- Email: [email protected]
Mania in prepubertal children: Has it been underdiagnosed?
Journul of Affective Elsevier
151
Disorders, 11 (1986) 151-154
JAD 00400
Mania in Prepubertal
Children:
Ronald A. Weller, Elizabeth
Has It Been Underdiagnosed?
B. Weller, Sheridan
G. Tucker and Mary A. Fristad
Psychiatry Department, Ohio State University, 473 W. 12th Avenue, Columbus, OH 43210, and Psychiatv University of Kansas Medical Center, 39th and Rainbow, Kansas Ciq, KS 66103 (U.S.A.) (Received (Accepted
Department.
26 April, 1985) 1 August, 1986)
Summary Prior to the introduction of lithium, mania was underdiagnosed in the U.S.A. Almost 50% of adults who met DSM-III criteria for mania had previously been diagnosed to have schizophrenia. To determine if mania had similarly been underdiagnosed in prepubertal children, 157 cases of ‘severely disturbed’ children described in the literature were reviewed. Approximately one-half (16/33) of the children diagnosed in this study as manic according to DSM-III had originally received another diagnosis. These results indicate that mania should be considered in the differential diagnosis of psychotic children, particularly those with affective symptoms.
Key words:
Mania
- PrepubertaI
children - Differential
Introduction Mania is a distinct alteration of mood (elevated, expansive, or irritable) associated with certain characteristic symptoms. In the past two decades there has been increased interest in the phenomenology of mania and its differentiation from other psychoses. This interest has been spurred by the discovery of lithium as an effective treatment for the disorder. Studies of diagnostic trends in adults have found that prior to the introduction of lithium, mania was underdiagnosed in the U.S.A. In several studies almost 50% of those who met DSM-III or similar diagnostic criteria for mania previously had been diagnosed to have schizophrenia (Mendelwicz et al. 1972; Taylor and Abrams 1973; Garvey and Tauson 1980; Horgan 1981). Although mania is now well recognized in 0165-0327/86/$03.50
Q 1986 Elsevier Science Publishers
diagnosis
adults, it has been infrequently diagnosed and seldom considered in the differential diagnosis of psychotic children. This resulted from a lack of accepted diagnostic criteria for mania in children - none were even proposed until 1960 (Anthony and Scott) - and the widely held belief that its occurrence was virtually nonexistent. Despite these biases against its diagnosis, mania has been observed in adolescents (Kelly et al. 1976; White and O’Shanick 1977; Engstrom et al. 1978; Youngerman and Canino 1978; Carlson 1983) and prepubertal children (M&new et al. 1981; Poznanski 1982; Popper 1984). However, no study has assessed whether mania (as defined by DSM-III) had been previously underdiagnosed in children as it had been in adults. The purpose of this study was to determine if mania may have been underdiagnosed in prepu-
B.V. (Bit xnedical
Division)
152 bertal children previously or severely disturbed.
diagnosed
as psychotic
Method A retrospective review of all English language case descriptions of children aged 6-12 years diagnosed as having manic depression, psychosis, schizophrenia, atypical manic depression, or as being ‘severely disturbed’ was conducted. It was believed that these cases would include the diagnostic situations in which a manic episode would have possibly received another diagnosis. Cases of mania were also included to determine whether they also met DSM-III criteria. References were initially obtained through the use of three separate computer search programs (Medline, Medlar II, Bibliographical Retrieval Services). Secondary references were obtained from these articles to supply further cases. In addition, descriptions published in the series ‘The Psychoanalytic Study of the Child’ (1945-1984) and ‘The Nervous Child (1941-1956) were reviewed article by article. In all, over 200 articles from 1809 to 1982 were reviewed. Cases of children with evidence of mental retardation, organic brain disease, attention deficit disorder with hyperactivity, drug/alcohol misuse or symptoms suggestive of pervasive developmental disorder were excluded. After these initial exclusions were made, 157 cases remained for examination. * Each case was independently reviewed by two child psychiatrists. In all but four cases, the two psychiatrists agreed on the diagnosis. On three occasions, they disagreed as to whether the patient had probable or possible mania. In one case, one psychiatrist diagnosed possible mania, while the other diagnosed attention deficit disorder. In these four cases of disagreement, a third psychiatrist reviewed each case in a conference with the other psychiatrists to make a final determination of diagnosis. DSM-III criteria were used to diagnose mania. They include: (a) a distinct period of elevated, expansive, or irritable mood; and (b) duration of at least one week with at least three (or four with irritable mood) of the following symptoms present: (1) increased activity; (2) in* A detailed
list of cases reviewed is available
upon request.
