Child and Adolescent Mental Health 24, No. 1, 2019, pp. 103–105
12310
Debate: Dimensions of mania in youth: possibly
bipolar, probably risk indicators, certainly impairing
Pedro Mario Pan1,2 , Giovanni Salum2,3 & Rodrigo A. Bressan1,2
1

rio Interdisciplinar de Neurocie
Laborato ^ncias Cl
ınicas (LiNC), Deparment of Psychiatry, Universidade Federal de Sa
~o Paulo
Paulo, Sa
2
National Institute of Developmental Psychiatry for Children and Adolescents (INPD), Sa ~o Paulo
3
Department of Psychiatry, Hospital de Cl
ınicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
Introduction
In a recent review, Parry, Allison, and Bastiampillai
(2018) questioned the existence of pediatric Bipolar
Disorder (BD) in epidemiological studies. They
re-assessed data included in Van Meter, Moreira, and
Youngstrom (2011) metanalysis and concluded that the
high heterogeneity among studies0 methodologies dis-
couraged statistical comparisons, motivating this
Debate Series. Here, we want to add to this conversation
on whether BD can be identified in youth by exploring
some insights from epidemiological studies such as the
2007 British Child Adolescent Mental Health Survey
(B-CAMHS) (Stringaris, Stahl, Santosh, & Goodman,
2011), the European multisite IMAGEN study (String-
aris et al., 2014), and the Brazilian High Risk Cohort
Study for Psychiatric Disorders (HRC) (Pan et al., 2014;
Salum et al., 2015). These three community-based stud-
ies take a dimensional approach to youth BD research,
investigating the same underlying construct of mania in
the diverse settings of Brazil and Europe. They have
used the same semistructured interview to assess a
range of manic symptoms, which diminished the effects
of disparate methodological aspects outlined by Parry
et al. (2018). We will comment on the evidence for relia-
bility and validity of manic dimensions in youth and
whether those dimensions are clinically valid constructs
for the child psychiatry literature.
Are manic symptoms, as measured in
epidemiological studies, a reliable trait in
youth?
One of the first steps to investigate the reliability of a trait
in psychiatry is to test its internal consistency, i.e., do
questions addressing clustered symptoms (in a scale,
instrument, or interview) consistently relate to each other
as expected? Confirmatory Factor Analysis (CFA) is a
robust statistical approach to evaluate internal consis-
tency. We used this method to evaluate whether the
2-dimensional latent structure of manic symptoms found
in the B-CAMHS (n = 5247 parent-reports of 8–19-year-
olds and n = 3295 self-reports of 11–19-year-olds)
(Stringaris et al., 2011), and then confirmed in the ado-
lescent sample of the IMAGEN study (n = 1755; 14-
years-old at recruitment; average age 14.4 years,
SD = 0.43) (Stringaris et al., 2014), could be replicated
in the Brazilian HRC sample (n = 2503, 6–12-year-old
© 2019 Association for Child and Adolescent Mental Health.
Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
doi:10.1111/camh.
~o
parent-report). The episodic exuberance dimension
encompassed symptoms of elation and grandiosity, and
the episodic under-control dimension included symp-
toms such as irritability, risk taking behaviors, and poor
self-control. CFA statistically confirmed the similarity of
these manic dimensions among studies (Pan et al.,
2014). Therefore, similar questions inquiring about ‘epi-
sodes of going abnormally high’, including all manic
symptoms from the DSM, shared the same latent
structure in three independent, culturally diverse
samples. CFA goodness-of-fit indexes favored the two-
dimensional model, showing that both exuberance and
under-control dimensions gathered potentially discrimi-
native information.
Do the high levels of manic traits captured in
epidemiological studies reflect the clinically
relevant threshold of BD in youth?
These abovementioned analyses departed from a dimen-
sional approach, namely, that mania exists in popula-
tions not in an all-or-nothing fashion, but as a
continuum. The alternative is that mania is a distinct
psychopathological manifestation, different from normal
variation not only quantitatively, but also qualitatively.
