Not all mood swings are bipolar disorder
How to evaluate children with mood lability
Discuss this article at currentpsychiatry.blogspot.com/2011/02/not-all-mood-swings-are-bipolar.html
M, age 13, is referred by her pediatrician with the chief complaint of “severe mood swings, rule out bipolar disorder (BD).” In the past she was treated for attention-deficit/hyperactivity disorder (ADHD) with stimulants with mixed results. M’s parents are concerned about her “flipping out” whenever she is asked to do something she does not want to do. Her mother has a history of depression and anxiety; her father had a “drinking problem.” There is no history of BD in her first- or second-degree relatives. Are M’s rapid mood swings a sign of BD or another disorder?
The differential diagnosis of “mood swings” is important because they are a common presenting symptom of many children and adolescents with mood and behavioral disorders. Mood swings often occur in children and adolescents with ADHD, oppositional defiant disorder (ODD), developmental disorders, depressive disorders, BD, anxiety disorders, and conduct disorders. Mood swings are analogous to a fever in pediatrics—they indicate something potentially is wrong with the patient, but are not diagnostic as an isolated symptom.
Mood swings in children are common, nonspecific symptoms that more often are a sign of anxiety or behavioral disorders than BD. This article discusses the differential diagnosis of mood swings in children and adolescents and how to best screen and diagnose these patients.
What are ‘mood swings’?
Mood swings is a popular term that is nonspecific and not part of DSM-IV-TR diagnostic criteria for BD. The complaint of “mood swings” may reflect severe mood lability of pediatric patients with BD. This mood lability is best described by the Kiddie-Mania Rating Scale (K-MRS) developed by Axelson and colleagues as “rapid mood variation with several mood states within a brief period of time which appears internally driven without regard to the circumstance.”1 On K-MRS mood lability items, children with mania typically score:
- Moderate—many mood changes throughout the day, can vary from elevated mood to anger to sadness within a few hours; changes in mood are clearly out of proportion to circumstances and cause impairment in functioning
- Severe—rapid mood swings nearly all of the time, with mood intensity greatly out of proportion to circumstances
- Extreme—constant, explosive variability in mood, several mood changes occurring within minutes, difficult to identify a particular mood, changes in mood radically out of proportion to circumstances.
Patients with BD typically exhibit what is best described as a “mood cycle”—a pronounced shift in mood and energy from 1 extreme to another.2 An example of this would be a child who wakes up with extreme silliness, high energy, and intrusive behavior that persists for several hours and then later in the day becomes sad, depressed, and suicidal with no precipitant for either mood cycle. BD patients also will exhibit other symptoms of mania during these mood cycling periods.
Rapid cycling is a DSM-IV course specifier that indicates ≥4 mood episodes per year in patients with BD with a typical course of mania or hypomania followed by depression, or vice versa.3 The episodes must be demarcated by full or partial remission that lasts ≥2 months or by a switch to a mood state of opposite polarity. In the past, children with frequent mood swings were described incorrectly as “rapid cycling,” but this term has been dropped because it engenders confusion between adult and pediatric BD phenomenology.2
A more precise method of describing mood symptoms in a child or adolescent is to use the FIND criteria, which include:4
- Frequency of symptoms per week
- Intensity of mood symptoms
- Number of mood cycles per day
- Duration of symptoms per day.
Visit this article at CurrentPsychiatry.com to view a table that outlines what to look for when using the FIND criteria to evaluate common pediatric psychiatric disorders that include mood swings. Table 1
describes clinical characteristics and tools and resources used to differentiate these and other disorders.4
Clinical characteristics of psychiatric disorders that often feature mood swings
Chronic symptoms of hyperactivity, distractibility, impulsivity, poor attentional skills, disorganization
Conners’ Parent Rating Scale-Revised: Long Form (CPRS-R:L)
Chronic symptoms of oppositionality, negativity; short, frequent mood swings in response to being asked to do something they do not want to do
Excessive ‘worry,’ difficulty with transitions, increased mood swings during stressful periods, psychosomatic symptoms
Self-Report for Childhood Anxiety Related Disorders
History of exposure to alcohol in-utero; mild dysmorphia, attentional, mood, and executive functioning problems
National Organization on Fetal Alcohol Syndrome
In children: clustering together of episodes or ‘mini-episodes’ (several days) of increased energy, decreased need for sleep, increased mood cycling, pressured speech, etc. In adolescents: depressive episodes with episodes of hypomania or mania
Mood Disorders Questionnaire Kiddie Schedule for Affective Disorders and Schizophrenia Mania Rating Scale
ADHD: attention-deficit/hyperactivity disorder; ARND: alcohol-related neurodevelopmental disorder; ODD: oppositional defiant disorder
Source: Reference 4
Mood swings: A chart review
We recently completed a retrospective chart review of 100 patients consecutively referred to our pediatric mood disorders clinic for evaluation of “mood swings, rule out BD.” These patients were self-referred, referred by a psychiatrist for a second opinion, or referred by their primary care physician. The mean age of these patients was 8±2.8 years and 68% were male.
Two experienced clinicians (RAK and EM) interviewed each patient and their caregivers and reviewed results of the Conners’ Parent Rating Scale-Revised: Long Form (CPRS-R:L)5 and other outside information.
Figure 1 illustrates these patients’ diagnoses. Diagnoses for each of these disorders were made using DSM-IV-TR criteria.3
The most common diagnoses among patients with the chief complaint of mood swings were ADHD (39%); ODD with ADHD (15%); an anxiety disorder, usually generalized anxiety disorder (GAD) (15%); BD (12%); and a secondary mood disorder, usually fetal alcohol spectrum disorder (10%). We were surprised at how often ADHD, ODD, and anxiety disorders were found to be responsible for these patients’ mood swings and how frequently the referring clinician did not recognize these disorders. In the following sections, we discuss each of these disorders and how they differ from BD.