creased talkativeness; (3) flight of ideas/racing thoughts; (4) inflated self-esteem; (5) decreased need for sleep; (6) distractibility; and (7) excessive involvement in activities with a high potential for painful consequences. Patients with mood incongruent hallucinations, bizarre behavior, schizophrenia, schizophreniform disorder, paranoid disorder, or organic mental disorder are excluded from the diagnosis of mania. Unfortunately, as in any retrospective case review, data necessary to make diagnoses were not clearly described or lacking in some case reports. In general, a clear description of behavior was needed for symptoms to be scored positive except in such cases where a symptom appeared so compelling that it was considered positive, e.g., the statement ‘grandiose behavior was prominent’ was accepted as indicating the presence of inflated self-esteem. Because of the retrospective nature of this study, the following classifications were used. Definite mania was diagnosed when subjects met DSM-III criteria with the following minor modifications. Four symptoms were required for diagnosis regardless of whether mood was irritable or euphoric. Also, to avoid diagnosing children with attention deficit disorder (ADD) or conduct disorder as ‘manic’, the criterion ‘excessive involvement in activities that have a high potential for painful consequences’ was not scored. This was done because it was too difficult to retroactively distinguish this symptom from symptoms of ADD and/or conduct disorder. Thus, one less criterion was available to meet DSM-III criteria, making a positive diagnosis more difficult to achieve (i.e., four out of six possible symptoms instead of the usual three or four out of seven possible symptoms had to be present). Probable mania was diagnosed when a subject appeared to be manic by description but did not fulfill the adjusted DSM-III criteria described above because: (1) they had only three symptoms of mania and were thus one symptom short of the number required to meet the above criteria; or (2) they met the criterion of four symptoms present but either their mood or duration of symptoms was not specified. Possible mania was diagnosed when a subject appeared manic by description but was one symptom short of meeting the adjusted DSM-III criteria (i.e., they had only three symp-
153 toms) and mood or duration specified.
of symptoms
was not
Results and Discussion Of the 157 children aged 6-12 years whose cases were reviewed, there were 42 girls and 115 boys. The initial diagnosis was schizophrenia in 59 cases and mania in 19 cases. Other diagnoses had been given in the remaining 79 cases. Of these 157 cases, nine (6%) met the adjusted DSM-III criteria for definite mania, 12 (8%) were probable manics, and 12 (8%) were possible manics. In 17 of the 19 (89%) children originally reported as manic, our modified DSM-III criteria confirmed their diagnoses. However, 16 of the 138 (12%) children initially diagnosed as not manic were rediagnosed manic (definite, probable or possible) according to the modified DSM-III criteria (see Table 1). Of the nine definite manics, three had previously been diagnosed manic, three as schizophrenic, one as obsessive-compulsive, one as psychotic and one as a loss reaction. Of the 12 probable manics, eight had previously been diagnosed as manic or some manic variant (e.g., ‘embryonic mania’), two as schizophrenic, one as a ‘chronic personality change’, and one as a psychopathic personality. Six of the 12 possible manics had initially been diagnosed as manic, two as borderline, two as immature, one as schizophrenic, and one as neurotic. As a result of this review, a total of 33 children were diagnosed as manic, probably manic, or possibly manic. Of these, 17 (52%) had previously
TABLE
1
DIAGNOSIS OF MANIA IN 157 ‘PSYCHOTIC’ OR ‘SEVERELY DISTURBED’ PREPUBERTAL CHILDREN DETERMINED BY INDIVIDUAL CASE REVIEW USING DSM-III CRITERIA Initial clinical diagnosis
DSM-III Manic a
diagnosis Not manic
Total
Manic
17
2
19
Not manic
16
122
138
Total
33
124
157
a Includes
definite,
probable,
and possible
manic children.
