Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

Expert answer

Dear Len,

Your question intrigues me because I can't tell whether it is a rhetorical query posed out of indignation or is in fact a request for information about how bipolar disorder is diagnosed in children.

As you probably realize, this is an area of huge debate in psychiatry, and there is a movement to drop childhood bipolar disorder from the next version of the official psychiatric handbook, which will be called DSM-V. Given all these problems, the line between indignation and curiosity is in this case a thin one, so I hope I can provide a useful answer regardless of your intention in asking the question.

Let's start with the more general question of how one diagnoses bipolar disorder in general. Like all psychiatric diagnoses, this one is based on symptoms over time. There is no blood test or other definitive way to establish the diagnosis.

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By definition, bipolar disorder is defined as a history of at least one manic episode. Mania, in turn, is a condition in which everything is revved up.

People are euphoric, irritable (or both at the same time or in rapid succession), grandiose and prone to big risk taking. Sleep diminishes, sometimes to zero. Thoughts speed up and bodily passions are magnified. Speech often becomes rapid. Opportunities and benefits seem as common as sand by the sea and risks seem paltry by comparison. Crazy things are often done.

When mania really gets fired up, people often lose touch with reality and hear voices and start to believe fantastical things about themselves. For example, I had a patient years ago who, when manic, believed that she was located at the center of our universe and could see all the galaxies rotating around her.

It's an odd paradox of our diagnostic system that despite being called bipolar disorder, which employs two opposite poles, all one needs to have the diagnosis is a manic episode.

The saving grace for this inconsistency, of course, is the fact that what goes up must come down, meaning that almost everyone who goes manic will also experience depressive episodes. This is especially true for women. Although there are a few rare people who only have manias (mostly men), recent studies consistently show that most people with bipolar disorder spend the majority of their time in a depressed state.

A full-blown mania can be a shocking thing to see, but in fact the depression that bipolar patients struggle with is more damaging to life and limb than are the manic episodes.

If you follow trends in psychiatry, you will know that over the last decade there has been an increasing recognition that many people with lifelong struggles with depression will show subtle signs of bipolarity if one looks closely enough. Here the question becomes how to tell a mild mania (called hypomania) from a really good day, week or month.

The jury is still out on this one, but I'm one of the many who have become convinced that it is useful to look for subtle bipolarity in chronically depressed patients, if for no other reason than certain mood stabilizing medications may be differentially effective in depressed people with "a little bit of bipolar."

Bipolar disorder comes in two official flavors. To meet criteria for bipolar I disorder, one needs to have had at least one manic episode that wasn't explained by something physical like an illness or medication. To meet criteria for bipolar II disorder, one must have episodes of depression that are interspersed with hypomanic episodes.

If you're with me on this, you'll want to know what we call people who only have periods of hypomania. The answer is interesting: We have no answer -- there is no diagnosis for this pattern of mood symptoms, although this may change in the next version of the DSM.

As readers of this column know, I am not a big fan of our current diagnostic system, because I think recent scientific findings have made it somewhat obsolete.

Given this, I think of bipolar disorder as a chronic condition that lies between two extremes. At one extreme are people who have repeated depressions and periods of feeling energized that almost blend into a normal good mood. Whether to think of these folks as having unipolar depression or a very soft bipolar II type problem is the diagnostic challenge.

At the other extreme are people who have repeated agitated, hyperactive psychotic episodes and other periods when they get depressed. Over time many of these people deteriorate in a manner similar to what was once believed to be a hallmark of schizophrenia.

We know that most people with schizophrenia will have significant periods of depression, so you can see that where the lines are drawn between schizophrenia with comorbid depression and really bad bipolar disorder are again somewhat arbitrary.

In recognition of this quagmire, the DSM has a diagnosis called schizoaffective disorder, which attempts to give a name to the borderland between these two primary psychotic disorders (i.e. schizophrenia and bipolar disorder).

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