Answer: Bipolar II disorder
DISCUSSION
In a previous commentary—Poor Practice, Managed Care, and Magic Pills: Have We Created a Mental Health Monster?—I attributed the overdiagnosis of pediatric bipolar disorder to poor diagnostic practices and contemporary insurance and societal pressures.1 The responsibility for improvement was placed on psychiatrists: diagnostic skills had to be improved and patients and their families and caregivers as well as the general public needed to be better educated about the disorder and treatment options. Here, I will discuss how diagnostic accuracy can be significantly enhanced through the use of structured psychiatric interview tools, such as the MINI.2
This case clearly demonstrates that with clinical interviewing only, the correct diagnosis was made, but for the wrong reason (bipolar disorder diagnosis made because of rages), while the wrong diagnosis was made because of the right reason (major depressive disorder; rages not considered as symptom for bipolar disorder). However, a structured approach with a validated clinical tool identified major depressive symptoms and at least 1 hypomanic episode, which indicated a bipolar spectrum condition, regardless of severe angry outbursts.
Severe temper dysregulation, angry outbursts, and rages are not part of the diagnostic criteria for bipolar disorder, which requires a cyclical condition that includes core manic symptoms.3 Although outbursts can be part of bipolar disorder, they also occur in depressive disorders, ADHD, conduct disorder, and anxiety disorders and thus are not diagnostic in their own right. Structured interviews force the clinician to evaluate core symptoms of different disorders. In this case, neither the outpatient nor the inpatient psychiatrist identified core manic symptoms with unstructured clinical interviewing. In addition, benefits of using a structured interview include systematic evaluation of comorbidity and homogeneity of diagnostic assessments.
It is becoming increasingly important to differentiate pediatric bipolar disorder from other mood dysregulation syndromes. Ongoing research shows that in children who have mood disorders without core manic symptoms, bipolar disorder does not develop in later years, despite the severe impairment related to their temper dysregulation episodes.4
There is ongoing research to evaluate whether different treatment approaches, other than mood stabilizers, are more effective in children with nonbipolar mood disorders. Thus, correctly diagnosing severe mood-related symptoms in youths is not an academic exercise; it is needed to help make correct treatment decisions—behavioral and pharmacological.
Weigh in with your comments below. Dr Bastiaens will review your responses and give his feedback in coming weeks.
