Bipolar Disorder – Causes, Symptoms and Treatments

bipolar disorder in children

Also called: Manic Depressive Disorder, Manic Depression

Summary

Bipolar disorder is a psychiatric illness  characterized by extreme swings in mood, from highs (mania) to lows (depression). Therefore it used to be referred to as manic-depressive disorder. The condition affects roughly 2.3 million Americans, or about 1.2 percent of the population, according to the National Alliance on Mental Illness (NAMI). It is the sixth leading cause of disability worldwide.

The cause and risk factors of bipolar disorder are not completely understood. However, the condition appears to be strongly associated with genes since it can

run in families. Individuals who have relatives with a history of a mood disorder have a greater risk of developing bipolar disorder. Imbalance in the brain biochemicals called neurotransmitters, which convey messages between the nerves, also appears to play a major role. Too many or too few neurotransmitters are believed to cause alterations in mood.

Episodes of bipolar disorder may last from days to months and usually require life-long treatment. They generally follow a pattern for a particular patient, but may become more frequent as the patient ages.

Symptoms of bipolar disorder generally remain the same from one episode to the next in a patient, but they may get worse or better. Symptoms of mania include euphoria, increased self-esteem, rapid speech, racing thoughts, excessive irritability, increased energy, and decreased need for sleep. Symptoms of depression include sadness, loss of interest in activities, fatigue and thoughts of death. Psychotic features (e.g., hallucinations, delusions) may also occur.

Bipolar disorder is frequently misdiagnosed because people who are manic tend not to seek treatment. When treatment is sought during a depressive episode, the condition may be be mistaken for major depressive disorder.

The diagnosis of bipolar disorder involves a mental health evaluation. This evaluation includes a complete history of symptoms, including when they started, their duration and their severity. Diagnosis also includes ruling out other causes that may mimic symptoms of bipolar disorder, such as substance abuseor thyroid disorders.

Bipolar disorder may be difficult to diagnose in children because symptoms are often similar to those of other conditions (e.g., attention deficit hyperactivity disorder[ADHD]). In addition, children with bipolar disorder often do not fully meet established criteria for the condition.

There is no known way to prevent or cure bipolar disorder. However, effective treatments are available which substantially reduce the number and severity of episodes for most people.  Medication treatment with mood stabilizing drugs is an essential part of successful treatment for bipolar disorder. Lithium is the most common mood stabilizer and generally the first medication used. Anticonvulsant, antipsychotic and antidepressant medications may also be used to treat bipolar disorder. Psychotherapy is often effective in medication-stabilized patients. Electroconvulsive therapy (ECT) may be used in severe cases (such as if someone is very suicidal or psychotic), or in cases where medications are not effective.

About bipolar disorder

Bipolar disorder is a cycling mood disorder characterized by extreme shifts in mood, energy, and functioning. The condition is also called manic-depressive disorder because of the alternating periods of depression and mania. Bipolar disorder is often not recognized because many patients do not consider the “highs” of mania a symptom of a mental illness.  Treatment is usually sought during the depressive period, which often causes the condition to be misdiagnosed as major depression. Bipolar disorder is often mistaken for a health issue unrelated to mental illness (e.g., poor academic performance, difficult interpersonal relationships, substance abuse).

Bipolar disorder consists of specific types of episodes. They include:

  • Manic episodes. Characterized by highs in mood, very high self-esteem, increased activity and energy, and poor functioning. Patients may have extreme confidence with racing thoughts and make rash, impulsive decisions in situations where they would otherwise exhibit better judgment. For example, a patient may decide to go on a spending spree, have aggressive driving with road rage  or engage in sexually promiscuous behavior.

  • Depressive episodes. Lows in mood, often with reduced energy and motivation. Patients may not want to participate iny activities, and may feel that anything they attempt will fail or meet with disaster. Thoughts of suicide are also common in this period.

  • Mixed episodes. Episodes that display features of both mania and depression. These features may occur at the same time or may rapidly alternate. For example, a patient may feel very good emotionally but have very little energy, or may experience a sudden and drastic drop or increase in self-esteem.

  • Hypomanic episodes. Low-grade highs in mood, typically without the lapses in judgment common in full manic episodes. These are rarely recognized as mood episodes, but are generally seen as a particularly good mood.

Manic episodes may occur immediately before or after a depressive episode or there may be a period of normal mood between the episodes. Some patients retain some symptoms (e.g., shifting mood) between episodes. Episodes of altered mood generally follow a pattern characteristic for a particular patient. For example, one patient may always experience a very short hypomanic episode between a manic and a depressive episode whereas another may have short manic episodes followed consistently long hypomanic episodes. However, the time between episodes may decrease as the patient ages.

