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

240 B. Birmaher and D. Axelson% of patientsBP-spectrum MDD Other Axis I D/O252015105Fig. 10.20Suicide attemptBP > other axis I (P = 0.01)PsychosisBP > other axis I (P < 0.001)BP > MDD (P < 0.001)Conduct D/OBP > MDD (P = 0.003)Western Psychiatric Institute and Clinic (WPIC) mood and anxiety disorder outpatients.BP, bipolar; MDD, major depressive disorder; D/O, disorder.Similar to other studies, the youth presenting with manic symptoms to theWPIC outpatient services had severe psychopathology that was often more seriousthan other children and adolescents presenting for clinical treatment (Fig. 10.2).Compared to non-BP youth presenting with a major depressive disorder (MDD,n ¼ 916), children and adolescents with manic symptoms had significantly higherrates of psychosis (20% versus 7%) and conduct disorder (18% versus 11%).Youth presenting with manic symptoms also had higher rates of psychosis (20%versus 3%) and suicide attempts (25% versus 16%) compared with youth who metcriteria for other non-MDD, non-BP Axis I disorders (n ¼ 679).Depression during the current psychiatric episode was a pervasive feature ofchildren and adolescents who presented to our outpatient services with manicsymptoms. Approximately 66% of these patients had moderate or worse depressedmood and 78% of them met three or more DSM-IV criteria for MDD during thecurrent psychiatric episode. Forty-five (38%) of the children and adolescents whopresented with manic symptoms were also given a clinical diagnosis of MDDduring the current psychiatric episode. The high rates of mixed states and cyclingbetween depression and manic symptoms were similar to the ones reported inGeller and colleagues’ study, reported above. Also, as in the study by Geller et al.(1998b), irritability was a non-specific symptom that did not differentiate BPyouth from youth with other disorders. Irritability was present in 93% of youthpresenting with manic symptoms, while irritability was present in 89% of youthwith MDD and 60% of youth with other Axis I disorders.In addition to the BP presentations described above, there is a more controversialgroup of children who have been diagnosed as BP (Table 10.1). Thesechildren do not have typical manic/depressive symptoms but ongoing moodlability, very low frustration tolerance, agitation, frequent severe temper outbursts,