been diagnosed manic or some variant thereof, but 16 (48%) had been diagnosed as having some other disorder. Thus, approximately one-half of the children diagnosed manic in this systematic review had been reported originally as having another diagnosis. This corresponds with earlier reports of mania being underdiagnosed in adults. Although the retrospective nature of this study and lack of information in some cases made diagnosis difficult, a trend to underdiagnose mania appeared to be present. Had duration of symptoms and other criteria specific to DSM-III been reported more consistently, it is possible that diagnoses of ‘definite’ mania, ‘probable’ mania, or ‘possible’ mania may have increased. Also, had the criterion ‘excessive involvement’ not been eliminated in diagnosing mania, the number of manic diagnoses may have been greater. Despite the inevitable limitations of a retrospective literature review, this study found that almost all cases of prepubertal mania previously reported in the literature are consistent with DSM-III criteria for mania. Furthermore, many cases of apparent mania had initially received other diagnoses. Thus, mania should be carefully considered in the differential diagnosis of psychotic and other seriously disturbed children who show affective features. References Anthony, J. and Scott, P., Manic-depressive psychosis in childhood, J. Child Psychol. Psychiatry, 1 (1960) 53-72. Carlson, G.A., Bipolar affective disorders in childhood and adolescence. In: D.P. Cantwell and G.A. Carlson (Eds.), Affective Disorders in Childhood and Adolescence: An Update, Spectrum, New York, 1983. Engstrom, F.W., Robbins, D.R. and May, J.G., Manic depressive illness in adolescence: a case report, J. Am. Acad. Child Psychiatry, 17 (1978) 514-520. Garvey, M. and Tuason, V.B., Mania misdiagnosed as schizophrenia, J. Clin. Psychiatry, 41 (1980) 75-58. Horgan, D., Change of diagnosis to manic-depressive illness, Psychol. Med., 11 (1981) 517-523. Kelly, J.T., Koch, M. and Buegel, D., Lithium carbonate in juvenile manic-depressive illness, Dis. Nerv. Sys., 37 (1976) 90-92. McKnew, D.M., Cytryn, L., Buchsbaum, M.S., Hamovit, J., Lamour, M., Rapaport, J.L. and Gerson, E.S., Lithium in children of lithium responding parents, J. Psychiatr. Res., 4 (1981) 171-180. Mendelwicz, J., Fieve, R.R., Rainer, J.D. and Fleiss, J.L., Manic depressive illness: a comparative study of patients
154 with and without a family history, Br. .I. Psychiatry, 120 (1972) 523-530. Popper, C., Biological cyclicity in two preschool children. Paper presented at the 137th Annual Meeting of the American Psychiatric Association, Los Angeles, CA, May 9, 1984. Poznanski, E.O., Israel, M.C. and Grossman, J., Hypomania in a four-year-old, .I. Am. Acad. Child Psychiatry, 23 (1984) 105-110. Taylor, M.A. and Abrams, R., The phenomenology of mania: a new look at some old patients, Arch. Gen. Psychiatry, 29 (1973) 520-522.
The Nervous Child, Vols. l-11, Ed.: E. Harms, The Philosophical Library, New York, 1941-1956. The Psychoanalytic Study of the Child, Vols. l-34, Eds.: A. Freud et al., International Universities Press, New York, 194551984. White, J.H. and O’Shanick, F., Juvenile manic-depressive illness, Am. J. Psychiatry, 134(9) (1977) 1035-1036. Youngerman, J. and Canino, I., Lithium carbonate use in children and adolescents: a survey of the literature, Arch. Gen. Psychiatry, 35 (197X) 216-224.
