Childhood bipolar disorder should be formally described in both the DSM and ICD, the pediatric bipolar subgroup said. The group members also agreed that some presentations in children are similar to manic symptoms in adulthood; that bipolar disorder in children is not reducible to attention-deficit/hyperactivity disorder (ADHD), although these conditions are often present together; and that there is more risk of bipolar disorder in children whose families include persons with bipolar disorder.

"The task force wanted to state that children do have straightforward mania according to the DSM-IV current adult definition and that this definition, at the very least, should be used," Ghaemi said.

In its recommended revision to DSM-IV, the subgroup described pediatric bipolar disorder as follows: (A) presence of acute manic, mixed, or hypomanic plus depressed episodes before age 18; and (B) the definition of the acute manic or hypomanic or mixed episode meets adult criteria. If only irritable mood is present, and not euphoria, then documented spontaneously episodic fluctuations in the presence or absence of symptoms of mania are required for the diagnosis of an acute manic, hypomanic, or mixed episode.

Deletion
"Some researchers claim that schizoaffective disorder is consistent with the idea that there is no distinction to be made between schizophrenia and mood disorders, but the committee didn't agree with that," Ghaemi said.

Most of the evidence, he explained, suggests that schizoaffective disorder does not represent a separate categorical disease entity; rather, it is "a variation on schizophrenia or a variation on mood disorder or co-occurrence of the two."

The subgroup recommended dropping the schizoaffective disorder diagnostic category altogether from DSM-V and replacing it with additional specifiers for chronic psychosis in mood disorders and new specifiers for mood episodes in schizophrenia.

Mixed states According to Ghaemi, the mixed states subgroup turned out to have the most difficult job overall.

There was agreement in the subgroup that the current system of definition of mixed states is inadequate, but there was not sufficient agreement to recommend an adequate replacement, Ghaemi said. The subgroup's attempts to broaden the narrow DSM-IV definition of mixed manic-depressive states to include depressive mixed state and dysphoric mania were met with rejection by the peer reviewers.

The peer reviewers' lack of approval of the subgroup's article is indicative of the existence of differences in concepts concerning the nature of mixed states, said Ghaemi.

Diagnostic tools
While the subgroups' reports discussed possible revisions to current DSM-IV and ICD-10 definitions, they also described diagnostic tools that might aid clinicians. Among the self-report scales described were the Mood Disorder Questionnaire, which has 13 yes-or-no items derived from the DSM-IV criteria and from clinical experience; the Hypomania Checklist, a 32-item questionnaire to help identify hypomania in depressive epi-sodes and increase detection of bipolar II disorder and minor bipolar disorders; and the Bipolar Spectrum Diagnostic Scale (BSDS), designed to determine whether a bipolar disorder is present or absent.

The BSDS has a descriptive paragraph that presents multiple aspects of mood course in bipolar disorder. Patients are asked to endorse any of 19 aspects of mania and depression on the scale.

"Regarding clinician interview scales, the gold standard is the SCID-I [Structured Clinical Interview for DSM-IV Axis I Disorders], which is not difficult to use," Ghaemi said. "I use it in my own clinical practice. The mood module is about 2 pages long."

Ghaemi noted that Akiskal and Benazzi have adapted the mood module of the SCID in order to more accurately identify hypomania.

Another assessment instrument under development is the Bipolarity Index, currently being tested at Massachusetts General Hospital's bipolar clinic, Ghaemi said. Although not yet validated or standardized, the index allows for the illness to exist as a matter of degree and places patients on a presumed continuum of bipolarity rather than categorizing their illness as bipolar or unipolar.

Studies needed
One of the goals of the task force, according to Ghaemi, was to highlight areas requiring additional research. "Most of the research we drew on [for the task force reports was from] studies that clinicians and researchers did on their own, often with very little or no funding."

Ghaemi called for large, government-funded studies, including one focused on the bipolar spectrum concept, using diagnostic validators such as symptoms, family history, treatment response and course, and one study focused on childhood bipolar disorder. The goal is to compare the broad definition, which would include irritability and aggression, with more classic definitions of mania.

"Long-term studies into adulthood of children with bipolar disorder also are very important," he said, as are studies teasing out the differences between bipolar disorder and ADHD in children.

Overdiagnosis
As a final question, Ghaemi was asked if he believed bipolar disorder is being overdiagnosed. "While unipolar depression, personality disorders, and schizophrenia have each had periods of overdiagnosis, there has never been an era in which bipolar disorder has been overdiagnosed," he said, "no matter what skeptics claim."

He said that concerns about bipolar overdiagnosis are largely anecdotal, have not been empirically well-established, and ignore solid evidence of continued underdiagnosis.

The lack of focus on bipolar disorder has led to neglect and controversy, Ghaemi noted. "Our task force," he said, "is a step toward more consensus and less controversy."

 
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