Empirical evidence suggests that most behavioral symp-
toms are dimensional in their taxonomic nature (Mar-
kon, Chmielewski, & Miller, 2011). Nonetheless,
dimensional research in the BD field is less common,
possibly because manic symptoms present themselves
in episodes, and there is no consensus on whether
mania can be represented dimensionally. Perhaps
understanding youth BD as the high end of a dimen-
sional behavioral trait represents an oversimplification
of the underlying phenomena.
The existence of a qualitatively distinct aspect in men-
tal illness has emerged in recent formulations of ‘case-
ness’ in psychiatry (Kendler, 2018). Psychiatric
disorders may be more accurately, mathematically rep-
resented by complex systems, rather than the high end
of a given trait. In youth BD, this may represent that
high levels of manic latent traits are necessary but not
sufficient to reach clinical ‘caseness’ threshold. Perhaps
we must add some other dimensions, such as episodic-
ity, impairment, and normative developmental pro-
cesses, to reach a qualitative (categorical) threshold of
conversion into ‘caseness’. Kendler (2018) illustrates
this formulation of mental illnesses using snow
104 Pedro Mario Pan, Giovanni Salum & Rodrigo A. Bressan
avalanches. Briefly, snow melts under the sun in a
quantitative process that may provoke avalanches.
Though heavily affected by snow melting, avalanches are
distinct phenomena with a ‘dramatic threshold effect’.
Categories still guide our clinical practice and are the
current prevailing approach to BD research. Conse-
quently, a discrete approach to culturally diverse epi-
demiological data may also provide important insights to
the validity of youth BD. We ascertained lifetime BD in
the Brazilian HRC study using DSM-IV criteria, which
yielded a prevalence of 0.2% (Pan et al., 2014). Similar
procedures resulted in a 0.1% BD prevalence rate of ‘def-
inite or probable DSM-IV criteria’ cases in the British
B-CAMHS study (Stringaris, Santosh, Leibenluft, &
Goodman, 2010). Then, we tested the BD-Not Otherwise
Specified (BD-NOS) case definition applied by Stringaris
et al. (2010) to the B-CAMHS sample. It comprised youth
with episodic manic symptoms meeting the impairment
criteria but lasting <4 days. We could apply the exact
same cut-offs for duration and impairment questions as
the same clinical interview (Developmental and Well-
Being Assessment, DAWBA) was used. Noteworthy, HRC
6–12-year-old sample was assessed using parent-report
of manic symptoms only, which limits comparison
against studies that also included self-report. BD-NOS
prevalence was 1.6% in the Brazilian sample, compared
to 1.1% by parent-report and 1.5% by youth-report in
the British B-CAMHS (Pan et al., 2014; Stringaris et al.,
2010). We have also found that overall BD prevalence
was 1.8% in HRC study, exactly the same prevalence
rate reported in Van Meter et al. (2011) metanalysis.
This result adds to the pool of non-US studies in which
youth BD could be identified using both narrow (0.2%)
and broad (1.6%) criteria. However, this finding does not
necessarily mean that all these subjects are ‘true’ bipolar
cases, since we still do not understand the precise etiol-
ogy of BD or the longitudinal outcome for these cases.
Nonetheless, this cross-cultural comparison suggests
that eliminating variability due to the use of distinct
diagnostic instruments may be an important step to
investigate contributions from epidemiological studies.
Impairment, another dimension to determine
clinically relevant threshold for manic latent
traits
After establishing the internal consistency of a given
dimensional trait, it is important to establish its validity,
i.e., does this latent trait correlate with external valida-
tors? Clinical and epidemiological studies have consis-
tently found associations between manic symptoms in
youth and high levels of psychosocial impairment
(Birmaher et al., 2014; Paaren et al., 2014; Stringaris
et al., 2011, 2014). In HRC, we replicated this finding:
high levels of the episodic under-control dimension were
associated with psychosocial impairment beyond the
effect of comorbid diagnoses like ADHD and ODD (Pan
et al., 2014).
