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Key Features

Essentials of Diagnosis

  • Periods of abnormally and persistently elevated, expansive, or irritable mood, and heightened levels of energy and activity

  • Associated symptoms: grandiosity, diminished need for sleep, pressured speech, racing thoughts, impaired judgment

  • Not caused by prescribed or illicit drugs

  • The symptoms most commonly reported first are depressive symptoms

General Considerations

  • Defined as an episodic mood disorder manifested by alternating periods of mania and major depressive episodes or, less commonly, manic episodes alone

  • Children and adolescents often exhibit a variable course of mood instability combined with aggressive behavior and impulsivity.

  • Onset of bipolar disorder before puberty is uncommon

  • At least 20% of bipolar adults experience onset of symptoms before age 20 years

  • Lifetime prevalence of bipolar disorder in middle to late adolescence approaches 1%

Clinical Findings

  • In about 70% of patients, the first symptoms are primarily those of depression

  • In the remainder, manic, hypomanic, or mixed states dominate the presentation

  • Patients with mania display a variable pattern of elevated, expansive, or irritable mood along with rapid speech, high energy levels, difficulty in sustaining concentration, and a decreased need for sleep

  • The child or adolescent may also have hypersexual behavior

  • It is critical to rule out abuse, or be aware of abuse factors contributing to the clinical presentation

  • Patients often do not acknowledge any problem with their mood or behavior

  • Clinical picture can be quite dramatic, with florid psychotic symptoms of delusions and hallucinations accompanying extreme hyperactivity and impulsivity

  • Other illnesses on the bipolar spectrum are bipolar type II, which is characterized by

    • Recurrent major depressive episodes alternating with hypomanic episodes (lower intensity manic episodes that do not cause social impairment and do not typically last as long as manic episodes)

    • Cyclothymic disorder, which is diagnosed when the child or adolescent has had 1 year of hypomanic symptoms alternating with depressive symptoms that do not meet criteria for major depression

Differential Diagnosis

  • Physical or sexual abuse and exposure to domestic violence can also cause children to be mood labile, hyperactive, and aggressive

  • Posttraumatic stress disorder should be considered by reviewing the history for traumatic life events in children with these symptoms

  • Hyperthyroidism should be ruled out


  • While ADHD and bipolar disorder are highly comorbid, inattention and hyperactivity symptoms accompanied by mood swings can be an early sign of bipolar disorder before full criteria for the disorder have emerged and clustered together in a specific pattern

  • Diagnostic considerations should also include substance abuse disorders, and an acute organic process, especially if the change in personality has been relatively sudden, or is accompanied by other neurologic changes

  • Individuals with manic psychosis may resemble those with schizophrenia

  • Psychotic symptoms associated with bipolar disorder should clear with resolution of the mood symptoms, which should also be prominent


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