Extreme irritability -- is it childhood bipolar disorder?

Results of a new study may help improve the diagnosis and treatment of two debilitating childhood mental disorders - pediatric bipolar disorder (BD) and a syndrome called severe mood dysregulation (SMD). When the brain's electrical signals were measured during mildly frustrating situations, researchers from the National Institute of Mental Health (NIMH), of the National Institutes of Health, found a very different pattern in children with SMD, compared with children who had BD. The results indicate that different brain mechanisms may lead to irritability in children with SMD, suggesting that they may have an illness other than BD and may require different treatments.

"These aren't children with the occasional bad moods you see in most kids. They're typically very ill, with symptoms that interfere with their lives in major ways. Establishing clear diagnostic criteria is an essential step toward making sure they get the help they need," said NIMH Director Thomas R. Insel, M.D.

Children have a comparatively low rate of BD, but the rate increases with age, to approximately 1 percent among adolescents. About 3 percent of pre-adolescent and adolescent youth are estimated to have SMD. Mood-stabilizing and antipsychotic medications are used to treat children with BD, although the data on their effectiveness are limited and several studies are underway. Since SMD was only recently defined, there are no systematic studies on its treatment, and children with SMD are often treated as if they have BD.

Defining pediatric BD is a major issue in child psychiatry, because the disorder tends to be severe in this age group and the rate of diagnosed cases is rising. Until recent years, most studies of BD were conducted in adults. Some researchers maintain that pediatric BD should be defined more broadly to include children with SMD, an assertion countered by the new finding. Results of the study were published in the February 2007 issue of the American Journal of Psychiatry.

The classic definition of BD (http://www.nimh.nih.gov/publicat/bipolarupdate.cfm) includes extreme, sustained mood swings that range from over-excited, elated moods and irritability - the manic phase of the disorder - to depression. In contrast, children with SMD are extremely irritable and hyperactive, but do not have clear-cut manic episodes.

One component of irritability is the tendency to get acutely frustrated when a goal is not met. Thus, through electroencephalograms (EEGs), the researchers could observe the brain's electrical signals that occurred during frustration while children with either disorder performed simple tasks.

The new study shows that clinicians some day could use biological measurements, such as EEGs, to help make psychiatric diagnoses, in combination with clinical symptoms. Currently, clinicians diagnose mental illnesses based on symptoms alone. The difficulty of diagnosing BD in children is compounded by the frequent co-occurrence of one or more other mental disorders.