Adolescent Mania and Bipolar Disorder

Scott A. West, MD


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

In This Article


Although there are numerous comorbid diagnoses associated with bipolar disorder, attention-deficit hyperactivity disorder (ADHD) has received the most recognition for several important reasons. Etiologically, early-onset bipolar disorder appears to evolve from a constellation of symptoms diagnostically equivalent to ADHD in many patients. Indeed, Biederman and colleagues[11] have reported that 21% of children diagnosed with ADHD eventually develop mania. This is not particularly surprising because there is a significant amount of symptom overlap between the 2 disorders. Although every symptom of ADHD is a symptom of mania, the reverse is not true, suggesting that a core constellation of symptoms may initially be present and evolve over time. And although there is a considerable amount of symptom overlap, it is important to differentiate overlapping symptoms from overlapping diagnostic criteria, of which there are only 3 (psychomotor agitation, distractibility, and pressured speech). This issue was recently addressed by Milberger and associates,[12] who reported that in patients with early-onset mania, even when overlapping symptoms were removed, the majority of patients (56%) retained their diagnosis of bipolar disorder. This implies that the majority of young patients with mania have a large number of symptoms and often meet all of the diagnostic criteria.

ADHD as a comorbid diagnosis in manic adolescents has been reported to occur at high rates. Winokur and colleagues[13] reported that 21% of patients with bipolar disorder had histories of ADHD or ADHD-like symptoms in childhood, compared with only 9% in patients with major depression. Another study[14] reported that 57% of a cohort of adolescent bipolar patients also had ADHD, most of whom received pharmacologic treatment at an early age. This substantial amount of comorbidity may not only lead to diagnostic confusion, but also raises important questions regarding the pharmacologic management of such patients.

Other comorbid disorders have been reported to occur frequently in bipolar adolescents, most notably oppositional defiant disorder and conduct disorder. It is unclear whether these other externalizing disorders are true comorbid conditions or reflect manifestations of severe affective illness. Substance abuse is also frequently observed, although one study found the frequency to be lower in adolescents compared with bipolar adults, suggesting that as the illness continues, self-medication may occur, rather than substance abuse causing or worsening the illness.[10]


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