Figure 1 Underlying diagnoses of 100 children/adolescents referred for ‘mood swings’
ADHD: attention-deficit/hyperactivity disorder; BD: bipolar disorder; MDD: major depressive disorder; ODD: oppositional defiant disorder; PDD: pervasive developmental disorder
ADHD and ODD
In our sample, patients with undiagnosed ADHD made up the largest group of those with frequent mood swings. ADHD inattentive type was missed frequently in adolescent girls who still had behavioral aspects of ADHD, including impulsivity and aggression.6
The CPRS-R:L is useful for screening and diagnosing children and adolescents with ADHD and ODD. It contains 80 items, can be used in males and females and patients age 3 to 17, and has validated norms by age and sex.5 It takes parents approximately 10 minutes to fill out this questionnaire and the results can be scored by hand. The CPRS-R:L includes the following scales: oppositional; cognitive problems/inattention; hyperactivity; anxious-shy; perfectionism; social problems; psychosomatic; Connors’ global index; DSM-IV symptom subscales; and an ADHD index. Patients with mood swings and ADHD combined typically score >2 standard deviations above their age/sex mean on the CPRS-R:L hyperactivity scale, Connors’ Global Index, and ADHD index.5
A common childhood disorder, ODD has multiple etiologies.7 The first DSM-IV criteria for ODD is “often loses temper”3—essentially mood swings that often are expressed behaviorally as anger and at times as aggressive outbursts.
Dodge and Cole8 categorized aggression as reactive (impulsivity with a high affective valence) or proactive (characterized by low arousal and premeditation, ie, predatory conduct disorder). Reactive aggression typically is an angry defensive response to frustration, threat, or provocation, whereas proactive aggression is deliberate, coercive behavior often used to obtain a goal.9 Reactive aggression is common among children with ADHD and ODD and typically begins as a mood swing that escalates into reactive aggressive behavior. In a study of 268 consecutively referred children and adolescents with ADHD and 100 community controls, Connor et al10 found significantly more reactive than proactive forms of aggression in ADHD patients.
It can be difficult to differentiate the moods swings and symptoms of ODD from those of pediatric BD. Mick et al11 found that severe irritability may be a diagnostic indicator of BD in children with ADHD. Using the Kiddie Schedule for Affective Disorders and Schizophrenia (epidemiologic version) structured diagnostic interview,12 they evaluated 274 children (mean age 10.8±3.2) with ADHD; 37% had no comorbid mood disorder, 36% had ADHD with depression, and 11% had ADHD with BD. Researchers characterized 3 types of irritability in these patients:
- ODD-type irritability characterized by a low frustration tolerance that is seen in ODD
- Mad/cranky irritability found in depressive disorders
- Super-angry/grouchy/cranky irritability with frequent, prolonged, and largely unprovoked anger episodes and characteristics of mania.
ODD-type irritability was common among all ADHD patients, was the least impairing type of irritability, and did not increase the risk of a mood disorder. Mad/cranky irritability was common only in children with ADHD and a mood disorder (depression or BD), was more impairing than ODD-type irritability, and was most predictive of unipolar depression. Super-angry/grouchy/cranky irritability was common only among children with ADHD and BD (77%), was the most impairing, and was predictive of both unipolar depression and BD. The type of irritability and clustering of DSM-IV manic symptoms best differentiated ADHD subjects from those with ADHD and BD. Figure 2 illustrates symptoms that differentiated patients with ADHD from those with ADHD and comorbid BD.11
A review of pharmacotherapy for aggression in children found the largest effects for methylphenidate for aggression in ADHD (mean effect size=0.9, combined N=844).13 Our clinical experience has been that pediatric patients with ADHD or ODD with ADHD often have high levels of reactive aggression that presents as mood swings, and aggressively treating ADHD often results in improved mood and other ADHD symptoms.
Figure 2 Symptoms that differentiate BD from BD with comorbid ADHD
ADHD: attention-deficit/hyperactivity disorder; BD: bipolar disorder
Source: Reference 11
The estimated prevalence of child and adolescent anxiety disorders is 10% to 20%14; in our sample the prevalence was 15%. These disorders include GAD, separation anxiety disorder, social phobias, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder. Often, children with GAD worry excessively and become upset during transitions when things don’t proceed as they expect, with resultant angry outbursts and mood swings. Mood swings and difficulty sleeping are common in children with anxiety disorders or BD. Anxiety disorders often will be missed unless specific triggers of the mood swings or angry outbursts—as well as differentiating symptoms such as excessive fear, worry, and psychosomatic symptoms—are assessed.
In our clinical experience, simply asking a child if he or she is anxious is not sufficient to uncover an anxiety disorder. Although the CPRS-L:R will screen for anxiety disorders, we have found that the Self-Report for Childhood Anxiety Related Disorders (SCARED) developed by Birmaher et al15 is more specific. This tool can be used in patients age ≥8. The parent and child versions of the SCARED contain 41 items that measure 5 factors:
- general anxiety
- separation anxiety
- social phobia
- school phobia
- physical symptoms of anxiety.
The SCARED takes 5 minutes to fill out and is available in parent and child versions.
Secondary mood disorders
Many patients in our sample had a mood disorder secondary to the neurologic effects of alcohol on the developing brain. For more about maternal alcohol use, fetal alcohol spectrum disorders, and mood swings, visit this article at CurrentPsychiatry.com.