Differences in the symptomatic expression of BD in youth versus adults have not been consistent across studies. For instance, Ballenger et al  found psychotic symptoms to be more common among manic patients under the age of 21 as compared to manic patients over the age of 30, yet McElroy et al  in a larger, more recent study, found that adolescents had fewer psychotic features during mania than adults. There has been more consistency in the findings that youth with BD appear to have higher rates of mixed mania [32-34] and rapid or ultra-rapid cycling . Of interest, an Indian study found that 21 youth with DSM-III-R diagnosed BD had presentations that were very similar to adults with the illness. The most common symptoms among the youth with mania were psychomotor agitation (100%), reduced sleep duration (90%), and pressure of speech (90%). Rapid cycling was only evident in 19% of the youth, and none had a comorbid diagnosis of ADHD .
Fewer studies have examined differences in the symptomatic expression of bipolar depression. Goodwin and Jamison  summarized the results of several studies, and showed that youth with bipolar depression were significantly less likely to experience anhedonia, morning worsening, fatigue, anorexia, hopelessness, agitation, psychomotor retardation, and definite delusions as compared with adults. On the other hand, youth with bipolar depression were significantly more likely than adults to have a depressed appearance, poor self-esteem, somatic complaints, and hallucinations.
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