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

242 B. Birmaher and D. Axelsonet al., 1985; Bowring and Kovacs, 1992; Carlson and Weintraub, 1993;Carlson, 1995; Geller et al., 1995, 1998a, b; 2000a, b; 2002a, b; Lewinsohnet al., 1995, 2000; Weller et al., 1995;Wozniaket al., 1995;Axelsonet al., 1998).(3) Most children and adolescents with BP disorder have comorbidity withADHD and behavior-disruptive disorders (Bowring and Kovacs, 1992;Carlson, 1995; Geller et al., 1995, 1998a, b, 2002a; Kovacs and Pollock, 1995;Lewinsohn et al., 1995, 2000; Weller et al., 1995; Wozniak et al., 1995; Axelsonet al., 1998; Biederman, 1998). These comorbid conditions usually confoundthe diagnosis of BP disorder in youth.(4) It appears that early-onset BP disorder conveys a worse course and outcomethan BP disorder that started during adulthood (Geller et al., 2002a, b).(5) The child’s emotional, cognitive, and behavioral developmental stages need tobe taken into consideration when assessing symptoms of BP disorder (e.g.,fantasies versus grandiosity; Bowring and Kovacs, 1992; Carlson, 1995).(6) Environmental factors (e.g., family conflicts, parental psychopathology, negativelife events) may affect the clinical presentation and course of illness(Geller et al., 2002b).(7) Overdiagnosis of BP disorder in children and adolescents also has seriousconsequences, as youth with other psychiatric conditions are unnecessarilyexposed to medications with significant risk for side-effects and do not receivepotentially therapeutic treatments for their actual disorder.Longitudinal courseLewinsohn et al. (1995) evaluated 1709 high-schoolers (ages 16.6 1.2 years old,54% females, 91% Caucasian) with the K-SADS Present and Epidemiological versionsand found 1% (18) with BP disorder (mainly BP-II and cyclothymia) and 5.7%(97) with subsyndromal BP symptoms. These patients were reinterviewed 14 monthsafter intake and compared with 316 subjects with MDD and 845 normal controls.The BP patients had the worse course, with a median duration for their index episodeof illness of 80 weeks. Also they had more functional impairment, psychosis, suicidality,comorbid anxiety and disruptive disorders, and mental health utilization thanthe other two groups (Fig. 10.3). The subjects with subsyndromal BP symptoms hadlevels of impairment and comorbidity that were comparable to the BP group.Strober et al. (1995) reported results from a 5-year naturalistic, prospectivefollow-up of a small sample (n ¼ 54) of inpatient adolescents with BP-I disorderutilizing semiannual assessments. Although the absolute likelihood of recovery( 8 weeks with < 2 symptoms) was high in the sample as a whole, 20% of thesample had suicide attempts requiring medical attention and time to recovery