A Focus On: The Controversy of Juvenile Bipolar Disorder
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Juvenile bipolar disorder has a long history. Since the eighteenth century this disorder was viewed as a real analogue of adult bipolar disorder (under a number of names, over the decades). Up until the 1990s juvenile bipolar disorder was viewed as a rare phenomenon but then papers published in the Massachusetts General Group during the 1990s began to change that perception. These researchers viewed pediatric bipolar disorder as common and viewed irritability rather than mood as its hallmark. Other researchers and clinicians wrote that, in their view, irritability displacing mania as the hallmark of the syndrome made the syndrome questionable. They argued that while irritability in children was thought by some to be associated with juvenile bipolar disorder, it was a fairly common finding in children and adults. They went on to discuss how, while linked with many psychiatric disorders, irritability was not itself pathognomonic of any disorder. These differing views have been the center of great diagnostic controversy.
In recent years there has been great conflict of opinion about this situation, especially in the United States where a great many children have been given this diagnosis and prescribed very major medications, because of the literature. In contrast, in the United Kingdom few children are given the diagnosis of juvenile bipolar disorder. The difference in diagnosis between the two countries has to do with whether the diagnosis of a major mood disorder in young children requires major alterations of mood or can be based on the phenomenon of irritability. Partisans of both views have had strong disagreements.
The DSM-5 nosology has a new diagnosis which may help bring these differing views together. It is known as ‘disruptive mood dysregulation disorder’ and it has been introduced perhaps to decrease the split among psychiatrists and others about the juvenile bipolar diagnosis; for the diagnosis to be made, does it require mood symptoms or irritability symptoms? The diagnosis of ‘disruptive mood dysregulation disorder’ originated from a laboratory program at NIMH and essentially encompasses children who have great irritability but not true mania. The diagnosis is controversial because it is questionable whether it represents a “real” phenomenon or one created in the confines of a study, but it can only help the current murky status of juvenile bipolar disorder.
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Lloyd Wells, M.D., Ph.D., is Emeritus Consultant in Psychiatry, and Associate Professor of Psychiatry, Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
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