151
Disorders, 11 (1986) 151-154
JAD 00400
Mania in Prepubertal
Children:
Ronald A. Weller, Elizabeth
Has It Been Underdiagnosed?
B. Weller, Sheridan
G. Tucker and Mary A. Fristad
Psychiatry Department, Ohio State University, 473 W. 12th Avenue, Columbus, OH 43210, and Psychiatv University of Kansas Medical Center, 39th and Rainbow, Kansas Ciq, KS 66103 (U.S.A.) (Received (Accepted
Department.
26 April, 1985) 1 August, 1986)
Summary Prior to the introduction of lithium, mania was underdiagnosed in the U.S.A. Almost 50% of adults who met DSM-III criteria for mania had previously been diagnosed to have schizophrenia. To determine if mania had similarly been underdiagnosed in prepubertal children, 157 cases of ‘severely disturbed’ children described in the literature were reviewed. Approximately one-half (16/33) of the children diagnosed in this study as manic according to DSM-III had originally received another diagnosis. These results indicate that mania should be considered in the differential diagnosis of psychotic children, particularly those with affective symptoms.
Key words:
Mania
- PrepubertaI
children - Differential
Introduction Mania is a distinct alteration of mood (elevated, expansive, or irritable) associated with certain characteristic symptoms. In the past two decades there has been increased interest in the phenomenology of mania and its differentiation from other psychoses. This interest has been spurred by the discovery of lithium as an effective treatment for the disorder. Studies of diagnostic trends in adults have found that prior to the introduction of lithium, mania was underdiagnosed in the U.S.A. In several studies almost 50% of those who met DSM-III or similar diagnostic criteria for mania previously had been diagnosed to have schizophrenia (Mendelwicz et al. 1972; Taylor and Abrams 1973; Garvey and Tauson 1980; Horgan 1981). Although mania is now well recognized in 0165-0327/86/$03.50
Q 1986 Elsevier Science Publishers
diagnosis
adults, it has been infrequently diagnosed and seldom considered in the differential diagnosis of psychotic children. This resulted from a lack of accepted diagnostic criteria for mania in children - none were even proposed until 1960 (Anthony and Scott) - and the widely held belief that its occurrence was virtually nonexistent. Despite these biases against its diagnosis, mania has been observed in adolescents (Kelly et al. 1976; White and O’Shanick 1977; Engstrom et al. 1978; Youngerman and Canino 1978; Carlson 1983) and prepubertal children (M&new et al. 1981; Poznanski 1982; Popper 1984). However, no study has assessed whether mania (as defined by DSM-III) had been previously underdiagnosed in children as it had been in adults. The purpose of this study was to determine if mania may have been underdiagnosed in prepu-
B.V. (Bit xnedical
Division)
152 bertal children previously or severely disturbed.
diagnosed
as psychotic
Method A retrospective review of all English language case descriptions of children aged 6-12 years diagnosed as having manic depression, psychosis, schizophrenia, atypical manic depression, or as being ‘severely disturbed’ was conducted. It was believed that these cases would include the diagnostic situations in which a manic episode would have possibly received another diagnosis. Cases of mania were also included to determine whether they also met DSM-III criteria. References were initially obtained through the use of three separate computer search programs (Medline, Medlar II, Bibliographical Retrieval Services). Secondary references were obtained from these articles to supply further cases. In addition, descriptions published in the series ‘The Psychoanalytic Study of the Child’ (1945-1984) and ‘The Nervous Child (1941-1956) were reviewed article by article. In all, over 200 articles from 1809 to 1982 were reviewed. Cases of children with evidence of mental retardation, organic brain disease, attention deficit disorder with hyperactivity, drug/alcohol misuse or symptoms suggestive of pervasive developmental disorder were excluded. After these initial exclusions were made, 157 cases remained for examination. * Each case was independently reviewed by two child psychiatrists. In all but four cases, the two psychiatrists agreed on the diagnosis. On three occasions, they disagreed as to whether the patient had probable or possible mania. In one case, one psychiatrist diagnosed possible mania, while the other diagnosed attention deficit disorder. In these four cases of disagreement, a third psychiatrist reviewed each case in a conference with the other psychiatrists to make a final determination of diagnosis. DSM-III criteria were used to diagnose mania. They include: (a) a distinct period of elevated, expansive, or irritable mood; and (b) duration of at least one week with at least three (or four with irritable mood) of the following symptoms present: (1) increased activity; (2) in* A detailed
list of cases reviewed is available
upon request.
