Irritability and euphoria in childhood can be the initial symptoms of a future bipolar disorder in adolescence
INTRODUCTION
EThere is a great deal of controversy about the existence, or not of Pediatric Bipolar Disorder (BPD)Some deny its existence, others speak of subclinical situations, and still others have no doubt about its presence, although with age-dependent symptoms. The truth is that retrospective and prospective longitudinal studies show that the majority of adults with Bipolar Disorder (BD) They already showed warning signs in their childhood. The importance of this debate lies primarily in the need to detect clinical markers early, allowing us to intervene preventively.
The clinical presentation of TB has been known since the 1st century, despite limited advances in treatment. Areteus of Cappadocia who best described TB: "Some patients, after being melancholic, have changes to mania...that is why this mania is probably a variety of the melancholic state...Mania is expressed as fury, excitement and great joy...Other types of mania have expansive delirious manifestations: the patient has delirium, studies astronomy, philosophy...he feels powerful and inspired" (1). He even indirectly observed the therapeutic benefits of lithium, although he did not know it, by noting that some patients improved after drinking certain waters that were later found to be rich in lithium.
In medical literature, a distinction is usually made between Childhood TB (under 12 years old) and adolescent bipolar disorder (over 13 years old)It is also known that the presence of family background of affective disorders, significantly increases the risk in childhood. It is estimated that assisted prevalence of approximately 2%.
Do you want to assess irritability and other symptoms of bipolar disorder in children and adolescents? We offer two questionnaires to evaluate these symptoms. The first is called Affective Reactivity Index and, to the second, YOUNG'S SCALE to assess the symptoms of bipolar disorder
TB SYMPTOMS
The DSM-5 does not distinguish between bipolar disorder in adults and in childhood/adolescence. It merely introduces explanatory notes regarding mood and weight. In the first case, it indicates that in childhood and adolescence, mood "may be irritable," and in the second, "consider failure to gain expected weight."
Personally, in my entire professional life, I have only encountered one prepubertal case that met the DSM-5 criteria for a manic episode. Its presentation in post-pubertal ages is considerably more frequent. Hence the importance of the article by Serra G et al. (2017) (2) in the preventive attitude towards TB. These authors of Babino Iesu Hospital They conduct a critical review on the importance that euphoria and irritability They acquire in the early detection of TB.
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- Characteristics of irritability and euphoria and elation in bipolar disorder
Irritability It often takes different forms of expression depending primarily on age. The most important thing to keep in mind is that irritability in childhood is not always pathological. It only indicates a possible bipolar disorder when it is especially intense, frequent, and debilitating. Its manifestations include provocations, confrontations, being very demanding, insulting, whining, shouting, cruelty, and episodes of explosive, abusive, and destructive rage that pose a danger to the child.
Irritability without euphoria is the most frequently reported symptom of bipolar disorder in childhood (under 12 years). This irritability is often associated with impulsive behavior, psychomotor restlessness, violent behavior, and suicidal thoughts and gestures are not uncommon.
Unfortunately, it is when such intense symptoms are present that medical consultation takes place.
The relationship and the euphoria It often manifests as elation, high energy (seemingly tireless), and grandiosity of feelings and ideas. They are perpetually cheerful, excessively playful, and prone to grandiosity (elarity). Immature behaviors that are difficult for parents and peers to manage are also common, often proving quite disruptive. They may exhibit excessive self-confidence, unrealistic plans, and frequently display extreme defiance toward adult authority.
Mixed states, (The simultaneous presence of euphoria and irritability), although less frequent than in adults, is the most common combination in childhood. Mood swings are usually ultra-rapid, with cycles occurring within the same day in prepubertal bipolar disorder, while juvenile bipolar disorder tends to more closely resemble that of adults.
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- Importance of irritability and euphoria/elation for diagnosis.
Some consider euphoria to be the pathognomonic symptom of bipolar disorder. In fact, these same researchers use it as an inclusion/exclusion criterion in their studies, which clearly contributes to maintaining their clinical perspective. Using this exclusion criterion, irritability would be present in only 29% of cases. Their argument is that irritability is an excessively nonspecific symptom.
However, meta-analyses conducted to date confirm the opposite: irritability is the most important and common symptom in childhood bipolar disorder, appearing in 100% of cases in many studies. Therefore, it is proposed as a clinical marker In childhood bipolar disorder, grandiosity and euphoria are less frequent than in adolescence and adulthood.
Similarly, the primacy of irritability as a symptom is supported by both retrospective and prospective longitudinal studies. These studies have found that irritability, emotional lability, and loss of impulse control are the most common symptoms in childhood bipolar disorder.
Other researchers, faced with the constant presence of irritability, speak of irritable mania in early childhood and that irritability would disappear with age.
EVOLUTION
When adults with TB are questioned about their childhood history, we find that 30-50% They have presented psychopathological symptoms. Retrospective research speaks of 28% in the prepubertal stage and 37% in adolescenceThe most frequent symptoms are: mood swings, sleep disturbances, motor restlessness, irritability, and behavioral disorders.
Adults who have experienced the aforementioned symptoms during childhood tend to have a greater number of episodes, longer duration and intensity of these episodes, tend to be rapid cyclers, and present a greater psychiatric comorbidity (anxiety, suicide attempts, drug use, and a greater number of violent acts).
Prospective studies have found that children with a depressive/manic sub-syndrome typically experience their first bipolar disorder episode 8-12 years after the onset of these initial symptoms. Once appropriate treatment is implemented, a second episode usually occurs 8-10 years after the first.
Currently, with the publication of the DSM-5, some researchers have included outbursts of rage, previously considered short episodes of mania, in the DSM-5 as the Disruptive emotional dysregulation disorder (DEDD) with the idea of differentiating between those who present chronic versus episodic states of irritability.
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