Byline: M. Reddy Diagnostic and Statistical Manual of Mental Disorders, 5 [sup]th edition (DSM 5) [sup][1] of bipolar disorder (BD) makes it necessary to meet the following criteria for a manic episode: distinct period of abnormally and persistently elevated, expansive, OR IRRITABLE MOOD… lasting at least one week and present most of the day, nearly everyday…. It is elation or irritation, along with three or four other symptoms. DSM 5 criteria for BD are applicable to all age groups with the same weightage. Irritable occupies a prominent place in the diagnostic criteria of many other disorders, especially childhood and adolescent disorders like oppositional defiant disorder; intermittent explosive disorder; conduct disorder; disruptive mood dysregulation disorder (DMDD); other and unspecified disruptive, impulse control, and conduct disorders; and attention deficit/hyperactivity disorder (ADHD) in the classificatory systems. With irritable sharing space in the diagnostic criteria of BD and several childhood and adolescent diagnostic disorders, there looms a possibility of over diagnosis of childhood adolescent bipolar disorder. misdiagnosis, whenever it occurs, hopefully less often, leads to a major therapeutic mismatch resulting in polypharmacy and treatment failures. National Institute of Mental Health research roundtable on prepubertal bipolar disorder, 2001 recommends that patients with grandiosity/elation be classified as bipolar I and irritability/rage be classified as bipolar NOS (DSM IV TR). There was always a doubt about reliability of irritability as a symptom criterion in the of mania as shown in this USA-UK study: USA-UK project (2005) Elation/grandiose - mania - 96.4% USA and 88.9% UK Irritability/rage - mania - 86.2% USA and 31.1% UK There is rather unacceptable poor concordance, with irritability as the criterion. A few valid arguments that merit attention are the following: *That delusions/hallucinations occur only in BD (true, but a significant majority of patients with BD do not have delusions/hallucinations). *Family H/O of BD favors of bipolar illness (yes, very valuable supporting point in those who have a family history). *BD is an episodic disorder, whereas other childhood disorders outlined above are all continuous in course. Is it true? Let us look at the existing data. Evidence Age of onset The greatest frequency of first attacks falls, however, in the period of development with its increased emotional excitability between the fifteenth and twentieth In rare cases, the first beginnings can be traced back even to before the tenth year…. - Kraepelin, 1921 In 28% of the BD patients recruited into the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study, age at onset was younger than 13, and in the Bipolar Collaborative Network study, 15% of patients had illness onset before the age of 13 years. younger age of onset in BD seems to be a well-documented fact. Diagnosis Some studies have defined mania by the presence of highly labile moods with intense irritability, rage, explosiveness and destructiveness; extreme agitation, and behavioral dysregulation. [sup][2],[3],[4],[5] picture that emerges from several independent research groups is that prepubertal children with BD typically have multiple daily mood swings and that irritability is much more common than euphoria. [sup][6],[7] Course Studies indicate a highly pernicious course with substantial chronicity. In 81% of a well-defined group of patients, Geller et al . [sup][6] reported continuous daily cycling from mania or hypomania to euthymia or depression. In this study, 1-year mania recovery rate stood at 37%. …