Juvenile Onset Bipolar Disorder

Initially thought to be only a disorder of adolescence or adulthood, bipolar disorder (BD) is now increasingly being recognized and diagnosed in prepubertal children. Considerable ambiguity remains about the actual prevalence of BD in children. Lifetime prevalence of BD is estimated at 1%. A point prevalence of mania in 14- to 16-year-olds of 0.6% was identified by Carlson and Kashani. The comorbidity with ADHD has also not been established, although data suggest it may be common (around 30%). Some symptoms (high levels of activity, talkativeness, appears as if powered by a motor) may be similar, and it is important to differentiate a mood component in the differential diagnosis. Other frequent comorbidities are conduct disorder, substance abuse disorders, anxiety disorders, trauma-induced disorders, and borderline personality disorder traits. Schizophrenia may be confused with bipolar disorder. Although BD in adults tends to be gender neutral, it is estimated that prepubertal BD is almost four times more frequently diagnosed in boys. Compared with adults, children and adolescents with BD may have a more prolonged early course and be less responsive to treatment.

Clinical Description

Bipolar I disorder requires the existence of a manic or mixed episode. A manic episode is defined in the DSM-IV-TR as a distinct period of “abnormally and persistently elevated, expansive,
or irritable mood.” A mixed episode is characterized by “rapidly alternating mood with symptoms of a manic episode and a major depressive episode.” Children with manic episodes may not present with the same discrete periods seen in adults. Early onset bipolar disorder has been described as highly variable, often with a rapid-cycling, chronic, nonepisodic presentation. Additionally, irritability and unpredictable, labile mood and psychotic features may be more common in young people presenting with the disease.

Bipolar II disorder includes major depressive episodes alternating with hypomanic episodes. Hypomania may present as elevated, expansive, or irritable mood, which is less severe and less functionally impairing than a manic episode.

Cyclothymic disorder is a chronic and fluctuating mood disorder, with hypomanic and depressive symptoms that are less functionally impairing that BD and that have been persistent for a year.

Diagnosis of Manic Episode

A mnemonic that is helpful in recalling the essential features of mania is DIGFAST. The term may refer to the speed with which a manic patient would dig a hole if put to the task, as they may appear as if “driven by a motor.” At least three symptoms are required (four if mood is only irritable):

Distractibility
Indiscretion (excessive involvement in pleasurable activities that are likely to have adverse consequences)
Grandiosity or inflated self-esteem
Flight of ideas or racing thoughts
Activity increase (increase in goal-directed activity or psychomotor agitation)
Sleep deficit
Talkativeness or pressured speech