Skip to main content
  • Letter to the Editor
  • Open access
  • Published:

Prepubertal bipolar disorder: a diagnostic quandary?

Duffy and colleagues (Duffy et al. 2020) (this issue) detail how differing perspectives that created controversy concerning the diagnosis of pre-pubertal bipolar disorder (PPBD), have in more recent times fostered a desire to find common ground. At the crux of this diagnostic dispute, lie a number of diagnostic requirements that build on the supposition that adult bipolar disorder begins early in life and therefore must manifest in childhood. To capture this earliest form that occurs prior to puberty, a couple of conditions need to be met. The first of these is that it should be a separate illness, and the second is that it’s trajectory should be distinguishable from normative development. Thus, the core assumption is that PPBD is a distinct illness in childhood with a unique profile that is maintained as it evolves into adult bipolar disorder.

However, the idea that PPBD is a separate and diagnosable disorder in childhood, is based on the observation that adult bipolar disorder (BD) is a distinct illness that is defined by episodes of mania and depression. Therefore, a similar episodic pattern should be evident early in the course of the illness and this can be used to define PPBD. But, the theoretical argument for this assumption is weak and empirical evidence is lacking. For example, it is clear that many of the symptoms of mania cannot be experienced by children in the same way as they are in adults, and therefore their expression is very different or lacking altogether. For example, heightened libido, grandiosity and diminished insight don’t have meaningful equivalents in children. Furthermore, many of the symptoms, thought to be distinctive of mania in adults, are less remarkable when they occur in children, and may even be regarded age-appropriate. For example, believing you are a superhero with special powers is of some concern in an 18-year-old but is perfectly normal in an 8-year-old. As a consequence, other symptoms have attracted interest, e.g. irritability. But even irritability, a seemingly familiar and all too common symptom, has proven to be a complex trans-diagnostic phenomenon that is difficult to characterise at any age (Toohey 2019; Toohey and DiGiuseppe 2017). Thus, the very first requirement that PPBD should be a diagnosable and distinct entity, poses a considerable challenge.

However, if for a moment we assume that PPBD is distinguishable in childhood, the subsequent requirement, namely that it pursues a trajectory separable from normative development, is equally problematic. Theoretically, such separation is conceivable, but if PPBD cannot be distinguished in childhood, the prospect of mapping its trajectory through puberty and into adolescence seems highly improbable.

A more fundamental difficulty that affects these considerations concerns whether BD in adults is indeed ‘bi-polar’. In other words, is bipolar disorder best characterised as an illness comprising two poles—mania and depression? Recently, the myriad clinical patterns of BD have been the focus of diagnostic debates (Malhi et al. 2018) and there has been a recrudescence of interest in mixed presentations, which are common in BD adults (Malhi et al. 2019). Hence, given the prevalence of adult mixed states, any childhood precursor of BD is also likely to have mixed symptoms (Malhi and Bell 2019). If this is the case, then it further complicates the transposition of clinical phenotype from adults to children and makes the prospect of identifying definable antecedents exceptionally challenging. This is especially so, given that mixed states are extremely poorly defined in adult bipolar presentations (Malhi 2013).

Hence, we remain at an impasse. And while we await a breakthrough that leads to greater knowledge, we suggest that greater efforts be made to conduct detailed longitudinal studies that carefully track phenomenology from childhood onwards through to adulthood without prior assumptions as to what bipolar disorder might look like in children.

Availability of data and materials

Not applicable


  • Duffy A, Carlson G, Dubicka B, Hillegers M. Pre-pubertal bipolar disorder: origins and current status of the controversy. Int J Bipolar Disord. 2020;.

    Article  Google Scholar 

  • Malhi GS. Diagnosis of bipolar disorder: who is in a mixed state? Lancet. 2013;381(9878):1599–600.

    Article  Google Scholar 

  • Malhi GS, Irwin L, Hamilton A, Morris G, Boyce P, Mulder R, et al. Modelling mood disorders: an ACE solution? Bipolar Disord. 2018;20(S2):4–16.

    Article  Google Scholar 

  • Malhi GS, Fritz K, Elangovan P, Irwin L. Mixed States: modelling and Management. CNS Drugs. 2019;33(4):301–13.

    Article  Google Scholar 

  • Malhi GS, Bell E. Detecting classical bipolar disorder: a classic mistake? Bipolar Disord. 2019;21(8):679–83.

    Article  Google Scholar 

  • Toohey MJ. Irritability characteristics and parameters in an international sample. J Affect Disord. 2019;263:558–67.

    Article  Google Scholar 

  • Toohey MJ, DiGiuseppe R. Defining and measuring irritability: construct clarification and differentiation. Clin Psychol Rev. 2017;53:93–108.

    Article  Google Scholar 

Download references


The authors received no financial support for the research, authorship, and/or publication of this article.

Author information

Authors and Affiliations



GM and EB equally contributed to the formulation and writing of this manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Gin S. Malhi.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

GS.M. has received grant or research support from National Health and Medical Research Council, Australian Rotary Health, NSW Health, American Foundation for Suicide Prevention, Ramsay Research and Teaching Fund, Elsevier, AstraZeneca, Janssen-Cilag, Lundbeck, Otsuka and Servier; and has been a consultant for AstraZeneca, Janssen-Cilag, Lundbeck, Otsuka and Servier. The author EB declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Malhi, G.S., Bell, E. Prepubertal bipolar disorder: a diagnostic quandary?. Int J Bipolar Disord 8, 20 (2020).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: