114 Chapter 11
short episodes every day (‘ultradian cycling’) as an episode that had
lasted x days.
2 Chronic irritability. The classical ICD-10 and DSM-IV definitions of mania
accept irritability as an alternative to elevated or expansive mood,
but specify that the altered mood must occur in distinctive episodes
that clearly differ from the individual’s normal state. Some assert that
the requirement for episodicity (non-chronicity) can be dropped for
children and adolescents. Others agree that chronic irritability is a
significant problem – possibly to be included in DSM-V asDisruptive
Mood Dysregulation Disorder– but demonstrate that it differs in so many
ways from classically defined bipolar disorder that the two should not
be grouped together.
Is there a case for accepting juvenile-specific criteria for bipolar disorder?
On the one hand, some people say that it is in the nature of children and
adolescents to get over-excited or irritable, and that there is no justification
for turning these features into disorders and then treating them. On the
other hand, it could be true that individuals who are going to develop a
classically defined bipolar disorder as adults pass through a phase of having
mania-like episodes in childhood or adolescence that do not meet classical
criteria. If so, individuals who meet juvenile-specific criteria for bipolar
disorder, sometimes referred to as ‘pediatric bipolar disorder’, might do better
in the long term if they received early treatment. Overall, the evidence is
mixed and generally weak. An alternative view is that the majority with
this symptom profile suffer from oppositional-defiant disorder and will do
well if managed with parent training, which is likely to make them better
over the long term and avoid unpleasant side-effects of medication. The
well-worn phrase that “more research is needed” certainly applies here.
One thing that does seem fairly clear is that those individuals who meet
juvenile-specific criteria for bipolar disorder also frequently have other
disorders, particularly disruptive behavioural disorders and ADHD. This
raises a further question as to whether having an externalizing disorder
sometimes result in relatively brief episodes of irritability, ‘clowning about’
or over-excitement that look like mania without actually being mania. If
that is the case, they may do best if managed with the sorts of treatment
approaches for externalising disorders described in the Chapters 5 and 6. Is
pediatric bipolar disorder truly on the bipolar spectrum, or is it not really
bipolar at all despite its superficial similarity? The jury is still out.
In the absence of compelling research findings one way or the other,
large numbers of clinicians seem to have made up their minds anyway. In
many places – starting in the USA but now spreading globally – a growing
number of children and adolescents are diagnosed as having pediatric
bipolar disorder and many of them, including some preschool children,
are then treated with mood stabilisers and neuroleptics. The evidence that
this is beneficial is not compelling, while the potential for serious adverse
effects is considerable. Many leading US experts have expressed grave
reservations about this trend.