Bipolar disorder (previously called manic-depression) is a mental condition characterized by mood swings that vary between the “high” episodes of mania and the “low” periods of depression. Research studies suggest that bipolar disorder may be relatively common among autistic individuals. According to Jessica Hellings and Andrea Witwer some studies have found that as many as 27% of individuals diagnosed with autism have symptoms of bipolar disorder (http://bit.ly/1LRIkiV). These investigators believe that the high prevalence rate may represent an over diagnosis due to an overlap or commonality between the symptoms of both conditions; other researchers believe that the cited figure under represents this comorbidity as affected patients may find it difficult to express some of their symptomatology due to language and/or intellectual impairment.
Although we are uncertain as to the cause of bipolar disorder (both genetic and environmental factors seem to play a role) treatment protocols for it have been well established and are effective in a majority of cases. This makes it imperative to appropriately diagnose those autistic individuals who may have bipolar disorder.
Rates for bipolar disorders appear to be similar for both men and women with a prevalence in the general population of 1-2%. Mean age of onset for symptoms is 19 to 25 years. In about one third of patients the diagnosis is obtained after more than 10 years of symptom onset. Diagnostic delay in the latter cases may be attributed to some existing comorbidities (e.g., drug abuse, ADHD) that may serve to divert the attention away from a diagnosis of bipolar disorder. Note: A problem with comorbidities, especially ADHD, is that you would not like to give a stimulant to a bipolar patient as response to this therapy is unpredictable. In some susceptible bipolar individuals stimulants may precipitate full blown manic symptoms.
Many people use the word bipolar disorder with different meanings. There is a general tendency to self-diagnose as bipolar because of perceived anxiousness, feelings of hostility or because of poor concentration. I believe that if you think you have mania but somebody else has not noticed it, it is not mania. True manic symptoms include markedly decreased need for sleep, inflated self-esteem, talkativeness, and distractability. If untreated it will last some 9 months and has a 15% mortality rate. Although the increased mortality rate is attributed in many cases to suicide other deaths are cardiac related probably due to the stress of the condition. In addition to those symptoms mentioned above, manic symptom may include racing thoughts (i.e., you can’t keep on with your thoughts), increased psychomotor activity (as in ADHD), promiscuity, and unrestrainined spending sprees. Some manic patients may manifest hypergraphia (ie., a rambling style of writing without punctuation).
There are different types of bipolar disorders. Bipolar 1 has manias or both manias and depression. Bipolar II has hypomanias and depression while cyclothymia has hypomania and depressive symptoms. (Note: symptoms of hypomania are similar to those of mania but last fewer days and patients may remain functional and productive during this period of time). Substance abuse, some prescribed medications and medical condition can lead to or precipitate symptoms of bipolar disorder, e.g. asthma medication, stimulants, interferon, corticosteroids.
The basic screening tool for bipolar disorders is the MDQ (Mood Disorder Questionnaire). The questionnaire probes whether reported symptoms have occurred during the same period of time (i.e., simultaneously), whether symptoms caused moderate to severe problems with work, family, money or legal troubles, arguments or fighting. The questionnaire provides for many false positives; however, it tends to weed out the negatives.
Prevalence prior to adolescence is low, likely less than 1%. In these cases, for a bipolar 1 diagnosis, a patient must meet all criteria for mania, just like an adult. Irritability alone does not mean the presence of a bipolar disorder. When confronted with a child with a presumed diagnosis of bipolar disorder the diagnostician should consider disruptive mood dysregulation disorder. According to the American Academy of Child and Adolescent Psychiatry: “Disruptive Mood Dysregulation Disorder (DMDD) is a relatively new diagnosis in the field of mental health. Children with DMDD have severe and frequent temper tantrums that interfere with their ability to function at home, in school or with their friends. Some of these children were previously diagnosed with bipolar disorder, even though they often did not have all the signs and symptoms. Research has also demonstrated that children with DMDD usually do not go on to have a bipolar disorder in adulthood. They are more likely to develop problems with depression or anxiety” (http://bit.ly/1kWc5oD).
Before starting treatment ask the patient on what medication are they on. Are they on stimulants? If so, you will have to take them off from the same. Also withdraw any tricyclics and any serotonin norepinephrine reuptake inhibitors. Are there any other medical issues? If manic, before starting medication, see if you can get them to sleep as it will start calming down. For pediatric patients lithium, olanzepine (Note: astronomical weight gain, sedation can be very strong, no initial lab, diabetes and cholesterol risk), risperidone, quetiapine (note: has a good sedative effect, weight gain is a big deal but it does not have much in terms of involuntary movement disorder), aripiprazone, asenapine have been approved for use in children. For depression some prefer treatment with olanzepine (down to 4 years of age). For maintenance, lithium is the only available medication although there is no safety data under 12 years of age. Lithium is fairly safe, a lot of data has accumulated in regards to its use for different age groups, but has many side effects, e.g., diarrhea, acne, weight gain, tremor, hypothyroidism, hyperparathyroidism, and diabetes. Lithium is inexpensive but proves inconvenient to some patients as it needs follow-up laboratory work. Depakote has been around for a long time. It is effective for mania but not for depression. Depakote requires lab monitoring and has many side effects: hair loss, nausea, vomiting, weight gain. Use in women of child bearing age may be difficult because of teratogenic effects.
Note: As with autism, members of the Neurodiversity movement claim that bipolar disorder is the result of normal variability within the human genome. They believe that bipolars posses an alternate cognitive style within society that should be preserved and accepted rather than treated. In this regard they cite historical accounts of figures like Wolfgang Amadeus Mozart and Vincent Van Gogh as possible bipolars who greatly contributed to society.
Although manic states may be associated in some individuals with increased creativity, in other cases the individual may be deluded as to the significance of his/her own efforts and achievements. A thousand page manuscript meant as a manifesto by a bipolar during his/her manic phase will almost always show gibberish verbiage of little intellectual significance. The truth is that for many bipolar individuals the disorder is a painful condition, in the physical sense, that bears a 15% mortality rate. Although many of those who die do so because of suicide others die of cardiac problems apparently precipitated by stress. Furthermore, offsprings of parents with bipolar disorder may inherit a susceptibility to affective disorders (Note: this relationship may appear more important that thought at first instance. It may help explain some of the pathology and the so-called “genetics” of autism see Stevens et al, 2013 at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3532962/). Contrary to claims by the Neurodiversity movement medical treatment in bipolar disorder can greatly benefit the affected individual.