Irritability, Depression and the Overdiagnosis of Child Bipolar Disorder
Posted Nov 10, 2013
One of the most disturbing psychological tribulations of parenthood is a child who is chronically irritable, angry, on edge, unhappy, and who explodes into temper tantrums. Anger and irritability are among the most common reasons parents consult mental health professionals, and intractable anger and disruptive behavior are the most common reasons for child psychiatric hospitalization. The devastating psychological effects of chronic anger and temper outbursts in children, and an absence of effective treatment for these problems, were important motivations for the development of the concept of bipolar disorder in children. It was hoped that understanding these children as having bipolar disorder might increase the ability of researchers to study the problem and lead to more effective treatment. These speculations led to the treatment of children with the presumptive diagnosis of bipolar disorder with the same agents that are used to treat adult bipolar disorder. This strategy failed; children don’t have bipolar disorder and treating the misdiagnosed children with agents used to treat bipolar disorder in adults has not been helpful. Compounding the errors of misdiagnosis and poor choices of psychopharmacological agents, medications that showed considerable promise for these children were often withheld.
Irritability is a non-specific symptom of psychiatric disorder: it is found as a DSM diagnostic criterion in approximately 76% of psychiatric disorders. It has been a major source of the overdiagnosis of bipolar disorder in children and adolescents. The influential child psychiatry division at Harvard University continues to insist that the core symptom of bipolar disorder in preschool children, school aged children, and adolescents consists of extreme irritability (1,2).
This perspective has been repudiated by NIMH and the DSM-5 Children’s Committee (3). In an effort to limit the overdiagnosis of bipolar disorder based on extreme irritability, the DSM-5 Children’s Committee successfully advocated for a new diagnosis –Disruptive Mood Dysregulation Disorder (DMDD). Although there are many diagnostic criteria for this disorder, the basic requirement is that chronically irritable child patients have at minimum three temper outbursts per week with a persistently angry or irritable mood between the tantrums. It was hoped that this diagnosis of DMDD would curtail the number of children incorrectly diagnosed as having bipolar disorder based on the symptom of irritability alone.
The scientific basis of DMDD rests largely on a series of longitudinal studies of irritable children conducted by Stringaris and colleagues (4, 5). Irritable children were followed longitudinally for up to 20 years. Because irritability is associated with bipolar disorder, it was expected that many of these children would develop bipolar disorder. The irritable children did not develop bipolar disorder; they developed depression and to a lesser extent anxiety. Only those irritable children with brief episodes of hypomania went on to develop bipolar disorder. Irritable, angry children with frequent tantrums in the absence of hypomania became depressed as adults.
Studies of irritability in depressed adults and children support the importance of irritability in depression. In a classic study that played a major part in defining depression in children and adolescence, 80% of the depressed children and adolescents were irritable (6). In children and adolescents, irritability is part of the A criteria (most important criteria) for depression in DSM-IV and DSM-5. Irritability alone in children and adolescents can substitute for the crucial A criteria of sadness for the diagnosis of depression.
In adults, irritability is not a diagnostic criterion for depression in DSM-IV or DSM-5. Despite its absence as a DSM diagnostic criterion for depression in adults, irritability plays a major role in the symptomatic expression of the disorder. In a recent, major national study by Fava and colleagues (7), in which subjects from households across the U.S. were randomly sampled, 50% of depressed adults were found to be irritable. Patients with bipolar disorder were screened out of the sample. The irritable depressed adult subjects differed from the depressed adult subjects without irritability in several respects. The irritable depressed subjects were older (age 60+ years) than the depressed subjects without irritability (ages 20-44 years). The irritable depressed subjects had more additional psychiatric diagnoses related to impulse control such as ADHD and oppositional defiant disorder than did the depressed subjects who were not irritable. There was no evidence that the irritable depression was associated with bipolar disorder. Overall, there was no difference in severity of depressive symptoms between the two groups.
Because both depression and irritability are prominent features of adult bipolar disorder, it is easy to imagine that irritable children with temper tantrums and chronic unhappiness would develop bipolar disorder as adolescents or young adults. This prediction has not been fulfilled. As Stringaris, et al., have shown above, these children develop depression, not bipolar disorder. Similarly, the work of Fava, et al., discussed above, suggests that there is an absence of bipolar disorder in irritable depressed adults
In longitudinal studies of irritable children and adolescents, and in a cross sectional studies of adults, irritability and depression are strongly associated. There is little to support those who make the claim that irritability alone is diagnostic of bipolar disorder in children and adolescents.
1.Biederman, J. The evolving face of pediatric mania. BiolPsychiatry. 2006;60.901-902
3.Towbin, K et al. Differentiatiating Bipolar Disorder-Not Otherwise Specified and Severe Mood Dysregulation. JAACAP 2013. 52: (5)466-481.
4.Stringaris et al. Pediatric bipolar disorder versus severe mood dysregulation: risk for manic episodes on follow-up. 2010. JAACAP 49:(4)397-405.
5.Stringaris et al Adult outcomes of youth irritability: a 20-year prospective community based study. Amer J Psychiatry. 2009.166:1048-1054.
6.Ryan, N. et al. The clinical picture of major depression in children and adolescents. Arch Gen Psychiatry. 1987. 44:854-861.
7.Fava,M. et al. The importance of irritability as a symptom of major depressive disorder:results from the National Comorbidity Survey Replication. Mol Psychiatry 2010. 15:856-867.
Copyright Stuart L. Kaplan, MD, 2013
Stuart L. Kaplan, M.D., is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis.