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Bipolar diagnosed in younger and younger patients

Asked by Len, Idaho

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This week, Dr. Charles Raison offers part two of his answer to the viewer question: Can a 9- or 10-year-old be bipolar?

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Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

Expert answer

Dear Len

This is the second part of a two-part answer to your very brief question. Last week, I reviewed how bipolar disorder is diagnosed in adults, not shying away from the multiple diagnostic challenges that enshroud the condition. Now we turn to the question of how bipolar disorder can be diagnosed in a child as young as 9 or 10.

When I went to medical school, I was taught bipolar disorder usually began in a person's mid- to late 20s. But a major change has happened since my time as a student.

Many studies now suggest that bipolar disorder, and in fact all mood disorders, are developing in younger and younger people. I could use two or three of these columns just to discuss all the reasons why this trend may be occurring. Suffice it to say more young people appear to be developing classic cases of bipolar disorder, with clear-cut manic and depressive episodes.

So one of the reasons people began diagnosing bipolar disorder in children, especially adolescents, is that nonambiguous cases of the disease have been more common in this population. But there is a second and probably more important reason for the current trend in childhood bipolar disorder.

When researchers began to look closely into the pasts of people with clear bipolar disorder, they began to notice that many of these people showed a range of abnormalities and troubles long before they had their first full manic episode.

Often, people who grew up to be bipolar had childhoods characterized by temper tantrums, mood swings, problems paying attention in school and lots of anxiety.

These findings demonstrated that for many patients, bipolar disorder is for all intents and purposes a lifelong condition. From this vantage point, it appears to start in childhood with many nonspecific symptoms that impair functioning and then progresses in early adulthood into a lifetime see-saw ride of painful lows and dangerous highs.

Over time, an interesting thing happened. Because most people with bipolar disorder have multiple problems in childhood, it seemed fairly straightforward that children with these problems were likely to grow up to have bipolar disorder.

Given how devastating bipolar disorder is, it seemed logical and humane to attempt early intervention with medications, both because these problems devastate children's lives and because early treatment might prevent or forestall progression to full-blown bipolar illness.

But here is the problem. Let's turn to a popular Web site for a list of symptoms that suggest a diagnosis of childhood bipolar disorder:

• Bed-wetting (especially in boys)

• Night terrors

• Rapid or pressured speech

• Obsessional behavior

• Excessive daydreaming

• Compulsive behavior

• Motor and vocal tics

• Learning disabilities

• Poor short-term memory

• Lack of organization

• Fascination with gore or morbid topics

• Hypersexuality

• Manipulative behavior

• Bossiness

• Lying

• Suicidal thoughts

• Destruction of property

• Paranoia

• Hallucinations and delusions

While it's true many people who grow up to have bipolar disorder may have at least some of these problems as children, the trouble arises from the fact that most people with these symptoms in childhood will not grow up to be bipolar.

In scientific jargon, we'd say that the symptoms are sensitive, but not specific. Here is an overblown analogy: You notice that almost everyone who wins the Georgia lottery lives in Georgia (living in Georgia has high sensitivity as a fact for identifying lottery winners). You want to win the Georgia lottery so you move to Georgia (bad move because living in Georgia has low specificity for identifying lottery winners -- most people who live in Georgia never win the lottery).

Recent studies have really brought this home. When children and adolescents who get a diagnosis of bipolar disorder are followed prospectively into adulthood, most of them do not end up having bipolar disorder. Some of them grow up without mental health disorders. Others develop schizophrenia, obsessive compulsive disorder, major depression or they become sociopaths.

This nonspecificity has led to the proposal that childhood bipolar disorder be stricken from the next version of the DSM, which is the "bible" for psychiatric diagnoses.

Children and adolescents with clear manias and depressions will have bipolar disorder, no different from adults with these symptoms. Children with the sorts of nonspecific mood, cognitive and behavioral problems that have been lumped into childhood bipolar disorder will now be used to create a new diagnosis to be known as Dysregulation Disorder with Dysphoria.

This rather turgid title makes no assumptions about symptoms that may develop -- it merely names the fact that lots of kids have a hard time controlling their moods and tempers and they tend to be emotionally miserable (hence "dysphoria").

Whether this is a step forward or not I leave to my readers.

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