Differences Between Adult Adolescent And Childonset Bipolar Disorder

The DSM-IV criteria for mania were developed from data on adults with bipolar disorder and do not consider the differences between bipolar adults and bipolar children and adolescents. Paediatric bipolar disorder has been described as atypical when compared to adult bipolar disorder. The similarities in the clinical presentation of adults with mixed states and preadolescents diagnosed with mania have been noticed. Several authors have drawn a comparison between the ''virulent'' form of the disorder in adults (with absence of discrete episodes) and the severe course observed in many pre-pubertal children [37,47,48].

Leibenluft et al. [40] suggested a phenotypic system of classifying juvenile mania consisting of a narrow phenotype, two intermediate phenotypes and a broad phenotype. Patients who meet the full DSM-IV diagnostic criteria for hypomania or mania (including the duration criterion and the presence of hallmark symptoms such as elevated mood or grandiosity) exhibit the narrow phenotype of juvenile mania. Patients with intermediate phenotype are those with clear episodes and hallmark symptoms, but a duration of episodes between 1 and 3 days, and those with demarcated episodes with irritable (but not elevated) mood. The broad phenotype is exhibited by patients who have a chronic, non-episodic illness that does not include the hallmark symptoms of mania but shares with the narrower phenotypes the symptoms of severe irritability and hyperarousal.

On 27 April, 2000, the National Institute of Mental Health (NIMH) Developmental Psychopathology and Prevention Research Branch, in collaboration with the Child and Adolescent Treatment and Prevention Intervention Research Branch, convened a small roundtable meeting to discuss research issues on the diagnosis of pre-pubertal bipolar disorder [49]. A proposal from this meeting was to categorize children with symptoms of bipolar disorder into two groups: (1) those who meet the DSM-IV criteria for bipolar I or II disorder and (2) those who do not meet the DSM-IV criteria but are severely impaired from mood and behavioural symptoms of bipolar disorder. Children who were in the latter group were categorized as suffering from bipolar disorder not otherwise specified (NOS) and further subdivided into four subcategories: (1) the signs and symptoms are present but do not last long enough to meet DSM-IV criteria; (2) the signs and symptoms are one short to fulfil the DSM-IV criteria; (3) signs and symptoms occur only in one setting, most typically at home; and (4) the symptoms are chronic, i.e. not episodic.

A few published studies have investigated the differences between child-onset and adolescent-onset bipolar disorder. Faraone et al. [50] recruited 68 children (12 years old or younger) and 42 adolescents (older than 13 years) who were hospitalized and met criteria for mania. Comparison groups were 527 non-manic referrals and 100 normal controls. With the exception of comorbidity with ADHD, there were more similarities than differences between the children and adolescents with mania. There was an inverse relationship between the rate of comorbidity with ADHD and age of onset of mania, i.e. higher in manic children, intermediate in adolescents with childhood-onset mania, and lower in adolescents with adolescent-onset mania. The authors concluded ADHD was more common in childhood-onset compared with adolescent-onset bipolar disorder and suggested ADHD may signal a very early onset of bipolar disorder in some cases.

In another study [51], adolescent-onset bipolar disorder was associated with a much higher risk for substance use disorder than childhood-onset bipolar disorder, which was not accounted for by conduct disorder or other comorbid psychopathology. In mid-adolescence, youth with adolescent-onset bipolar disorder were at significantly increased risk for substance use disorder relative to those with child-onset bipolar disorder (39% versus 8%, p = 0.001). Compared with those with child-onset bipolar disorder, those

Table 5.1 Differences in phenomenology related to age of onset in bipolar disorder (adapted from Carlson [52])

Onset

Onset

Onset

<10 years

10-25 years

> 30 years

Clear mood episodes

Absent

Present

Present

Comorbidity

>90%

50%

20%

Disruptive behaviour disorder

Very often

Sometimes

Never

Substance abuse

-

Often

Rare

Euphoric mania

Rare

Sometimes

Often

Psychomotor retarded depression

Rare

Yes

Yes

Confusion with schizophrenia

Rare

Often

Rare

Switch from major depressive disorder

Yes

Yes

Rare

Family history of mood disorder

Frequent

Frequent

Less frequent

Uncomplicated bipolar disorder

Rare

Common

Common

Rate of chronicity

High

5-10%

5%

Lithium response

Poor

Intermediate

Common

with adolescent-onset bipolar disorder had 8.8 times the risk for substance use disorder.

Table 5.1 summarizes the main differences among childhood-onset, adolescent-onset and adult-onset bipolar disorder.

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