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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 1  |  Issue : 2  |  Page : 126-128

Pediatric bipolar disorder


1 Department of Psychiatry, Pt. BDS University of Health Sciences, Rohtak, Haryana, India
2 Department of Psychiatry, BPS Govt. Medical College, Khanpur Kalan, Haryana, India

Date of Web Publication27-Sep-2012

Correspondence Address:
Prerna Malik
Department of Psychiatry, Pt.BDS University of Health Sciences, Rohtak- 124001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.101721

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  Abstract 

Although it been reported by several case reports and studies, affective disorders in children are considered to be uncommon, because of different presentation than adults and also its association with other co morbid disorders. Here forth is presented a case of bipolar affective disorder first episode mania in a 13-year-old boy.

Keywords: Bipolar disorder, children, mania


How to cite this article:
Malik P, Gandhi R, Goyal A, Kundu S, Gulia AK. Pediatric bipolar disorder. Int J Health Allied Sci 2012;1:126-8

How to cite this URL:
Malik P, Gandhi R, Goyal A, Kundu S, Gulia AK. Pediatric bipolar disorder. Int J Health Allied Sci [serial online] 2012 [cited 2019 Sep 21];1:126-8. Available from: http://www.ijhas.in/text.asp?2012/1/2/126/101721


  Introduction Top


Bipolar disorder in children is among the most active and controversial areas of child and adolescent psychiatry research. The diagnostic dilemmas are (1) whether elevated mood vs. irritable mood is essential for diagnosis, (2) minimum duration of manic episode, and (3) co-morbid diagnosis. [1],[2] A manic episode consists of a distinct period of persistently elevated, expansive or irritable mood lasting for more than 1 week or more than 4 days for hypomanic episode and the presence of neurovegetative symptoms such as grandiose thinking or inflated self esteem, decreased need for sleep, pressured speech, or increased verbalizations, racing thoughts or flight of ideas, distractibility, increase in goal-directed activities or ideation and helplessness, which seems to be equally likely at any age. No modifications of manic episodes apply to children or adolescents according to DSM-IV. [3] Here we report a case of manic episode in a male child of 13 years of age.


  Case Report Top


A 13-year-old boy of 6th class from rural background was brought to psychiatry outpatient clinic of Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India with symptoms of scholastic backwardness, sleep disturbances, running away from school, and with increased communication for past 1 month. He refused to do school assignment and was relatively slow in completing them. He would run away from school or would not listen to teachers and even make fun of other students. He would talk more and roam around the house. Sometimes he would even run out of the house without informing anyone at home. He started saying that he is very powerful and he could give them money and lots of gold. Whenever family members contradict him, he would get violent and aggressive and even hit them. He would try to talk to people in village not known to him and even make fun of them by passing comments and laughing at them. He would visit neighbors and discuss his family issues with them and spend long time at other people houses, when asked to go home he would become angry and abuse them. He would order his father to bring new clothes and eatables for him. He also started demanding money. Upon refusal, he would throw house hold things and on getting money, he would go to the market and eat sweets, fast food. When family members decided not to talk to him thinking that this will improve his behavior, he would sing songs. Throughout the illness, patient's mood used to remain irritable. He did not manifest hallucinations or had thought alienation, thought broadcasting, passivity, or depersonalization. He had no inappropriate or precocious sexual behavior. There was no history of delinquent behavior, bed-wetting, sleep talking, seizure, substance abus, and head trauma. Birth and developmental history was normal with no significant past and family history. Prior to the onset of illness, he was a boy of timid nature, shy, reserved, having very few friends. He had good faith and belief in God and used to offer daily prayers and visit temples often.

General physical examination was within normal limits. Mental state examination revealed an average built boy, cooperative, increased psychomotor activity with decrease reaction time, spontaneous speech, inflated self-esteem, and delusion of grandiosity. He was found to be irritable throughout the interview.

Neurological examination, routine laboratory test, thyroid, visual examination, and CT scan head were normal. He was submitted for psychometric investigation with Binet-Kamat test of mental ability, Wechsler intelligence scale for children, Rorschach inkblot test. There were no schizophrenic indicators in inkblot test. His IQ was around 90, with above-average intelligence. Based on the clinical and psychometric assessment, a diagnosis of pediatric bipolar disorder was made. The patient was admitted and started on risperidone 2 mg and later increased to 4 mg with significant improvement. No psychosocial intervention was done. The patient is maintaining well and is still under treatment for last 5 months though dose has been decreased to 2 mg risperidone.