Episodes may last from days to months and usually recur over a lifetime. Most patients who experience a single manic episode will experience other types of episodes in the future. These episodes may be manic, mixed, hypomanic or major depressive episodes.

According to the National Alliance on Mental Illness (NAMI), about 2.3 million adult Americans, or around 1.2 percent or the population, are diagnosed with bipolar disorder. The condition occurs equally in all genders, races and ethnicities.

The onset of bipolar disorder usually occurs in late adolescence or early adulthood, and the average age of onset is 20. However, the disorder can occur at any age. Bipolar disorder was once thought to be very rare in children under the age of 12 years, but recent studies show that it may be more common than previously believed.

Men are more likely to experience a manic episode before a depressive episode. The number of manic episodes also tends to outnumber the depressive episodes in men. By contrast, women are more likely to have a major depressive episode before a manic episode and more depressive episodes than manic episodes. Women are also more likely to experience rapid cycling (four or more episodes per year). Ultradian cycling (drastic mood changes in the course of a single day) is rare and less studied in both genders.

Bipolar disorder appears to affect children more severely than adults. According to the Course and Outcome of Bipolar Illness in Youth (COBY) study, children with the disorder experience longer symptomatic periods, more frequent cycling and/or more mixed episodes than adults. The National Institutes of Health-funded study also found that the severity of the disorder in children progresses at a much higher rate than in adults with bipolar disorder.

Bipolar disorder has one of the highest mortality rates of all mental illnesses. Delusions of invulnerability may lead to dangerous, reckless behavior. Furthermore, according to the National Mental Health Association (NMHA), one in five patients with bipolar disorder die by suicide.

Alcohol and other substance abuse problems are common in patients with bipolar disorder and may worsen the condition. Numerous mental health disorders including panic disorder, attention deficit hyperactivity disorder(ADHD) and borderline personality disorder (BPD) are also associated with bipolar disorder.

Thyroid disorder occurs frequently with bipolar disorder and may lead to episodes or worsen symptoms in patients with bipolar disorder. This is more common in women. Neurological disorders may occur along with bipolar disorder in patients who first experience a manic episode in their older years, and this comorbidity may increase mortality. In some cases, a patient’s mood may stabilize during pregnancy. However, there is an increased risk of postpartum (following pregnancy)  fluctuations, including postpartum depression(PPD) or psychosis. Bipolar disorder significantly affects the economy. It may result in functional impairment and disability, and costs the U.S. workplace $14.1 billion annually in lost productivity, according to the NIH. According to the NAMI, bipolar disorder is the 6th leading cause of disability worldwide and the most expensive mental health diagnosis, both for patients and insurance providers.

Types and differences of bipolar disorder

Bipolar disorder is divided into four categories:

  • Bipolar I disorder. The most common type of bipolar disorder. This diagnosis requires at least one manic or mixed episode (mania accompanied by some depressive features). Episodes of major depression usually (but not always) occur. Men and women are equally affected and episodes may be particularly severe or psychotic (with delusions or hallucinations) and may require hospitalization. This category is divided into six separate disorders, depending on whether the patient has experienced only one (single episode) or multiple episodes and, in the case of multiple episodes, the nature of the last episode (hypomanic, manic, mixed, depressed or unspecified).
  • Bipolar II disorder. At least one episode of hypomania and one episode of major depression must have occurred for this diagnosis. Further, the patient must have never had a manic or mixed episode. Hypomanic episodes do not lead to psychosis or require hospitalization, though depressive episodes may. Bipolar II disorder is more common in women than in men and may be difficult to diagnose because many patients do not view hypomanic episodes as a cause for concern. They often do not remember them during depressive episodes without reminders from others. This disorder may develop into bipolar I disorder if a manic episode occurs.
  • Cyclothymia. Cycling between hypomania and lows in mood that do not meet the criteria for major depressive episodes. These milder episodes may be less severe and/or shorter in duration. They are, however, chronic and last for at least two years with no lapse in symptoms for more than two months at a time. This disorder may develop into bipolar I disorder if a manic episode occurs or into bipolar II disorder if a major depressive episode occurs.
  • Nonspecified bipolar disorder. Bipolar disorder with features that do not match those noted above. This may be more common in early onset bipolar disorder.

Risk factors and causes of bipolar disorder

The cause of bipolar disorder is not well understood. However, it appears that brain chemistry plays a major role in its development. Brain chemicals called neurotransmitters convey messages between the nerves.  Too many or too few neurotransmitters are believed to cause alterations in mood.

