Pediatric Bipolar Disorder Versus Severe Mood Dysregulation: Risk for Manic Episodes on Follow-Up

Abstract

Objective-An important question in pediatric bipolar research is whether marked nonepisodic irritability is a manifestation of bipolar disorder in youth. This study tests the hypothesis that youth with severe mood dysregulation (SMD), a category created for the purpose of studying children presenting with severe nonepisodic irritability, will be significantly less likely to develop (hypo-)manic or mixed episodes over time than will youth with bipolar disorder (BD). Method-Patients with SMD (N = 84) and narrowly defined BD (N = 93) at baseline were followed up in 6-monthly intervals using the relevant K-SADS modules to ascertain (hypo-)manic or mixed episodes.Results-Only one of 84 SMD subjects (1/84 [1.2%]; 95% confidence interval CI = 0.0003 to 0.064) experienced a (hypo-)manic or mixed episode during the study (median follow-up = 28.7 months). The frequency of such episodes was more than 50 times higher in those with narrowly defined BD (58/93 [62.4%]; 95% CI 0.52 to 0.72).Conclusions-These data suggest that, over an approximately 2-year follow-up period, youth with SMD are unlikely to develop (hypo-)manic or mixed episodes. Keywords bipolar disorder; pediatric; severe mood dysregulation; irritability; ADHD In American psychiatric clinics and inpatient settings, dramatic increases in the rates of diagnosis of pediatric bipolar disorder (BD) have been documented over the past decade, 1,2 with a concomitant increase in prescription rates for antipsychotic medication. 3 This rapid increase in the diagnosis of pediatric BD has coincided with the contention that the clinical presentation of BD differs between children and adults. 4,5 The debate regarding the pediatric presentation of BD is complex. One important aspect of it has been the suggestion that marked irritability, even when it does not constitute an episodic change from baseline, is a manifestation of BD in youth. 4,6,7 To provide a framework for research on whether irritable children without distinct manic episodes have a developmental presentation of BD, we operationalized 8 a clinical syndrome, severe mood dysregulation (SMD), designed to capture chronically irritable children whose diagnostic status is in doubt. This paper uses a longitudinal sample to investigate the extent to which subjects with SMD develop episodes of (hypo-)mania, compared to youth with narrowly defined BD.The criteria for SMD require a persistent, nonepisodic clinical presentation of negatively valenced mood with frequent and impairing anger outbursts, combined with at least three of the "B" criteria of mania (pressured speech, agitation, insomnia, and flight of ideas/racing thoughts) and one (distractibility) that is also common to ADHD. 8 A community-based follow-up study suggests that SMD is common, with a lifetime prevalence of 3.3% in youth 9 to 19 years of age. 9 Furthermore, in that sample SMD predicted depressive disorder at 7-year follow-up in youths who were 9 to 19 years old at baseline. 9 Consistent with this finding, another community-based study of nonepisod...

Impaired fixation to eyes during facial emotion labelling in children with bipolar disorder or severe mood dysregulation

“…With regard to SMD, childhood irritability predicts anxiety disorders and depression in adulthood. 54,55 Therefore, abnormal gaze patterns associated with childhood irritability may be a biomarker of the increased risk for anxiety disorders developing in adulthood. Thus, our findings are consistent with the growing trend in psychiatric research to acknowledge shared pathophysiological links across diagnoses previously considered distinct.…”

Clinical Features of Young Children Referred for Impairing Temper Outbursts

“…(DSM-IV) (American Psychiatric Association 1994); criteria for bipolar disorder, to adolescents with severe temper outbursts, chronic irritability, and hyperarousal, a syndrome labeled severe mood dysregulation (SMD) (Leibenluft et al 2003). Differences between adolescents with SMD and those with bipolar disorder were found in physiological responses to frustration , neural responses to social stimuli , and longitudinal course (Stringaris et al 2010). These findings have directly informed the development of a new disorder, disruptive mood dysregulation disorder (DMDD) in American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th ed.…”

ADHD and DMDD Comorbidities, Similarities and Distinctions

“…According to Dickstein [14], average age is 11.04 and we find 78.1% of boys. There is thus a male ascendancy for DMDD [15], while both sexes are represented in an equivalent way in young bipolar people [1,16].…”

“…We find in DMDD children the difficulty to regulate negative emotions in response to social cues and the predominance of negative mood. This negative mood may include sadness and anger, but chronic dysphoria and chronic irritability are the central dimensions and are not found in ADHD [15].…”