Journal of the American Academy of Child & Adolescent Psychiatry
Volume 48, Issue 7 , Pages 730-739, July 2009

Irritability Without Elation in a Large Bipolar Youth Sample: Frequency and Clinical Description

Drs. Hunt, Dyl, Esposito-Smythers, Swenson, Stout, and Keller are with the Warren Alpert Medical School, Brown University; Drs. Birmaher, Axelson, Ryan, Goldstein, and Goldstein, and Ms. Yang and Gill are with the University of Pittsburgh Medical Center; and Dr. Strober is with the David Geffen School of Medicine, University of California, Los Angeles. Dr. Leonard, now deceased, was with Brown University

Accepted 11 March 2009.

Disclosure: Dr. Keller has consulted for or received honoraria from Abbott, CENEREX, Cephalon, Cypress Bioscience, Cyberonics, Forest Laboratories, Janssen, JDS, Medtronic, Organon, Novartis, Pfizer, Roche, Solvay, and Wyeth. He has received research grants from Pfizer. He has served on the advisory boards of Abbott Laboratories, Bristol-Myers Squibb, CENEREX, Cyberonics, Cypress Bioscience, Forest Laboratories, Janssen, Neuronetics, Novartis, Organon, and Pfizer. Dr. Birmaher receives research funding from the National Institute of Mental Health. He participated in the NeuroPsychiatric Regional Roundtable on Patient Compliance/Adherance & Substance Abuse sponsored by Solvay Pharmaceuticals and the Recent Developments in the Treatment of Bipolar Disorder: A Content Development Meeting for Psychiatrics sponsored by Abcomm. He spoke on the topic of bipolar disorders in children at an event sponsored by Solvay, for which payment was given to the WPIC Residency Training Program. He receives royalties from Random House. The other authors report no conflicts of interest.

Abstract 

Objective

To determine whether some children with bipolar disorder (BP) manifest irritability without elation and whether these children differ on sociodemographic, phenotypic, and familial features from those who have elation and no irritability and from those who have both.

Method

Three hundred sixty-one youths with BP recruited into the three-site Course and Outcome of Bipolar Illness in Youth study were assessed at baseline and for most severe past symptoms using standardized semistructured interviews. Bipolar disorder subtype was identified, and frequency and severity of manic symptoms were quantified. The subjects were required to have episodic mood disturbance to be diagnosed with BP. The sample was then reclassified and compared based on the most severe lifetime manic episode into three subgroups: elated only, irritable only, and both elated and irritable.

Results

Irritable-only and elated-only subgroups constituted 10% and 15% of the sample, respectively. Except for the irritable-only subjects being significantly younger than the other two subgroups, there were no other between-group sociodemographic differences. There were no significant between-group differences in the BP subtype, rate of psychiatric comorbidities, severity of illness, duration of illness, and family history of mania in first- or second-degree relatives and other psychiatric disorders in first-degree relatives, with the exception of depression and alcohol abuse occurring more frequently in the irritability-only subgroup. The elated-only group had higher scores on most DSM-IV mania criterion B items.

Conclusions

The results of this study support the DSM-IV A criteria for mania in youths. Irritable-only mania exists, particularly in younger children, but similar to elated-only mania, it occurs infrequently. The fact that the irritable-only subgroup has similar clinical characteristics and family histories of BP, as compared with subgroups with predominant elation, provides support for continuing to consider episodic irritability in the diagnosis of pediatric BP.

Key Words:  phenomenology , bipolar disorder , irritability , elation

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 This work was supported by grants MH59929 (B.B.), MH59977 (M.S.), and MH59691 (M.K.) from the National Institute of Mental Health.This paper is dedicated to Henrietta Leonard, M.D.The authors thank Mei Yang, M.S., and Robert Stout, Ph.D, for statistical expertise. The authors also thank Carol Kostek and Edith Nottelmann, Ph.D., for support, as well as the past and current Course and Outcome of Bipolar Illness in Youth raters: Mathew Arruda, BA.; Amy Broz, A.S.; Jennifer Fretwell, B.A.; Colleen Grimm, BA.; Risha Henry, Ph.D.; Heather Hower, M.S.W.; Norman Kim, Ph.D.; Marguerite Lee, B.S.; Stephanie Pincince, B.A.; Nadia Olszanski, BA.; Nicole Ryan, B.A.; Jeff Ryan, BA.; Heather Schwickrath, MA.; and Andrea Wo ford, B.A.

PII: S0890-8567(09)60110-6

doi:10.1097/CHI.0b013e3181a565db

Journal of the American Academy of Child & Adolescent Psychiatry
Volume 48, Issue 7 , Pages 730-739, July 2009

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