Bipolar disorder appears to be linked to genetics, and great strides are being made in identifying genes associated with the condition. Individuals who have relatives with a history of a mood disorder are at a higher risk of developing bipolar disorder. This is especially true for first degree relatives (e.g., parents, children, siblings). However, this is not a definite way of determining who may eventually develop bipolar disorder. For example, if one identical twin has the disorder, the other has an increased risk of developing it but may never actually do so. Some researches believe that some people inherit a tendency to develop the illness, which may then be triggered by environmental factors (e.g., stressful life events, disturbances in circadian or seasonal rhythms). Other possible triggers include sleep deprivation and treatment with antidepressants and certain herbal and dietary supplements (e.g., St. John’s wort).

Depression appears to be closely associated with bipolar disorder. According to the American Psychiatric Association, about 5 to 10 percent of patients who have had a major depressive episode will eventually have a manic episode and be diagnosed with bipolar disorder. According to the National Mental Health Association (NMHA), over half of all patients diagnosed with bipolar disorder have histories of substance abuse, which may precede the onset of the disorder or result from the condition itself. Some researchers believe that dependence on a substance may actually increase the risk of developing bipolar disorder.

Signs and symptoms of bipolar disorder

Symptoms of bipolar disorder generally remain constant from one episode of a given type (e.g., manic, depressive) to the next in the same patient, but they may improve or worsen during this time. For example, a patient who formerly had only hypomanic episodes may develop a manic episode, or vice versa. All patients with bipolar disorder suffer from some impairment in function. This may result from the episodes themselves or chronic unpredictable mood swings and unreliable ability to function.

Symptoms of manic episodes include:

  • Euphoria and elevated, “high” feelings or irritability. The patient may be in a good mood that remains despite occurrences that would normally dampen the mood.
  • Uncharacteristically elevated self-esteem, feelings of grandiosity or unrealistic confidence. Patients often feel very good about themselves or feel like they can take on the world.
  • Decreased need for sleep. The patient may wake up feeling rested after only a few hours of sleep.
  • Rapid talking, talking more than usual or feeling a need to keep talking. Patients may be excessively talkative. They may be loud or talk too fast.
  • “Flight of ideas,” feeling as though thoughts are racing, distraction or agitation. Patients may be easily distracted or restless. They may have rapidly shifting thoughts that may be revealed in conversation as the patient constantly changes the subject.
  • Increased goal-directed activity. Productivity may be increased.
  • Intrusive or aggressive behavior. The patient may seem nosy or aggressive, sometimes with destructive outbursts.
  • Denial that a problem exists. Because patients feel good and are often more productive, they may deny that there is a problem.
  • Seeking pleasure without regard to consequences, reckless behavior or poor judgment. Patient may engage in spending sprees, sexual promiscuity, substance abuse or other behaviors when they would normally exercise better judgment.

In children and adolescents, manic episodes are more likely to be characterized by irritability and destructive outbursts than by elation or euphoria.

Hypomanic episodes are similar to manic episodes, but are less severe or have a shorter duration. They may not cause actual impairment. In fact, hypomania often results in increased productivity.

Major depressive episodes are the most common episodes in bipolar disorder. Nearly all patients will have one at some point during their lifetime. However, if only major depressive episodes occur, without manic, mixed or hypomanic episodes, the diagnosis is major depression, not bipolar disorder. The symptoms of major depressive episodes include:

  • Altered mood. The patient may experience sadness, anxiety, anger, irritability or apathy (lack of emotion). They may be pessimistic (feel that everything in life will turn out badly) or discouraged and may experience crying spells or excessive emotional sensitivity.
  • Anhedonia. Reduction or loss of interest in activities the patient formerly found pleasurable, such as food, sex, work, friends, hobbies and entertainment.
  • Significant change in appetite or weight. Reduced or increased appetite or significant weight loss or gain.
  • Changes in sleep patterns. The patient may sleep too much (hypersomnia) or not enough (insomnia). Often, the patient wakes up early in the morning and cannot get back to sleep.
  • Physical or verbal activity. The patient may be agitated and anxious. They may wring their hands, pace or not be able to sit still. Conversely, the patient may have sluggish movements or speech. There may be a pause before answering questions or starting actions. The patient may speak quietly or not be able to be heard. They may not speak except in response to a direct question or may become completely mute (not talking at all).
  • Fatigue and loss of energy.
  • Self-worth. The patient may have feelings of worthlessness, self-reproach or excessive or inappropriate guilt.
  • Loss of concentration. There may be a diminished ability to think or concentrate.
  • Death thoughts. The patient may have recurrent thoughts of death and death wishes. They may think about committing suicide (suicidal ideation) or have suicidal actions. The patient may even attempt or complete suicide.

