Case history
Case history #1
A 15-year-old boy is brought to the emergency department by his parents owing to uncontrollable behavior over the previous month. The family had returned early from vacation because he had dismantled the hotel room in the belief that he was being monitored by the FBI and, because he had special telepathic powers, was on trial for a position as a secret agent. In the 3 months leading up to this episode he was stressed with his school work and was up late at night studying. Several relatives had a history of bipolar disorder, and he had been treated for depression after the death of a grandparent 2 years previously. When interviewed, he speaks rapidly, changing the subject frequently, convinced he is going to be summoned to the White House as a security adviser. He has been sleeping 3 hours a night, describes high levels of energy, and makes inappropriate comments.
Case history #2
A 13-year-old girl has been treated for ADHD since she was 4 years old, and her parents describe her behavior as deteriorating over the past year. She has always been oppositional and impulsive, and has struggled academically, but more recently she has become increasingly irritable and sexually provocative, with several recent boyfriends. She has trashed the house on several occasions, and her parents have discovered she has been accessing pornography on the internet and suspect she has been using cannabis. Several months ago, her parents separated acrimoniously and her mother has a new partner. When interviewed, she is wearing a lot of make-up and revealing clothing, and behaves in a seductive manner, talking rapidly. She is disinhibited, inattentive, and restless, and explodes angrily toward her parents. She describes high levels of energy, and her mood fluctuates from irritable to low, with occasional suicidal thoughts. There is a family history of ADHD, depression, and bipolar disorder.
Other presentations
Classical mania appears to be rare in children and adolescents.[8][9] Interpretations of atypical presentations may vary significantly between clinicians.[10] Opinions differ on the developmental appropriateness of applying adult criteria.[11] Definitions of key symptoms of mania - for example, grandiosity and elation - are not agreed upon by all investigators, and need to be distinguished from normal developmental stages.
ADHD and oppositional defiant disorder (ODD) are frequently comorbid with mania in children, and there exists a degree of symptom overlap with these disorders, particularly irritability.[12][13] In adolescents, diagnosis can be complicated by comorbid substance abuse and emerging personality disorder, as well as comorbid anxiety.[14][15][16] Mania in adolescents is often associated with psychotic symptoms, and/or mixed manic and depressive features, as well as labile moods or rapid cycling-type presentations.[17] Comorbidity and protracted episodes are common compared with adult presentations, making younger-onset bipolar cases appear more like treatment-refractory adult-onset cases.[18]
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