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Are Chronically Irritable Children Bipolar?

Or should there be a new diagnosis for them? 

by Dr. Ellen Leibenluft

One question that's being wrestled with right now in the psychiatric community is how we can best serve and treat children with very severe chronic irritability. With these children we see, day after day, a lot of very extreme temper outbursts, grouchiness, grumpiness. It's problematic all over—in school, at home, with peers. And the question that's been raised is whether this is actually bipolar disorder in children—whether the mania that is an episodic illness in adults presents in children instead as very chronic irritability.

It turns out that the studies that have looked at this find that irritability in children does not predict bipolar disorder in adults. Instead, irritability in children predicts increased rates of major depression, which is unipolar depression—without the manic component—and anxiety in adults.

And it also seems that the family history of irritable children is not the same as it is children with true episodic bipolar disorder. Children with true episodic bipolar disorder tend to have strong family histories of bipolar disorder. Children with this chronic irritability don't have particularly strong family histories of bipolar disorder; they have family histories of unipolar depression and of anxiety, but not necessarily bipolar disorder.

So we have been very concerned about how the DSM—that is, the Diagnostic and Statistical Manual, our guidebook to diagnosing mental disorders—can best serve these very severe chronically irritable children. Diagnosed according to the current DSM 4, these children would have oppositional defiant disorder, they typically have ADHD, they may have anxiety. But none of those diagnoses captures exactly how severe this syndrome is, because these children with very severe chronic irritability are as sick as children with bipolar disorder, they're as impaired, they're having as many difficulties, they're hospitalized as often, they're on as many medications.

So that's what the DSM committee is struggling with: Should there be a new diagnosis for these children.

Click here to learn more about bipolar disorder.

Ellen Leibenluft, MD, is Chief of the Section on Bipolar Spectrum Disorders, Emotion and Development Branch, Intramural Research Program, National Institute of Mental Health.

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