The experience from the high-risk for psychosis
research can aid to the present discussion. Psychotic
experiences are relatively common phenomena in youth;
however, an adolescent presenting high levels of persis-
tent psychotic experiences who seeks treatment for
these symptoms may be identified as ‘at risk’ for psy-
chosis (Ruhrmann, Schultze-Lutter, & Klosterkotter,
Child Adolesc Ment Health 2019; 24(1): 103–5
2010). High levels of psychosocial impairment and men-
tal health distress due to these experiences are common,
although only the minority will develop a psychotic dis-
order. Ruhrmann et al. (2010) argue that these ‘at risk’
adolescents are ‘probably at risk, [but] certainly ill’.
Therefore, until we do fully understand the underlying
pathophysiology of BD, impairment may help guide our
judgment when we face the hard task of distinguishing
manic symptoms from normative (and perhaps develop-
mentally essential) exuberant and under-controlled
behavior in youth.
Alongside subthreshold manic symptoms, nonspeci-
fic mental health problems – such as sleep disturbance
and anxiety – also occur as prodromal BP. However,
longitudinal validation of a bipolar ‘at-risk’ syndrome is
rare (Vieta et al., 2018). One prospective study
screened help-seeking young patients aged 15–24 years
using an ‘at-risk’ for BD definition based on subthresh-
old mania, depression plus cyclothymic features, and
depression plus genetic risk (the bipolar at-risk [BAR]
criteria). BAR criteria showed a conversion rate of 14%
over a 12-month period (Bechdolf et al., 2014), which is
somewhat lower than ‘at risk’ for psychosis 12-month
conversion rates. Therefore, defining a more precise
‘at-risk’ criteria for BD still is an ongoing challenge,
presumably because these adolescents have a more
heterogeneous presentation. Psychosocial impairment
specifically related to early BD manifestations may also
be key to further advancing these ‘at-risk’ definitions. It
can aid clinicians on how to differentiate subthreshold
manic symptoms from full-blown (hypo)mania, adoles-
cent normative behavior, and impairment due to psy-
chiatric comorbidity.
We are aware that identifying high-risk subjects and
early onset disorders may have negative consequences.
Ethical issues on how to best inform patients and their
families about such stigmatized (and presumably life-
long) conditions require further debate, particularly
because long-term longitudinal epidemiological studies
on youth BD are scarce. However, to leave them out of
our clinical attention or to deny these families a proper
case formulation is also problematic, with the risk of
neglecting adequate care to heavily impaired children
and adolescents.
Acknowledgments
PP is in receipt of a PNPD Post-Doctoral Fellowship from the
Brazilian governmental agency CAPES. RB has been on the
speakers’ bureau/advisory board of AstraZeneca, Bristol,
Janssen, and Lundbeck and has also received research grants
from Janssen, Eli-Lilly, Lundbeck, Novartis, Roche, FAPESP,
CNPq, CAPES, Fundacßa ~ o E.J. Safra, and Fundacßa
~ o ABAHDS.
GS is also a shareholder in Biomolecular Technology Ltd. GS
has declared that he has no competing or potential conflicts of
interest.
Ethical information
No ethical approval was required for this commentary.
Correspondence
Pedro Pan, LiNC - Laboratorio Interdisciplinar de
Neurociencias Clinicas, Departamento de Psiquiatria,
© 2019 Association for Child and Adolescent Mental Health.
doi:10.1111/camh.12310
UNIFESP, Edificio de Pesquisas II, Rua Pedro de Toledo,
669 - 3° andar fundos, Vila Clementino, Sao Paulo, SP,
Brazil; Email: pedro.pan@unifesp.br
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Accepted for publication: 13 December 2018