Sometimes, symptoms of depression may occur during a manic episode, resulting in a mixed episode. These may be more frequent in early onset bipolar disorder and in patients over the age of 60 years.

Psychotic features (e.g., hallucinations, delusions) may be present in manic, mixed or depressive episodes and tend to relate to the mood. For example, during manic episodes, patients may believe they are invulnerable to physical harm and, during major depressive episodes, patients may believe they are guilty of a great crime or sin. Obsessions and compulsions may also occur.The symptoms of bipolar disorder can lead to numerous behavioral problems, including school truancy (unexcused absence) or failure, occupational failure, divorce, antisocial behavior, child or spouse abuse or other violent behavior during severe episodes.

Diagnosis methods for bipolar disorder

The onset of bipolar disorder may begin with either a depressive or a manic episode. In general, however, patients experiencing both types of episodes are more likely to report depression to a physician.

Bipolar disorder is often under-diagnosed and misdiagnosed. According to the National Mental Health Association (NMHA), up to 80 percent of patients with the condition go undiagnosed or misdiagnosed for up to 10 years. However, there may be an over-representation of bipolar disorder in higher social-economic and education groups. This may be because these groups may be more aware of the disorder and are more likely to acknowledge and accept mental health disorders.

Before bipolar disorder can be diagnosed, a physician must perform a physical examination to rule out other potential causes of the symptoms, such as depression. Substance abuse, many medications or medical conditions (e.g., thyroid disorders, viral infections) can cause symptoms similar to bipolar disorder. Lab tests may also be ordered, particularly to check for thyroid dysfunction, which can make the symptoms of bipolar disorder worse.

The actual diagnosis of bipolar disorder begins with a mental health evaluation performed either by a physician or by referral to a mental health professional. This evaluation includes a complete history of symptoms, with particular attention to their onset, duration and severity. It is also noted whether the patient has had these symptoms before and, if so, whether and how they were treated. The Mood Disorder Questionnaire (MDQ) may be used, as well. This is a set of questions for the patient to answer that helps to determine if that patient has had any previous manic symptoms.

The physician or mental health professional will also ask about alcohol and drug use, whether the patient has thought about death or suicide and whether other family members have had a mood disorder. If the patient has a family history of mood disorders, they will be asked whether and how family members were treated and how effective the treatment was.

Bipolar disorder is generally characterized by many separate episodes of mania or depression. For an episode to be considered a new episode, the following criteria must exist:

  • There must be a shift in mood or lapse of time. The patient must display a drastic shift in mood, such as from major depression to mania. A new episode may also be diagnosed if it is separated from the previous episode by at least two months of normal mood.

  • Episodes must occur spontaneously. They cannot be directly caused by a general medical condition or the use of prescription or illegal substances.

  • Psychotic disorders (e.g., schizophrenia) must be ruled out.

Diagnosis of bipolar disorder is largely dependent on symptoms. For instance, if a manic or mixed episode ever occurs, bipolar I disorder is diagnosed . Bipolar disorder may be difficult to diagnose in children because symptoms are often similar to those of other conditions (e.g., attention deficit hyperactivity disorder[ADHD]). In addition, children with bipolar disorder often do not fully meet established criteria for the condition. However, bipolar disorder in children may be more severe than in adults. It may be characterized by a continuous state of rapidly cycling, irritable, mixed symptoms of mania and depression.

Treatment and prevention of bipolar disorder

Although there is no known cure for bipolar disorder, it is among the most treatable of mental illnesses. There is no known way to prevent bipolar disorder itself, but individual episodes may be prevented with the use of medications. Hospitalization may be necessary during severe episodes.

Medications are generally the first line of treatment for bipolar disorder. They are used to quickly control and eliminate dangerous or disabling symptoms and prevent further episodes. If thyroid dysfunction is present, it must be treated before symptoms of bipolar disorder can be addressed.

Mood stabilizing drugs are the primary medications for bipolar disorder. Different types of mood stabilizers may be more effective in different patients and a second mood stabilizer may be added if a single medication is not effective. Lithium is the most commonly used mood stabilizer, and generally the first medication used to treat bipolar disorder. It is typically more effective when started early in the course of the condition. It is also effective in preventing new episodes of both mania and depression and appears effective in reducing suicide among patients with bipolar disorder. However, lithium is not very effective in controlling acute manic symptoms in patients with mixed episodes.

Anticonvulsant drugs may be used for difficult and complex types of bipolar disorder (e.g., rapid cycling). They may also be used when other conditions, such as substance abuse, are present, or if there is a concern about lithium side effects. Lifelong maintenance with mood stabilizers is generally required to prevent new episodes and reduce the likelihood that subsequent episodes will be more severe.

