Onset and course. Bipolar disorder has a lifetime prevalence of 2.1% in adults and 1.8% in children4; at least two-thirds of the patients with bipolar disorder report onset before age 18.5 Younger onset is associated with positive family history of mood disorders, comorbidity with anxiety and substance abuse disorders, rapid cycling course, treatment resistance, more hospitalizations, and suicidal behavior.
The episodic course is only one of many courses of illness. Some patients may experience chronic, unremitting symptoms, while other patients may experience weeks or months with attenuated symptoms, or symptom-free intervals. In fact, the requirement of periodicity (recurring episodes of mania and depression) to diagnose BD has often resulted in the misdiagnosis of those with a chronic, non-episodic course of illness.
Clinical picture. The classic manic episode is characterized by the discrete appearance of euphoric/elated mood, talkativeness, decreased need for sleep, impulsivity, hyperactivity, and greater productivity, with rapid transitions to new and more stimulating projects. However, bipolar disorder in youth can also present with dysphoric (or mixed) mania characterized by marked irritability, negative/morbid thoughts, increased impulsivity, risk-taking and aggressive behaviors, and psychomotor agitation as well as a chronic course and ultra-rapid cycling episodes.
Circadian rhythms are altered, resulting in greater fluctuations of energy and activity. Evening hours are preferred with improved mood and energy in the later part of the day, early/middle/late insomnia, and sleep resistance.
Psychosis, including delusions, hallucinations, catatonic features, and bizarre behavior occurs frequently. Suicidality, including morbid ideation, suicidal ideation, and suicide attempts are common in children and adolescents with bipolar disorder as are various forms of aggression (eg, verbal aggression, anger dyscontrol, violent behavior leading to destruction of property or physical aggression).
An increased and precocious interest in sexual content as well as increased sexual behaviors have been described in children and adolescents with bipolar disorder. In such cases of inappropriately precocious sexualized behavior, it is extremely important to rule out any kind of inappropriate exposure to adult material, or sexual abuse.
Dr Marangoni is Attending Psychiatrist, Department of Mental Health, Mater Salutis Hospital, Azienda ULSS 9, Legnago, Italy. Dr Marangoni reports no conflicts of interest concerning the subject matter of this article.
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