Mental Health: Bipolar Disorder - The Common Zebra

Bipolar disorder (BD) can be an urgent and severe psychiatric disorder, which could warrant urgent psychiatric evaluation and treatment. However, these disorders are rare in children and adolescents. This article discusses the signs and symptoms of BD as well as common misconceptions.

A 2021 meta-analysis by Parry et al. reported the prevalence of pediatric bipolar spectrum disorders (bipolar I, bipolar II and bipolar not otherwise specified) as approximately 3.9%. It’s important to understand that bipolar symptoms don’t always need the same amount of medication or mental health treatment. For example, someone going through a sudden manic episode needs more intense treatment, such as mood stabilizers, antipsychotic medicines or even a stay in a psychiatric hospital. This is different from someone who shows some symptoms but doesn’t meet all the criteria for diagnosis. The study also noted that BD is very rare in childhood, and there is a significant risk of misdiagnosing BD in children, potentially resulting in unnecessary treatment and iatrogenic harm.¹

The risk of misdiagnosis is partly related to treatment protocols that involve mood stabilizers and antipsychotics, which have notable side effect profiles requiring frequent metabolic monitoring, as opposed to selective serotonin reuptake inhibitors (SSRIs), which may address underlying depression and anxiety in pediatric patients. Additionally, a diagnosis of BD may lead subsequent clinicians to overlook more common childhood psychiatric disorders such as depression, disruptive behavior disorders and attention-deficit/hyperactivity disorder (ADHD). Typically, BD symptoms begin to manifest in males during collegiate age and in females during the post-college period.

Diagnostic Criteria for Bipolar Type I and Type II

For a pediatric clinical provider, it is not uncommon for a family to come in and say their family member or the patient has been diagnosed with “bipolar.” I recommend conducting a full analysis of a patient’s behavior using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria.

To summarize the DSM-5 criteria:

• Bipolar I disorder requires a period of at least one week with “elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy” that is present “most of the day, nearly every day (or any duration if hospitalization is necessary).”
  • “At least 3 of the following symptoms need to present for a significant amount of time, or there is a marked change from baseline behaviors:
    • Grandiosity
    • Decreased need for sleep
    • Increased talkativeness or pressured speech
    • Flight of ideas
    • Distractibility
    • Increase goal-directed activity or hyperactivity
    • Increased risk-taking behaviors” ²
  • Bipolar II disorder requires the same mood and energy symptoms described above for “at least 4 consecutive days and present most of the day, nearly every day.” Diagnosis also requires at least three of the symptoms listed above.
  • The patient must also have met criteria for at least one major depressive episode.²

Based on these criteria, a quick screening question for manic episodes is based on how many days the patient has had these changes in behaviors and energy. If the patient has had symptoms for less than four days, and does not require hospitalization, the diagnosis is NOT bipolar disorder type I or type II.

If a patient does meet criteria for bipolar type I, and is currently in an unsafe state, I recommend urgent psychiatric evaluation in an inpatient medical setting. Given its rarity in children and adolescents, a full medical workup is necessary prior to a diagnosis.

If a patient does not meet criteria for BD, the clinician should evaluate more common psychiatric conditions in childhood and adolescence, such as ADHD, major depressive disorder, substance use disorders, and disruptive, impulse-control and conduct disorders. These conditions share signs and symptoms of BD.

Medical Workup

BD should be treated as a diagnosis of exclusion within the child and adolescent population. A psychiatry consult can aid in diagnostic determination of the cause for the presenting psychiatric symptoms.

Because several medical conditions can mimic BD, it is particularly important to get a thorough medical history. The most common medical mimics include:

• Substance/Medication-Induced
  • Recommended testing: Comprehensive urine drug screen for substance use intoxication or withdrawal. Medications that can induce a manic-like episode include steroids, stimulants, and antihistamines.
• Thyroid disorders
  • Recommended testing: TSH with reflex T4 and anti-TPO antibody to rule out metabolic disorders (e.g., hyperthyroidism).
• Neurologic causes (temporal lobe epilepsy, brain lesions, encephalopathy, excited catatonia)
  • Recommended testing:
    • Folate and B-12 and other vitamin levels to rule out vitamin deficiencies as an etiology for neuropsychiatric symptoms.
    • ERP, CRP, ANA, HIV, RPR, Anti-NMDA to rule out inflammatory markers seen in certain neurological disorders (e.g., catatonia, encephalopathy or paraneoplastic syndromes).
    • Imaging, ideally brain MRI with and without contrast.
    • One-hour EEG.

References:

1. Parry P, Allison S, Bastiampillai T. 'Pediatric Bipolar Disorder' rates are still lower than claimed: a re-examination of eight epidemiological surveys used by an updated meta-analysis. Int J Bipolar Disord. 2021;9(1):21. doi:10.1186/s40345-021-00225-5
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.