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Why it is Hard to Get a Diagnosis of Bipolar Disorder for a Child

The Core Phenotype - A Better Way to Diagnoise Bipolar in Children

Common Symptoms of Childhood Bipolar Disorder

Hidden Symptoms of Childhood Bipolar Disorder

Diagnosis in psychiatry is often difficult. There are no lab tests, and each person experiencing an illness does so in a unique way. Doctors rely on symptoms reported by patients, family history, the clinical course of the disorder, and observable behavior.

With children, it is even more challenging because they are still developing; there is an insufficient amount of time to establish a course of illness; many behaviors such as nonstop motion, impulsivity, and difficulties tolerating frustration or the word no, are everyday events.

Receiving a correct diagnosis is essential to a child's well-being as the diagnosis will be what is used to guide the treatment and also prevent the child from being given medications that could possibly worsen the disorder.

The American Psychiatric Association (APA) has established and outlined the most recent diagnostic criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, commonly referred to as the DSM-IV. The DSM-IV divides mood disorders into depressive disorders and bipolar disorders. While children are mentioned, they are basically still diagnosed according to the criteria for adults - and this can be where part of the problem in receiving a correct diagnosis begins.

The criteria that must be met before a diagnosis of a major depressive episode can be made are as follows:

CRITERIA FOR MAJOR DEPRESSIVE EPISODE

  1. Five (or more) ofthe following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood, or (2) loss of interest or pleasure. NOTE: Don't include symptoms which are clearly due to a general medical condition.
    1. Depressed mood for most of the day, nearly every day, as indicated by either subjective report (i.e., feels sad or empty), or observations made by others (i.e., appears tearful). NOTE: In children and adolescents, can be an irritable mood.
    2. Markedly diminished interest or pleasure in all, or almost all, activities for most of the day, nearly every day (as indicated by either patient report or observation by others).
    3. Significant weight loss when not dieting or weight gain (i.e., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. NOTE: In children, consider failure to make expected weight gains.
    4. Insomnia or hypersomnia nearly every day.
    5. Pyschomotor agitation or retardation nearly every day (observed by others, not merely subjective feelings of restlessness or being slowed down).
    6. Fatigue or loss of energy nearly every day.
    7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
    8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
    9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
  2. The symptoms do not meet criteria for a Mixed State (where a patient displays symptoms of mania and depression every day during at least a one-week period).
  3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The symptoms are not due to the direct phsyiological effect of a substance (i.e., a drug abuse, a medication) or a general medical conditon (i.e, hypothyroidism).
  5. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than two months, or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

CRITERIA FOR MANIC EPISODE

  1. A distinct period of abnormally and persistenly elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary).
  2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
    1. Inflated self-esteem or grandiosity.
    2. Decreased need for sleep (i.e, feels rested after only three hours of sleep).
    3. More talkative than usual or pressure to keep talking.
    4. Flight of ideas or subjective experience that thoughts are racing.
    5. Distractibility (i.e, attention too easily drawn to unimportant or irrelevant external stimuli).
    6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
    7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (i.e., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
  3. The symptoms do not meet criteria for a Mixed State.
  4. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
  5. The symptoms are not due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or other treatment), or a general medical condition (i.e., hyperthyroidism). NOTE: Manic-like episodes that are clearly caused by somatic antidepressant treatment (i.e., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

One of the biggest problems of the DSM-IV criteria as they apply to children is the fulfillment of the duration criteria. The DSM-IV specifies that either manic or depressive episodes must last for a specified period of time. In the case of early-onset bipolar disorder, many children have a form of the condition that is marked by mood and energy shifts so frequent that they may occur several times a day. By definition alone, an individual who has rapidly shifting mood states of less than the required durations cannot be formally diagnosed as having a bipolar disorder.

To include disorders with bipolar features that do not meet full duration criteria, the DSM-IV has a separate and distinct category, code number 296.7, or Bipolar Disorder Not Otherwise Specified (NOS). This category allows for identification within the bipolar spectrum of individuals who have a very rapid alteration of depressive and manic symptoms, but do not meet the minimum duration criteria. Most children with bipolar disorder will fit into this category, but it still does not provide for an accurate description of the condition as it presents in children.

The APA recognizes the need to include a separate category for children, but has no plans to publish a revised version of the DSM until at least 2012.

 
 

 

 
 

 

 
 

 

 
 

 

 

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