Clinical case presentation: therapeutic challenges in adolescent-onset bipolar disorder.

Abstract

CONTROVERSY HAS FLOURISHED in the past several years regarding the diagnosis of bipolar disorder in children and adolescents. In an attempt to address the issues in June 2002, the American Academy of Child and Adolescent Psychiatry convened a working conference entitled “Methodological Issues and Controversies in Clinical Trials with Child and Adolescent Patients with Bipolar Disorder” (Carlson et al. 2003). Conference participants agreed on several broad methodological questions to be addressed, so as to foster investigation and a better understanding of the clinical presentation, diagnostic criteria, natural history, and treatment of early-onset bipolar disorder. Although a work in progress, an important conclusion of the proceedings was the recommendation for methodologically rigorous, large-scale trials of treatment of acute mania in youth. One of the areas of greatest controversy has been the clinical presentation and diagnostic criteria for bipolar disorder in young patients (Geller and Luby 1997; Kafantaris 1995). Although young patients may present with classic “gold standard” symptomatology consistent with adult mania (e.g., elevated mood, grandiosity, and flight of ideas), younger patients may also present with less florid though no less challenging symptoms (e.g., unrelenting irritability, aggressive dyscontrol, and “mixed states”) (Steele and Fisman 1997; Wozniak et al. 1995). To complicate differential diagnosis further, many investigators have reported high levels of comorbidity with disruptive behavior disorders in association with early-onset bipolar disorder (Biederman et al. 1999). Unfortunately, to date, there has been a paucity of rigorous, well-controlled pharmacological studies, perhaps related to the difficulty of diagnosis, symptom severity, and limited response to agents used in adults. Thus, the evidence base for treatment remains quite limited. This case presentation illustrates some of these diagnostic and therapeutic challenges in an adolescent with bipolar disorder.