Severe Temper Outbursts in a 10-Year-Old Girl

We invite you to answer the following question after reading the Case Vignette. Discussion follows on the next page.

On the basis of the patient's depression symptoms in the past year and the hypomanic episodes, what is the diagnosis and why?

CASE VIGNETTE

Betty is a 10-year-old girl who initially presented to outpatient psychiatric care for severe temper outbursts-rages precipitated by minor issues. These lasted for 1 to 2 hours and included destruction of property, physical aggression, and suicidal threats. Bipolar disorder was diagnosed. She was initially treated with quetiapine and later with a combination of quetiapine and valproic acid. The medical record did not mention symptoms related to major depression, mania, ADHD, or anxiety.

Several months later, the Betty was hospitalized because of ongoing destructive psychiatric episodes. During the hospitalization, she was given a diagnosis of major depressive disorder and treatment with an antidepressant in conjunction with quetiapine was started. The hospital psychiatrist did not consider the outbursts as an indication of bipolar disorder; there was no record of manic symptoms.

Subsequent to the hospitalization, the patient was evaluated with the Mini International Neuropsychiatric Interview (MINI). During the evaluation, the presence of significant depressive symptoms, including low mood, reduced interest level in several activities, insomnia and fatigue, self-derogatory thinking, and poor concentration, were identified. Betty and her mother described a 5-day episode of clear hypomanic symptoms that had occurred 8 months earlier: euphoria, decreased need for sleep, grandiosity, very fast speech, and an increased activity level. A similar episode, of 2 days’ duration, occurred 4 months after the initial episode.

There were no symptoms of ADHD and no psychosis, trauma, PTSD, significant anxiety, or substance use. The family history was positive for bipolar disorder, although this could not be verified.

QUESTION:

On the basis of the patient's depression symptoms in the past year and the hypomanic episodes, what is the diagnosis and why?

Click here for answer and discussion.

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.