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 Table of Contents  
Year : 2020  |  Volume : 21  |  Issue : 2  |  Page : 119-121

Atypical presentation of bipolar disorder in adolescent

1 Senior Resident, Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Assistant Professor, Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
3 Clinical Psychologist, Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission08-Sep-2020
Date of Acceptance05-Dec-2020
Date of Web Publication14-Jan-2021

Correspondence Address:
Dr. Pratibha Gehlawat
Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AMH.AMH_40_20

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Mood disorders in children account for a significant amount of disability. However due to varied presentation of symptoms and subsyndromal episodes among children and adolescents, it is often difficult to correctly diagnose mood disorders. We are presenting a case of an adolescent male with atypical mood symptoms and highlighting on the difficulties faced in the diagnosis and the challenges in his management.

Keywords: Adolescent, atypical, bipolar disorder

How to cite this article:
Mahal P, Gehlawat P, Gupta T. Atypical presentation of bipolar disorder in adolescent. Arch Ment Health 2020;21:119-21

How to cite this URL:
Mahal P, Gehlawat P, Gupta T. Atypical presentation of bipolar disorder in adolescent. Arch Ment Health [serial online] 2020 [cited 2021 Oct 18];21:119-21. Available from: https://www.amhonline.org/text.asp?2020/21/2/119/306867

  Introduction Top

Almost half of the mental illnesses start during the adolescent age group but mostly remain undetected.[1] Mood disorders, consisting of depression and bipolar disorder, are among the major causes of disability in adolescence, leading to a significant effect on psychosocial and academic functioning.[2] We present a case of an adolescent with atypical mood symptoms causing diagnostic dilemma and challenges in management.

  Case Report Top

A 15-year-old male, studying in 7th class, belonging to middle socioeconomic status, presented with an episodic illness of 1 year. During these episodes, he would change behaviour, sleep pattern, eating habits, have decreased self-care and irritability. These episodes started abruptly during which he would not interact with anyone and remained bedridden for most of the day. Family members had to coax him to perform his daily routine activities. He would get irritable and always resisted in getting up. His sleep also increased to 12–15 h a day. He would not indulge in previously pleasurable activities like going out to play with his siblings, watching TV, or playing on mobile phones. His appetite increased and he frequently demanded for his favorite food. During the episodes, he was also found touching his genitalia multiple times a day without giving an explanation for the same. On a few instances, he would speak irrelevantly and used to sing some local songs at inappropriate times. These episodes would last for 7–10 days. He would recover without any residual symptoms. He used to have similar episodes every 1–2 months. Total of eight episodes occurred in the past 1 year and with complete inter-episodic remission.

He was admitted for observation and during ward stay, he would mostly be lying in the prone position on his bed and would not respond during the interview. He would remain irritable and not indulge in ward activities. Minimal reactivity in affect was observed. There was no change in his condition for the next 7 days and after a week, his symptoms subsided abruptly as he started to speak, eat food in normal quantity, participate in ward activities and cooperated during the interview. Considering the psychopathology as mainly depressive, he was started on C. Fluoxetine 20 mg to prevent further episodes. Pediatrics and Neurology consultation were also sought to rule out any organic cause in view of abrupt onset and short duration of mood symptoms with minimal remembrance of episodes. His CBC, LFT, KFT, S. electrolytes, thyroid function test, urine routine microscopy, lipid profile, and fasting blood sugar were within the normal limits. MRI Brain and EEG also did not show any abnormality. The cerebrospinal fluid analysis was performed to rule out the autoimmune cause but with no abnormal findings. Anti-NMDA antibodies test was also not significant.

The psychological assessment revealed average intelligence as assessed on Malin's Intelligence scale for Indian Children. Rorschach revealed the presence of affective illness with psychotic phenomena.

A working diagnosis of recurrent brief depressive disorder was considered and he was started on C. Fluoxetine 20 mg, which was hiked to 40 mg. In view of recurrent episodes, Fluoxetine was cross-tapered with Sertraline 50 mg, and Lithium was added and titrated up to 900 mg.

