Diagnosing Psychiatric Comorbidity in Pediatric Bipolar Disorder

Making an accurate assessment regarding whether or not a
youngster is suffering from a bipolar disorder can be a difficult task. What
makes the diagnostic process even more challenging is the fact that a
substantial number of these patients suffer from psychiatric comorbidity. Thus,
when faced with a young patient who indeed does suffer from a bipolar illness,
it is important to consider the possibility that this youth also suffers from a
comorbid psychiatric condition.

However, I have found that accurately assessing for
psychiatric comorbidity in pediatric patients with bipolar illness can be quite
difficult to do. One reason for this is that many of the symptoms of mood
episodes are also the symptoms of comorbidities. For example, patients in
hypomanic, mixed, or manic states can experience symptoms of restlessness,
distractibility, and impulsivity. These 3 symptoms are also key features of one
of the most commonly reported comorbidities in pediatric bipolar
illness—attention-deficit/hyperactivity disorder (ADHD). So, how does one try
to disentangle comorbidity from juvenile bipolarity?

One approach involves a careful longitudinal assessment. In
the instance of bipolar illness and ADHD, one may be able to ascertain whether
the conditions have separate ages at onset. In my experience, it is not
uncommon to hear about a patient with chronic symptoms consistent with the
diagnosis of ADHD who, several years later, started to develop “worsening” ADHD
that was also characterized by spontaneous mood episodes associated with
psychosocial dysfunction and emotional distress. In such instances, one might
strongly suspect an underlying diagnosis of ADHD upon which a mood disorder is superimposed.
Conversely, if one gets a long-term history that lacks core symptoms of ADHD,
the likelihood of this comorbidity is reduced.

Sometimes, the longitudinal history is not so clear. So,
what other approaches might one take? Another approach that I have found to be
useful is to do a meticulous family history. In many cases, one hears about a
family history of affective illness in one parent and a family history of
another heritable mental health condition in the other. This can help gauge
one’s index of suspicion about a particular psychiatric comorbidity in the
young patient.

In my experience, another key way to try to tease out the
presence or absence of psychiatric comorbidity is to identify recent periods of
euthymia. Since many youths suffering from bipolar illness have sustained mood
episodes, identifying recent epochs when the patient was euthymic can sometimes
be difficult. However, I have found that many parents and guardians can indeed
identify periods of neutral moods in these children. Identifying the presence
or absence of psychiatric symptomatology during these periods can be quite
helpful in either giving or eschewing a comorbid diagnosis.

I have found that identifying the presence or absence of
psychiatric comorbidity in a youngster can be very important. It can give
clinicians, patients, and patients’ families an appropriate perspective about
what to expect during treatment. For example, if faced with a youngster
suffering from a severe manic episode, it might be useful to anticipate what
residual problems might remain after the patient’s mood state has improved. In
addition, it can help patients and parents identify what may and may not be
addressed by thymoleptic medication, so that “treatment failures” in regard to
mood stabilization can be more precisely identified (rather than attributed to
untreated comorbid conditions).

Making an accurate assessment regarding comorbidity when
faced with a young patient with bipolar illness can be a substantive challenge.
However, since the start of an evidence-based treatment plan begins with a
correct diagnosis, it is important to do one’s best to get a precise
perspective of the patient. I have found that the approaches I have described
can be helpful when evaluating these vulnerable youths.

Financial disclosure:Dr Findling,
in the past 12 months, has received research support, acted as a consultant,
and/or served on a speaker’s bureau for Alexza, American Psychiatric Press,
AstraZeneca, Bristol-Myers Squibb, Dainippon Sumitomo Pharma, Forest,
GlaxoSmithKline, Guilford Press, Johns Hopkins University Press, Johnson &
Johnson, KemPharm, Eli Lilly, Lundbeck, Merck, NIH, Novartis, Otsuka, Pfizer,
Physicians Postgraduate Press, Rhodes, Roche, Sage, Shionogi, Shire, Stanley
Medical Research Institute, Sunovion, Supernus, Transcept, and WebMD.