A 17-year-old girl presents to her pediatrician because of debilitating depression and inability to function. Her mother accompanies her to the appointment and describes a period over the past 6 months where her daughter has gone from being an honor-roll student who is involved in many extracurricular activities and who had many friends to struggling in school both socially and academically and barely being able to function.
The patient describes having periods of time where she seems super-focused and has high energy to get a lot of things done. She describes her mind racing during these periods and feels like she needs to talk a lot and quickly, to get all of her thoughts out. Her mother confirms the pressured speech. She does not need much sleep during these times. She spends a lot of time at parties and with "friends" while she engages in risky behavior — for example, consumption of alcohol and drugs and engagement in risky sex. These periods are followed by times when she says she feels depleted and is unable to get out of bed, with no interest in anything or anyone, has no appetite, does not bathe and has very negative feelings about herself. During these times, she sleeps 16 to 18 hours per day. She has called out sick from school for 50 days this school year and is at risk of not being able to move to senior year with her class. Her mother notes that she episodically spends tremendous amounts of money on a whim, on shopping as well as to treat "friends" to meals and outings. She also shoplifts during those times. The patient is barely able to complete the school day and cannot function most of the time.
Physical examination is unremarkable. Blood pressure is 110/70 mm Hg and resting heart rate 62 beats/min. Heart, lung, and bowel sounds are normal on auscultation. There is no lymphadenopathy. Liver and spleen are normal on palpation. The patient is 5 ft 5 in and weighs 140 lb. Reflexes, vision and hearing are normal. The patient appears pale, tired, and worn out, with a relatively flat affect. She has no underlying comorbidities and takes no medication. Family history reveals nothing remarkable except for bipolar disorder in one male cousin 10 years her senior, on her mother's side (mother's sister's son).