Psychodynamics of Hypersexuality in Children and Adolescents with Bipolar Disorder

Abstract

It has recently become evident that bipolar disorder exists in children and adolescents. The criteria for making the diagnosis of juvenile bipolar disorder (JBD) are in the process of being proposed for the fifth edition of the Diagnostic and Statistical Manual (DSM-V). In adults, a criterion for bipolar disorder is excessive involvement in pleasurable activities including hypersexuality. Recently, some clinicians and researchers have suggested that hypersexuality be included as a criterion for JBD as well. Although abnormal sexuality has been reported to be present in some youth thought to have JBD, the reason for this association is not yet clear. Hypersexuality may be primary and intrinsic to bipolar disorder in youth, secondary and associated with it as the result of psychosocial influences or psychodynamic factors, or due to general aggression and disruptive behavior. Not only have developmental psychosocial factors that may influence sexuality in children and adolescence not been fully investigated, but psychodynamic influences have been omitted from modern etiological constructs as well. This report discusses the importance of psychosocial and psychodynamic influences on the sexual experience and activity of bipolar children. It is proposed that a developmental, psychodynamically informed model is helpful in understanding sexuality in children and adolescents with bipolar disorder. It is also suggested that assessment of psychosocial and psychodynamic influences on the sexuality of bipolar children is necessary in order to adequately assess whether hypersexuality should be a criterion of bipolar disorder in youth.

Is Increased Sexual Behavior a Symptom of Bipolar Disorder in Children and Adolescents?

“…In addition, the duration criteria for JBD present unique difficulties due to the preponderance of rapidly cycling and mixed states in youth with possible bipolar symptoms. Very rapidly cycling mood states lasting as little as four hours ("ultradian" cycling) has been found frequently; such brief cycles, which verge on the length of severe tantrums, may be clinically difficult to distinguish from maladaptive coping strategies in dysfunctional environments (Adelson, 2010;McClellan, Kowatch, Findling, & Work Group on Quality Issues, 2007).…”

“…For example, youth who display symptoms consistent with diagnoses of both bipolar disorder and ADHD would merit the diagnosis of bipolar disorder if it could be shown that the symptoms predict adult bipolar disorder in adulthood, and are characterized by biological markers such as genetic patterns shared with adult bipolar family members (Adelson, 2010). The predictive value of the current criteria of bipolar disorder in affectively dysregulated youth has not yet been definitively established (Leibenluft, 2011).…”

“…Second, out of 154 office visits for treatment of youth diagnosed with bipolar disorder, 90.6% (n = 141) involved prescription of psychotropic medications including mood stabilizers, antipsychotics, and antidepressants (Moreno et al, 2007), pharmacological treatments with potentially serious side effects. Therefore, there is a pressing need to develop reliable and valid diagnostic criteria for JBD that have reasonable discriminative validity (Adelson, 2010).…”

“…Aspects of increased sexual behavior that are described in the literature include the frequency or variety of sexual behaviors, precocious emergence of normally mature sexual behaviors, sexual preoccupation, diminished impulse control, and socially inappropriate expression of sexuality such as aggression or coercion (Adelson, 2010).…”

“…One especially challenging question about JBD is how to adapt criteria involving increased sexual behavior to adolescents and children (Adelson, 2010). The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, or DSM-IV (American Psychiatric Association, 1994) incorporated increased or disordered sexuality as a criterion for manic and mixed bipolar episodes under the symptom rubric "excessive involvement in pleasurable activities that have a high potential for painful consequences," examples of which include "sexual indiscretions."…”