One month later, he presented with similar symptoms and was hyperactive, singing songs with increased gesturing. Hence, Lithium was tapered, and Olanzapine 5 mg was started, up-titrated to 7.5 mg. His symptoms improved, and no new episode occurred for the next 3 months. However, he started to gain weight and felt sleepy mostly. Olanzapine was cross tapered with aripiprazole. He has been maintaining well for 8 months on aripiprazole 10 mg monotherapy.

  Discussion Top

The diagnosis of recurrent brief depressive disorder was initially entertained, considering depressive symptoms at the forefront. On longitudinal assessment, various atypical features such as occasional increased activity, gesturing, sexual movements, appetite, and sleep without mood reactivity with no or minimal remembrance of the symptoms postepisode were also found. Kluver Bucy syndrome and Auto-immune encephalitis were considered as differentials but ruled out. There were on and off symptoms of other polarity and thus, the diagnosis was revised as bipolar disorder. After seeing the patient's course and symptomatology and the response with medication, we conceptualized this case as Bipolar disorder not otherwise specified. Atypical or melancholic features in the patient having recurrent brief depressive episodes point toward bipolarity. Therefore, proper identification of brief hypomanic episodes in a significant subgroup of adolescents is the key for correct diagnosis.[3]

Both childhood and adolescent-onset bipolar disorders have greater severity and worse prognosis as they have long episodes, significant chronicity, rapid cycling, and mixed episodes.[4],[5] The mood episodes are often characterized by sub-syndromal symptoms and mainly consist of depressive and mixed symptoms, as seen in the index patient. Second-generation antipsychotics are recommended as first-line therapy followed by mood stabilizers for pediatric Bipolar disorders.[2] In cases of metabolic side effects, aripiprazole is a safer option as it causes less weight gain and prolactin increase than olanzapine, quetiapine, or risperidone.[6]

Therefore, it is suggested that Bipolar disorder not otherwise specified should be considered as an episodic illness distinct from the symptomatology of youths with behavior disorders and “severe mood dysregulation.”[7] Treatment of bipolar disorder in adolescence should be initiated as early as possible because it is more treatment-resistant than adult BD.[8] Hence, clinicians should be more vigilant in interviewing adolescent patients with mood symptoms to have an accurate diagnosis.

Appropriate assent from the patient and informed consent from the parents about the clinical information to be reported was taken. It has also been ensured that anonymity is preserved.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

WHO. Adolescent Mental Health. Available from: https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health. [Last accessed on 2020 May 26].  Back to cited text no. 1
Saxena K, Kurian S, Saxena J, Goldberg A, Chen E, Simonetti A, et al. Mixed states in early-onset bipolar disorder. Psychiatr Clin North Am 2020;43:95-111.  Back to cited text no. 2
Lövdahl H, Andersson S, Hynnekleiv T, Malt UF. The phenomenology of recurrent brief depression with and without hypomanic features. J Affect Disord 2009;112:151-64.  Back to cited text no. 3
Goldstein BI, Sassi R, Diler RS. Pharmacologic treatment of bipolar disorder in children and adolescents. Child Adolesc Psychiatr Clin N Am 2012;21:911-39.  Back to cited text no. 4
Strawn JR, Delbello MP. Olanzapine for the treatment of bipolar disorder in children and adolescents. Expert Opin Pharmacother 2008;9:467-74.  Back to cited text no. 5
Uttley L, Kearns B, Ren S, Stevenson M. Aripiprazole for the treatment and prevention of acute manic and mixed episodes in bipolar I disorder in children and adolescents: A NICE single technology appraisal. Pharmacoeconomics 2013;31:981-90.  Back to cited text no. 6
Birmaher B, Axelson D, Goldstein B, Strober M, Gill MK, Hunt J, et al. Four-year longitudinal course of children and adolescents with bipolar spectrum disorders: The course and outcome of bipolar youth (COBY) study. Am J Psychiatry 2009;166:795-804.  Back to cited text no. 7
Masi G, Perugi G, Toni C, Millepiedi S, Mucci M, Bertini N, et al. Predictors of treatment nonresponse in bipolar children and adolescents with manic or mixed episodes. J Child Adolesc Psychopharmacol 2004;14:395-404.  Back to cited text no. 8


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