Bipolar Disorder and Autism
For some reason many folks with autism that I am seeing lately also have a diagnosis of Bipolar Disorder. Whether this is a "fad diagnosis" or something new that is going on, I will leave to the scientists. I thought I would share some things that have helped me and helped the people I know with both autism and Bipolar Disorder.
Diagnosing Bipolar Disorder
Bipolar Disorder is also known by the older term for the disorder, Manic-Depression. The idea of "bipolar" is that the person experiences fluctuations in mood as if they had two "poles" of mood or behavior that occasionally switched on or off. But the diagnosis is actually quite complicated. It involves not just looking at the behaviors that indicate symptoms but also defining what type of episode (depressive, manic, hypomanic, or mixed) is going on. In addition, there are many related disorders that can mimic the symptoms of Bipolar Disorder (viz., Major Depressive Disorder, Dysthymic Disorder, Cyclothymic Disorder, and the various Bipolar I and II Disorders). In my experience, the most common form of Bipolar Disorder that is seen in association with autism is Bipolar I Disorder, Most Recent Episode Hypomanic or Manic. However, keep in mind that this is my opinion and I am not a researcher. I will be sharing the diagnostic criteria for Bipolar I Disorder and mania. Here are the DSM-IV symptoms:
Bipolar I Disorder, Most Recent Episode Hypomanic -
A. Currently (or most recently) in a Hypomanic Episode.
B. There has previously been at least one Manic Episode or Mixed Episode.
C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
In order to use the above criteria, you need to know how to diagnose a Manic, Hypomanic, and a Mixed Episode. Here's the criteria for that:
Manic Episode -
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. more talkative than usual or pressure to keep talking
4. flight of ideas or subjective experience that thoughts are racing
5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The symptoms do not meet the criteria for a Mixed Episode.
D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
E. The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication or other treatment) or a general medical condition (e.g., hyperthyroidism).
Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.
Mixed Episode -
A. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.
B. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
NOTE: Mixed-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.
Hypomanic Episode -
A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. more talkative than usual or pressure to keep talking
4. flight of ideas or subjective experience that thoughts are racing
5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
NOTE: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder.
Mania
Let's discuss how mania may present itself in a child with autism. You will recognize the seven symptoms of mania or hypomania below. Next to each symptom we will explain how it may apply to a child with autism:
inflated self-esteem or grandiosity - When a child cannot talk or has a communication disorder, it may be hard to identify this symptom. Many of our kids act like they are in charge of the world anyway.
What you may see in a child with autism is a marked improvement in the child's usual mood. The child may seem overly happy, silly, or laugh inappropriately or even hysterically. A child who once feared certain situations may show no fear. The child may show irritability rather than a good mood. Behavior may become more aggressive than usual. Tantrums may increase dramatically. The child may act like the rules no longer apply to him or her. The child may act as if he or she has "super powers". The child may say he or she will report others to the prinicpal or to the police, etc.
decreased need for sleep (e.g., feels rested after only 3 hours of sleep) - Many children with autism have sleep issues to begin with so this may be a difficult symptom to track. What you may see in a child with autism is that the child may not sleep at all or their normal sleep times are decreased significantly. Alternatively, since sleep is usually a pleasurable activity, the child may sleep too much in the beginning of a manic cycle. Many children and adults with Bipolar Disorder have a "crash" after a manic phase and may not want to get out of bed at that time.
more talkative than usual or pressure to keep talking - For children who have a communication disorder this symptom would not seem to apply. However, many children and adults with autism and Bipolar Disorder show an increase in their speech and vocalizations during a manic cycle. I have had many parents report the "good news" that their child is suddenly more verbal only to later report that the child is driving them crazy with the accompanying manic behavior. Children with autism may use more words, talk/vocalize faster than normal, be difficult to stop or interrupt, and/or may talk through the night.
flight of ideas or subjective experience that thoughts are racing - The child's interest in activities may increase dramatically. The child will be restless, bombard you with "requests" for activities or other things, and will flit from one activity or thought to another. If the child is verbal he or she may be able to talk about their many conflicting thoughts and interests. Their speech may make no sense, may be a series of unrelated sentences or words, or may be songs or rhymes that have little relation to what is going on. May be expressed as extreme hyperactivity.
distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) - Many children with autism and ADHD have this symptom already. However, in a manic cycle the distractibility would be more than usual. May focus on unusual aspects of objects that are different from their usual interests.
increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation - May be impossible to redirect in their ritualistic behaviors. Once the child starts an activity he or she is almost impossible to stop. May repeat activities over and over (with more intensity than usual). The child may masturbate or engage in other sexual activity to an extreme degree. Extreme hyperactivity.
excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) - As above, sexual activity/interest may be taken to the extreme. The child may sleep excessively, self-stim excessively, eat excessively, toilet excessively, or engage in any other pleasurable behavior with more frequency and intensity.
To screen your child for Bipolar Disorder/Mania, see the following links:
The Mood Disorder Questionnaire
Parent Version of the Young Mania Rating Scale (P-YMRS)
What To Do?
If you suspect your child has Bipolar Disorder, talk with your child's physician about a referral for an evaluation. Usually a psychiatrist will make the diagnosis. Treatment often involves medication but there are behavioral interventions and alternatives to medication that are also effective. An important fact to remember is that Bipolar Disorder is not something that "takes over" your child - he or she is a participant in the process. There are steps you can take to lessen the impact of a manic phase. For great strategies, see this link: How To Avoid a Manic Episode. For information on the medical treatment of Bipolar Disorder see the American Psychiatric Association's Practice Guideline for the Treatment of Patients with Bipolar Disorder. For information on the alternatives to medication, see: Omega-3 Fatty Acids in Bipolar Disorder, and Nutritional Supplements for Bipolar Disorder.
For More Information on Bipolar Disorder See:
About Pediatric Bipolar Disorder
Bipolar Disorder in Children/ Early-Onset Bipolar Disorder
Child & Adolescent Bipolar Foundation
Treating a Child With Asperger’s Disorder and Comorbid Bipolar Disorder
Bipolar Disorder: A Summary of Clinical Issues and Treatment Options
The above information is for education purposes only.