behavioral BP symptomatology described in adult BP populations,with a great proportion having mixed and rapid cycles. These youths usuallyrepresent the minority of BP disorder cases seen at the clinics. In contrast, mostBP children and adolescents do not have the time duration (7 days for mania and4 days for hypomania) required by the DSM nomenclature and are usuallydiagnosed as BP-not otherwise specified (NOS). These patients usually displaymixed or very-rapid-cycling presentations but it is not clear whether they can be