Mania vs. Asperger's

A reader asked:

How do you differentiate grandiose thoughts associated with mania from unusual thoughts and emotional dysregulation associated with Asperger's syndrome in young children?

Dr. Dave:

There are really two questions here- one about grandiosity versus unusual thought content in Asperger's, and the other about emotional dysregulation.  First, bipolar mania should never be diagnosed on the basis of a single symptom like grandiosity.  We look for grandiosity in combination with elation or irritability, plus decreased need for sleep, plus increased energy, plus impulsive risk-taking behavior all in the same interval, before we diagnose a child or teen with mania. 

In mania, grandiosity usually takes the form of feeling smarter or more clever than anyone else, having special abilities or powers (eg, being able to read people's minds), the ability to accomplish great things without any training, etc.  So, for example, a teen talked about being able to hang out a shingle and practice law without ever having gone to law school; another said she'd become a famous rock n' roll guitarist even tough she had never taken music lessons. Sometimes it takes the form of wanting to do big, over-the-top things - I want to rent some land and start an art school over the holidays (a 15 year old).

In Asperger's, kids can have what looks like grandiosity but is really more like a misunderstanding of socia relationships, for example, "I can walk up to anyone at school and they'll like me immediately;" "I got rid of the school bully by just staring at him from across the playground." Often, the thinking disturbance in Asperger's is more about getting stuck on a certain idea or topic and not being able to let go of it, which can become grandiose at times.

Asperger's kids can have emotional dysregulation too; but emotional dysregulation just means difficulty coping with strong emotions.  Mania and depression are clusters of symptoms encompassing emotions (for eample, irritability), thinking (for ex., grandiosity), and behaviors (for example, impulsive spending or hypersexuality).  It is rare to see this combintion of symptoms in Asperger kids occuring at the same time, unless they also have bipolar disorder. It is also not episodic like bipolar disorder (that is, occurring in phases with a return to relavtive normalcy in between).

I hope this answers your question. Happy holidays.