Dr. Pliszka and Colleagues Reply

To the Editor: We thank Dr. Alessi for his thoughtful comments on our study of mood disorders in juvenile offenders. Dr. Alessi is concerned by the high rate of mania found in our subjects, in contrast to the 4% rate found in his own work (Alessi et al., 1984). However, his own work has shown that 36% of the offenders had “agitated subtypes” of depression. He notes that he and his colleagues did not consider agitation/irritability a primary mood symptom in identifying bipolar illness, only “euphoria of a relatively prolonged nature.” DSM-IV clearly states, however, that “a manic episode is defined by a distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood” (p. 328). Since Dr. Alessi and colleagues used a more narrow definition of mania, it is not surprising that they found a lower rate of bipolar illness in offenders than did we. Of note, we found that only three (6%) out of 50 juveniles met the criteria for pure euphoric mania, which is consistent with the 4% rate of euphoric mania found by Dr. Alessi and colleagues (Alessi et al., 1984).

The offenders who were diagnosed as manic in our study had not only an irritable mood but all the other requirements of a manic episode—e.g., inflated self-esteem, constant talking, flights of ideas. They did not receive the diagnosis of mania on the basis of irritability alone. We agree with Dr. Alessi that the division between bipolar disorder and the cluster B externalizing personality disorders requires more study. He is correct that we did not specifically interview for the diagnosis of borderline personality disorder in our offender group. However, personality disorders and bipolar disorder may overlap rather than be mutually exclusive, as Dr. Alessi suggests. Kutcher et al. (1) examined 20 well-diagnosed bipolar youth and found that 35% met criteria for one personality disorder, whereas three of these concurrently met criteria for borderline personality disorder. A reasonable body of evidence suggests that borderline personality traits may in fact be precursors of bipolar disorder (2). More careful studies are needed to separate youth with severe personality disorders and those with bipolar disorder, but the field should not move to early closure on this issue.