creased talkativeness; (3) flight of ideas/racing thoughts; (4) inflated self-esteem; (5) decreased need for sleep; (6) distractibility; and (7) excessive involvement in activities with a high potential for painful consequences. Patients with mood incongruent hallucinations, bizarre behavior, schizophrenia, schizophreniform disorder, paranoid disorder, or organic mental disorder are excluded from the diagnosis of mania. Unfortunately, as in any retrospective case review, data necessary to make diagnoses were not clearly described or lacking in some case reports. In general, a clear description of behavior was needed for symptoms to be scored positive except in such cases where a symptom appeared so compelling that it was considered positive, e.g., the statement ‘grandiose behavior was prominent’ was accepted as indicating the presence of inflated self-esteem. Because of the retrospective nature of this study, the following classifications were used. Definite mania was diagnosed when subjects met DSM-III criteria with the following minor modifications. Four symptoms were required for diagnosis regardless of whether mood was irritable or euphoric. Also, to avoid diagnosing children with attention deficit disorder (ADD) or conduct disorder as ‘manic’, the criterion ‘excessive involvement in activities that have a high potential for painful consequences’ was not scored. This was done because it was too difficult to retroactively distinguish this symptom from symptoms of ADD and/or conduct disorder. Thus, one less criterion was available to meet DSM-III criteria, making a positive diagnosis more difficult to achieve (i.e., four out of six possible symptoms instead of the usual three or four out of seven possible symptoms had to be present). Probable mania was diagnosed when a subject appeared to be manic by description but did not fulfill the adjusted DSM-III criteria described above because: (1) they had only three symptoms of mania and were thus one symptom short of the number required to meet the above criteria; or (2) they met the criterion of four symptoms present but either their mood or duration of symptoms was not specified. Possible mania was diagnosed when a subject appeared manic by description but was one symptom short of meeting the adjusted DSM-III criteria (i.e., they had only three symp-
153 toms) and mood or duration specified.
of symptoms
was not
Results and Discussion Of the 157 children aged 6-12 years whose cases were reviewed, there were 42 girls and 115 boys. The initial diagnosis was schizophrenia in 59 cases and mania in 19 cases. Other diagnoses had been given in the remaining 79 cases. Of these 157 cases, nine (6%) met the adjusted DSM-III criteria for definite mania, 12 (8%) were probable manics, and 12 (8%) were possible manics. In 17 of the 19 (89%) children originally reported as manic, our modified DSM-III criteria confirmed their diagnoses. However, 16 of the 138 (12%) children initially diagnosed as not manic were rediagnosed manic (definite, probable or possible) according to the modified DSM-III criteria (see Table 1). Of the nine definite manics, three had previously been diagnosed manic, three as schizophrenic, one as obsessive-compulsive, one as psychotic and one as a loss reaction. Of the 12 probable manics, eight had previously been diagnosed as manic or some manic variant (e.g., ‘embryonic mania’), two as schizophrenic, one as a ‘chronic personality change’, and one as a psychopathic personality. Six of the 12 possible manics had initially been diagnosed as manic, two as borderline, two as immature, one as schizophrenic, and one as neurotic. As a result of this review, a total of 33 children were diagnosed as manic, probably manic, or possibly manic. Of these, 17 (52%) had previously
TABLE
1
DIAGNOSIS OF MANIA IN 157 ‘PSYCHOTIC’ OR ‘SEVERELY DISTURBED’ PREPUBERTAL CHILDREN DETERMINED BY INDIVIDUAL CASE REVIEW USING DSM-III CRITERIA Initial clinical diagnosis
DSM-III Manic a
diagnosis Not manic
Total
Manic
17
2
19
Not manic
16
122
138
Total
33
124
157
a Includes
definite,
probable,
and possible
manic children.
