Description

The differential diagnosis and comorbidity of bipolar disorder, mania and adhd.

PREVALENCE:

The prevalence of child and adolescent manic depression (bipolar disorder) is said to affect 1% of youth, with equal rates of boys and girls and may be increasing.  The diagnosis of bipolar disorder in youth is often very difficult, as the symptoms typically do not follow the symptoms and course of adults with this disorder.  Also, there is an overlap of symptoms with several other more common childhood disorders. 

DEFINITION:

Bipolar disorder is a severe mental illness manifested by recurrent episodes of depression, mania and/or mixed symptom states.  Children and some adolescents show a much greater percentage of mixed symptoms, expressing both depressive and manic behaviors at the same time (agitated dysphoria) or rapidly fluctuating moods.  Children most commonly present  with a mixed and dysphoric picture, characterized by frequent short periods of intense emotional ability and irritability rather than classic euphoria. Bipolar disorder beginning in childhood or early adolescence may be a more severe illness than in older adolescent or adult onset disease.

THE DIFFERENTIAL DIAGNOSIS:

In late adolescents with bipolar disorder, the most common mistaken diagnoses are schizophrenia and conduct disorder.  Attention deficit hyperactivity disorder has been the main differential problem in prepubertal and early adolescent patients. The difficulty in distinguishing these two disorders is due to the high prevalence of coexisting ADHD among childhood onset bipolar patients and from the overlap of certain DSM-IV criteria for mania and ADHD (hyperactivity, distractibility and impulsivity).  Although irritability is one of the most frequent symptoms of mania/hypomania in all ages, it is of little help in the differential diagnosis in children because of its ubiquity across a number of childhood diagnoses, including mania, major depressive disorder, ADHD, autism, and oppositional defiant/conduct disorders.  Only a small percentage of children with irritability have mania.

MANIA VS. ADHD:

The differentiation of mania from ADHD is difficult. The response or lack of response to stimulant medications is not diagnostically helpful.  Elevated mood and grandiosity are the symptoms best able to distinguish between pediatric bipolar disorder and ADHD.  With bipolar disorder, hyperactivity may be more episodic.  However, ADHD may be the first manifestation of mania and is often comorbid with mania in children.  An overwhelming majority of manic youth also have ADHD.  Almost one quarter of youth with ADHD meet the criteria for mania.  Prepubertal onset bipolar disorder is a nonspecific chronic rapid cycling mixed manic state that may co-occur with ADHD and conduct disorder or have features of ADHD and/or conduct disorder as the initial manifestation.  The high rate of comorbidity of ADHD with bipolar disorder may be an age dependent child manifestation that will decrease with age.  The onset of bipolar disorder in patients with a history of ADHD is often between 11 and 12 years of age.  Many children who develop bipolar disorder develop a depressive disorder first.  Of youth with major depression, up to 1/3 go on to develop mania/bipolar disorder.

WHAT IS MANIA IN CHILDREN?

Mania in children is seldom characterized by euphoric mood; the most common mood disturbance is severe irritability with "affective storms" (prolonged and aggressive temper outbursts).  In between outbursts, these children are described as persistently irritable or angry.  Manic children often have a decreased need for sleep-not insomnia, but an ability to function well on less sleep than normal.  These children frequently receive a diagnosis of conduct disorder.  Aggressive symptoms may be the primary reason for the high rate of psychiatric hospitalizations in manic children. 

SYMPTOMS WHICH DISTINGUISH MANIA FROM ADHD:

Children are incapable of presenting many manifestations of bipolar symptoms described in adults.  Studies have shown that five behavioral symptoms in children/early adolescents aid in correctly diagnosing childhood bipolar disorder.  These manic symptoms which do not overlap with ADHD are elation, grandiosity, flight of ideas/racing thoughts, a decreased need for sleep, and hypersexuality (in the in absence of sexual abuse or overstimulation).  These five symptoms provide the best discrimination of childhood/early onset bipolar patients from uncomplicated ADHD patients.  Irritability, hyperactivity, accelerated speech and distractibility are frequent in both pediatric bipolar disorder and ADHD and are not useful in differentiating between the two disorders.  Mixed mania (simultaneous mania and depression) is highly prevalent in childhood bipolar disorder.

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