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

241 Bipolar disorder in children and adolescentsTable 10.2 Consequences of bipolar disorder* Poor academic functioning* Interpersonal and family difficulties* Increased risk for suicide* Increased use of tobacco, alcohol, and other substances* Behavior problems* Legal difficulties* Increased health services utilization (e.g., hospitalizations)irritability, ADHD-like symptomatology, sometimes silliness, and short periods ofdysphoria (Wozniak et al., 1995; Biederman, 1998). Since these children have‘‘continuous manic symptoms’’ without accompanying elation or grandiosity, it isdifficult to differentiate them from other psychiatric disorders and in particularADHD or oppositional defiant disorder (ODD).This last group of children represents the majority of patients currently referredto our clinics to rule out BP disorder. They usually have heterogeneous psychiatricdisorders (e.g., ADHD, ODD, Asperger’s disorder, recurrent MDD) accompaniedby mood lability. An undetermined proportion of these children are likely to haveBP disorder.It is imperative to improve the diagnostic accuracy of BP disorder in youth.Early-onset BP disorder has severe negative psychosocial and academic consequencesthat can be potentially ameliorated by proper diagnosis and treatment(Table 10.2). In addition to delay in proper treatment, BP youth who are misdiagnosedas simply ADHD or depressed often receive stimulant medication and/or antidepressants that, without concomitant mood-stabilizer treatment, mayworsen the course of illness.To identify BP disorder in youth, clinicians as well as researchers need to takeinto account the following issues:(1) As stated before, it appears that the manic/hypomanic symptoms in youthfrequently do not persist long enough to meet the time duration criteria requiredby the DSM-IV for a manic and hypomanic episode (Klein et al., 1985; Gelleret al., 1995, 1998a, b;Wozniaket al., 1995;GellerandLuby,1997;Axelsonet al.,1998; Biederman,1998). These shorter periods of mania or hypomania can beeasily overlooked and patients can be misdiagnosed with unipolar depressions,ADHD plus MDD, and personality disorders (e.g., borderline).(2) Childhood-onset BP disorder is frequently manifested by mixed or veryrapid-cyclingepisodes of very short duration instead of the classical DSM-IV mixed and rapid-cycling DSM-IV classification (Akiskal et al., 1985; Klein