Antidepressants are known to cause or worsen manic episodes in bipolar patients. However, they may occasionally be carefully used with mood stabilizers in the treatment of depressive episodes. Monoamine oxidase inhibitors (MAOIs) and selective serotonin reuptake inhibitors (SSRIs) appear to be the safest antidepressants for use in the treatment of bipolar disorder.

Patients should be aware that a physician may need to adjust the dosage or change medications to achieve the best results with minimal side effects. In addition, the U.S. Food and Drug Administration (FDA) has advised that antidepressants may increase the risk of suicidal thinking in some patients and all people being treated with them should be monitored closely for unusual changes in behavior.

Other possible treatments for bipolar disorder are currently being studied. For instance, researchers are investigating whether certain antipsychotic medications are effective in reducing symptoms of the condition. In addition, omega-3 fatty acids, which are found in fish oil and flaxseed oil, may have benefits when prescribed with conventional medication. However, the research is not conclusive and further study is needed regarding the benefits or risks of omega-3 fatty acids.

Psychotherapy is typically only used when the most severe symptoms are under control. It is often effective in medication-stabilized patients. Psychotherapy encourages patients to take medication properly, assists patients and families in establishing and maintaining appropriate behavioral boundaries and provides counseling and support. Psychotherapies commonly used in the treatment of bipolar disorder include:

  • Cognitive behavioral therapy(CBT). The patient learns to change and control inappropriate thought patterns and behaviors.

  • Psychoeducation. Teaches patients about bipolar disorder, its treatment and how to recognize early signs of new episodes so that early intervention can take place. This is often helpful for family members of patients with bipolar disorder as well.

  • Family therapy. Reduces the levels of distress within the family that may contribute to or result from the symptoms of bipolar disorder.

  • Interpersonal therapy (IPT) and social rhythm therapy. Improve the interpersonal relationships of patients and normalize their daily routines and sleep schedules to give them more control of their lives and their condition.

  • Group therapy. Focuses on acceptance of bipolar disorder and the need for long-term medication. This may include families.

Electroconvulsive therapy (ECT) is generally considered only in severe cases or in cases where medications are not effective. However, it may be an alternative to medications for pregnant or breastfeeding women. Modern techniques are much improved and problems, such as long-lasting memory loss, have been greatly reduced. ECT is administered using brief anesthesia and muscle relaxants. Electrodes are precisely placed to deliver electrical impulses to the brain. Several sessions are typically needed, usually at a rate of three per week, for full therapeutic effect.

Tips for coping with bipolar disorder

Bipolar disorder can have a major effect on the lives of patients. However, with treatment, patients can live full lives. Tips for patients living with bipolar disorder include:

  • Follow the prescribed treatment regimen closely. Take medications as directed, without skipping any doses. If psychotherapy has been recommended, attend sessions regularly. Do not make any changes in therapy without consulting a physician or mental health professional.

  • Be on the lookout for signs of an upcoming episode. If specific triggers of episodes have been identified, be aware of them and avoid them when possible. Friends and family members can often help patients recognize these triggers. As soon as it seems that a mood episode may be developing, contact a physician or mental health professional.

  • Keep a monthly mood chart and share it regularly with your doctor. A mood chart is a monthly diary of your moods, medications and certain lifestyle factors that can reveal a pattern behind bipolar’s phases. Over time, a mood chart can help predict if a depressive or manic phase is about to begin.

  • Do not make important decisions during mood episodes. Mania and depression affect judgment. Important decisions may need to be delegated to someone else or put off until the patient is experiencing a normal mood.

  • Avoid drugs and alcohol. Many substances, both legal and illegal, can affect the mood and also interact with other medications. Recreational or club drugs can be particularly dangerous, but legal drugs such as diet drugs may also need to be avoided. It is also important to discuss any over-the-counter or prescription medications and nutritional supplements with the physician or mental health professional who is treating the patient’s bipolar disorder.

Questions for your doctor on bipolar disorder

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following bipolar disorder-related questions:

  1. Do you have experience treating patients with mood disorders?
  2. Why do you suspect I may have bipolar disorder?
  3. What form of bipolar disorder do I have?
  4. How severe is my bipolar disorder?
  5. Which medications are right for me?
  6. What are the side effects of my medications?
  7. Do blood levels of my medications need to be checked regularly?
  8. For how long will I have to take medication?
  9. What if I want to become pregnant or breastfeed?
  10. Which psychotherapies should I consider?
  11. What are the chances that my children may develop bipolar disorder?
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