  Discussion Top


Bipolar disorder has been recognized in children since 1990s; even then, there was intense debate whether it could occur prior to the age of 12 years. The incidence and prevalence of the disorder and the associated co-morbidities vary according to study setting and criteria used. The overall rate of bipolar disorder was 1.8% (95% CI, 1.1-3.0%). There was no significant difference in the mean rates between US and non-US studies, but the US studies had a wider range of rates. [4] One community study showed a lifetime prevalence of bipolar disorder of 1% in youths aged 14 to 18 years, using the schedule for affective disorders and schizophrenia for school-age children. [5] Phenomenology of childhood mania, especially in younger children can vary from the classic description of bipolar disorder in adults. Adolescent presentation may be bizarre, mood incongruent and/or paranoid. Schneiderian first-rank symptoms occur in 20% of cases. Early-onset bipolar disorder may be missed in 50%. [6],[7] Also bipolar disorder in children has been found to have symptom overlap with other psychiatric disorders like conduct disorder, attention deficit hyperactivity disorder, substance use, anxiety disorders, etc. Mania in children is seldom characterized by euphoric mood. [8],[9] Rather, the most common mood disturbance in manic children is severe irritability, with "affective storms," or prolonged and aggressive temper outbursts. [10] The type of irritability observed in manic children is very severe, persistent and often violent. [11] The outbursts often include threatening or attacking behavior towards family members, other children, adults, and teachers. In between outbursts, these children are described as persistently irritable or angry in mood. [8],[9],[12] Thus, it is not surprising that these children frequently receive the diagnosis of conduct disorder. Conduct disorder according to ICD-10 should start before the age of 6 and according to DSM-IV, before the age of 7 and symptoms of truancy, lying, stealing, cruelty to animals, etc should be present at least for 6 months or longer and also not as an isolated act. [13] The psychopharmacological interventions for childhood mania include lithium, valproate, and/or atypical antipsychotics. All mood stabilizers and antipsychotic agents are commonly used for early-onset bipolar disorder in clinical settings. Lithium has been found to be therapeutically effective in the management of pediatric bipolar disorder. [14],[15] In a retrospective study of 28 youths with bipolar disorder, 82% of subjects showed improvement in both manic and aggressive symptoms with risperidone treatment. [16] In contrast to the duration of treatment required for improvement with mood stabilizers, the average time to optimal response was 1.9 ±1.0 months of therapy. Children with bipolar disorder may be relatively uncommon in outpatient settings, but clinical experience suggests that they may account for a substantial number of child psychiatric hospitalizations and that they are plagued with chronic psychiatric and psychosocial disability. [17],[18] This case report highlights the occurrence of bipolar disorder in the pediatric age group which though considered rare is usually missed due to its different phenomenology as well as confusion with other childhood co morbid disorders. Long-term studies on its prevalence, phenomenology, and treatment are needed.

 
  References Top

1.Geller B, Zimerman B, Williams M, Delbello MP, Frazier J, Beringer L. Phenomenology of prepubertal and early adolescent bipolar disorder: Examples of elated mood, grandiose behaviors, decreased need for sleep, racing thoughts and hypersexually. J Child Adolesc Psychopharmacol 2002;12:3-9.  Back to cited text no. 1
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2.Wozniak J, Biederman J. Childhood mania: Insights into diagnostic and treatment issues. J Assoc Acad Minor Phys 1997;8:78-84.  Back to cited text no. 2
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3.American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Revision:4th ed. Washington, DC: APA; 2000.  Back to cited text no. 3
    
4.Van Meter AR,Moreira AL,Youngstrom EA. Meta analysis of epidemiologic studies of pediatric bipolar disorder. J Clin Psychiatry 2011;72:1250-6.  Back to cited text no. 4
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5.Pavuluri MN,Birmaher B,Naylor MW.Pediatric bipolar disorder: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 2005;44:846-71.  Back to cited text no. 5
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6.James AC, Javaloyes AM. The treatment of bipolar disorder in children and adolescents. J Child Psychol Psychiatry 2001;42:439-49.  Back to cited text no. 6
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7.Giedd JN. Bipolar and attention-deficit/hyperactivity disorder in children and adolescents. J Clin Psychiatry 2000;61:31-4.  Back to cited text no. 7
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8.Carlson GA. Bipolar affective disorders in childhood and adolescence. In: Cantwell DP, Carlson GA, editors. Affective disorders in childhood and adolescence. New York: Spectrum; 1983. p. 61-83.  Back to cited text no. 8
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9.Carlson GA. Classification issues of bipolar disorders in childhood. Psychiatr Dev 1984;2:273-85.  Back to cited text no. 9
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10.Davis RE. Manic-depressive variant syndrome of childhood: A preliminary report. Am J Psychiatry 1979;136:702-6.  Back to cited text no. 10
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11.Wozniak J, Biederman J, Kiely K, AblonJS, Faraone SV, Mundy E, et al. Mania-like symptoms suggestive of childhood onset bipolar disorder in clinically referred children. J Am Acad Child Adolesc Psychiatry 1995;34:867-76.  Back to cited text no. 11
    
12.Geller B, Luby J. Child and adolescent bipolar disorder: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1997;36:1168-76.  Back to cited text no. 12
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13.World Health Organization. The ICD-10 classification of mental and behavioural disorders: Clinical description and diagnostic guidelines. Geneva: World Health Organization;1992.  Back to cited text no. 13
    
14.Brumback RA, Weiberg WA. Mania in childhood: II Therapeutic trial of lithium carbonate and further description of manic-depressive illness in children. Am J Dis Child1977;131:1122-6.  Back to cited text no. 14
    
15.Carlson GA, Rapport MD, Pataki CS, Kelly KL. Lithium in hospitalized children at 4 and 8 weeks: Mood, behavior and cognitive effects. J Child Psychol Psychiatry1992;33:411-25.  Back to cited text no. 15
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16.Frazier JA, Meyer MC, Biederman J, Wozniak J, Wilens TE, Spencer TJ, et al. Risperidone treatment for juvenile bipolar disorder: A retrospective chart review. J Am Acad Child Adolesc Psychiatry 1999;38:960-5.  Back to cited text no. 16
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17.Kovacs M, Pollock M. Bipolar disorder and comorbid conduct disorder in childhood and adolescence. J Am Acad Child Adolesc Psychiatry 1995;34:715-23.  Back to cited text no. 17
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18.West SA, McElroy SL, Strakowski SM, Keck PE Jr, McConville BJ. Attention deficit hyperactivity disorder in adolescent mania. Am J Psychiatry 1995;152:271-3.  Back to cited text no. 18
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