A 15-year-old boy is brought to the office by his parents after he was caught shoplifting from an art supply store. The patient's father says, "For the past 2 weeks, my son has been impossible to manage. He has become loud, obnoxious, and rude. He skips doing household chores and stays up all night drawing in his room." The boy's mother received a phone call from his school last week after he told his teacher that she was "incompetent" and that he intended to drop out. The patient tells the physician that he lives in "the most boring place in the world" and that his parents are jealous that he is "making a masterpiece that will be famous." He has a history of a specific learning disorder with impairment in reading. Family history is significant for depression in a cousin and alcohol abuse in a paternal aunt. On mental status examination, the patient is easily distracted and struggles to sit still. He speaks quickly and becomes irritable when the physician attempts to clarify what he is saying. Routine laboratory tests are within normal range, and urine drug screen is negative. Which of the following is the most likely explanation for this patient's behavior?
Manic episode | |
Clinical |
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Severity |
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This patient's presentation meets criteria for a manic episode, given the abrupt change in behavior accompanied by a decreased need for sleep, goal-directed activity, grandiosity, and risky behavior (shoplifting), all lasting for a 2-week period. Difficulty sitting still, distractibility, and rapid, loud speech are also characteristic. To diagnose bipolar disorder, a single manic episode is required, although most patients will go on to have multiple lifetime manic and depressive episodes.
Adolescents may exhibit mood changes and defiance as they test authority figures in the pursuit of autonomy. They may also have an unrealistic sense of their abilities and a willingness to engage in risky behavior without a full appreciation of the consequences. However, a decreased need for sleep, distractibility, and goal-directed activity that represents a distinct change from the patient's baseline should raise suspicion for mania and not be dismissed as normal adolescent behavior (Choice E). Untreated bipolar disorder impacts psychosocial development and academic achievement and increases the risk for substance use, suicide, psychosis, and legal difficulties.
(Choice A) Attention-deficit hyperactivity disorder can also present with distractibility, hyperactivity, impulsivity, and talkativeness. However, symptoms are chronic, lasting ≥6 months, with some symptoms presenting prior to age 12. In comparison, manic episodes are distinct occurrences, as in this case where the patient has experienced abrupt changes in behavior over a 2-week period.
(Choices C and F) Oppositional defiant disorder presents with an irritable or angry mood, argumentativeness or deliberately annoying behavior, and vindictiveness. Conduct disorder is more severe, where the rights of others or societal norms are purposefully violated (eg, stealing, destroying property, assaulting others). Neither would explain an abrupt change in behavior, decreased need for sleep, and increased goal-directed activity.
(Choice D) Patients with disruptive mood dysregulation disorder have temper outbursts that are out of proportion to the stimulus and inconsistent with developmental age. Symptoms manifest prior to age 10.
Educational objective:
Mania in adolescence may be confused with normal adolescent moodiness, defiance, overconfidence, and risk taking. However, an abrupt change from baseline, together with decreased need for sleep, distractibility, excessive goal-directed activity, and grandiosity, should raise suspicion for a manic episode.