been diagnosed manic or some variant thereof, but 16 (48%) had been diagnosed as having some other disorder. Thus, approximately one-half of the children diagnosed manic in this systematic review had been reported originally as having another diagnosis. This corresponds with earlier reports of mania being underdiagnosed in adults. Although the retrospective nature of this study and lack of information in some cases made diagnosis difficult, a trend to underdiagnose mania appeared to be present. Had duration of symptoms and other criteria specific to DSM-III been reported more consistently, it is possible that diagnoses of ‘definite’ mania, ‘probable’ mania, or ‘possible’ mania may have increased. Also, had the criterion ‘excessive involvement’ not been eliminated in diagnosing mania, the number of manic diagnoses may have been greater. Despite the inevitable limitations of a retrospective literature review, this study found that almost all cases of prepubertal mania previously reported in the literature are consistent with DSM-III criteria for mania. Furthermore, many cases of apparent mania had initially received other diagnoses. Thus, mania should be carefully considered in the differential diagnosis of psychotic and other seriously disturbed children who show affective features. References Anthony, J. and Scott, P., Manic-depressive psychosis in childhood, J. Child Psychol. Psychiatry, 1 (1960) 53-72. Carlson, G.A., Bipolar affective disorders in childhood and adolescence. In: D.P. Cantwell and G.A. Carlson (Eds.), Affective Disorders in Childhood and Adolescence: An Update, Spectrum, New York, 1983. Engstrom, F.W., Robbins, D.R. and May, J.G., Manic depressive illness in adolescence: a case report, J. Am. Acad. Child Psychiatry, 17 (1978) 514-520. Garvey, M. and Tuason, V.B., Mania misdiagnosed as schizophrenia, J. Clin. Psychiatry, 41 (1980) 75-58. Horgan, D., Change of diagnosis to manic-depressive illness, Psychol. Med., 11 (1981) 517-523. Kelly, J.T., Koch, M. and Buegel, D., Lithium carbonate in juvenile manic-depressive illness, Dis. Nerv. Sys., 37 (1976) 90-92. McKnew, D.M., Cytryn, L., Buchsbaum, M.S., Hamovit, J., Lamour, M., Rapaport, J.L. and Gerson, E.S., Lithium in children of lithium responding parents, J. Psychiatr. Res., 4 (1981) 171-180. Mendelwicz, J., Fieve, R.R., Rainer, J.D. and Fleiss, J.L., Manic depressive illness: a comparative study of patients
154 with and without a family history, Br. .I. Psychiatry, 120 (1972) 523-530. Popper, C., Biological cyclicity in two preschool children. Paper presented at the 137th Annual Meeting of the American Psychiatric Association, Los Angeles, CA, May 9, 1984. Poznanski, E.O., Israel, M.C. and Grossman, J., Hypomania in a four-year-old, .I. Am. Acad. Child Psychiatry, 23 (1984) 105-110. Taylor, M.A. and Abrams, R., The phenomenology of mania: a new look at some old patients, Arch. Gen. Psychiatry, 29 (1973) 520-522.
The Nervous Child, Vols. l-11, Ed.: E. Harms, The Philosophical Library, New York, 1941-1956. The Psychoanalytic Study of the Child, Vols. l-34, Eds.: A. Freud et al., International Universities Press, New York, 194551984. White, J.H. and O’Shanick, F., Juvenile manic-depressive illness, Am. J. Psychiatry, 134(9) (1977) 1035-1036. Youngerman, J. and Canino, I., Lithium carbonate use in children and adolescents: a survey of the literature, Arch. Gen. Psychiatry, 35 (197X) 216-224.