Adolescent Mania and Bipolar Disorder

Scott A. West, MD

Disclosures

Medscape Psychiatry & Mental Health eJournal. 1997;2(5) 

In This Article

Phenomenology

Numerous studies have reported that mood disturbance in bipolar adolescents is primarily that of prominent irritability rather than euphoria.[2] Furthermore, manic episodes commonly have mixed features, a state wherein patients experience co-occurring symptoms of mania and major depression. West and colleagues[3] reported that in adolescents hospitalized for the treatment of acute mania, mixed states were twice as common as pure manic states. Interestingly, 30% of patients with mixed mania in this sample had previously received antidepressant medication, compared with none in the purely manic group. This suggests that, like adults, adolescents may be quite vulnerable to the induction of mixed states and rapid cycling resulting from the use of antidepressants.[4] Wozniak and associates[5] have also reported that over half of their sample had mixed states rather than pure mania. Because mixed states are quite prevalent and often present with a confusing array of symptoms, diagnoses in this population are often inaccurate.

The course of illness and cycle length may further distinguish early-onset mania from adult-onset mania. Children and adolescents often display a chronic and continual course, with symptoms ever present but fluctuating in intensity.[6] They may also have relatively short mood episodes, or "affective storms," ranging from days to hours to minutes. This intense affective lability may make it difficult to sort out symptomatology into any particular diagnosis.[7] With more limited periods of euthymia, and mood states commonly fluctuating between mixed and depressed states, it is often difficult to chart a clear pattern of distinct mood episodes. Rather, it becomes easier to conceptualize mood state and severity as a spectrum with an unlimited range of possibilities.

Psychotic symptoms appear to be common in adolescents with mania, and have often resulted in the misdiagnosis of schizophrenia.[8] Ballenger and associates[9] reported that two thirds of their small sample of juvenile bipolar patients had psychotic symptoms. Likewise, in a group of 40 hospitalized manic adolescents, McElroy and colleagues[10] found that 75% of the patients exhibited psychotic symptoms, most notably, delusions and hallucinations. In contrast, Wozniak and associates[5] reported that only 16% of 43 manic children displayed psychotic symptoms. In this study, children were aged 12 years and younger and were evaluated in an outpatient setting (versus inpatient), 2 variables that may contribute to the discrepancy in the prevalence of psychosis.

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