Bipolar Disorder: The devil's in the diagnosing
- Sara L
- May 10, 2024
- 7 min read
Bipolar Disorder is a complex condition. At its core it is an energy regulation problem.
So what does that mean?
Researchers think there is some degree of mitochondrial dysfunction going on, in other words, there are issues inside the tiny powerhouses of the cells (responsible for generating energy) causing symptoms¹.
For every 100 children, between 1-2 will have bipolar disorder². The condition is actually part of what we call the 'mood disorder spectrum'.
At one end of this spectrum we have major depressive disorder, and at the opposite end we have Bipolar Type 1 Disorder, characterized by mania, where people feel and act as if they are on top of the world.
They are unusually happy, excited, have racing thoughts, are talkative, irritable, elevated and take risks with their money and health. They will have a sudden surge of energy that stops them from sleeping for days on end.
Bipolar Type 2 Disorder is a step down from Bipolar Type 1 Disorder in that in Bipolar Type 2, the mania experienced is not as severe as in Bipolar Type 1 (it is instead referred to as hypomania) and won't last as many days (4 days instead of the 7 or more seen in Bipolar Type 1 Disorder).
There are also a few other noticeable difference between the two³:
For individuals with Bipolar Type 1 Disorder, one third of their lifetime will be spent feeling depressed, 50% of the time they will feel fine and only 10% of the time will they experience mania or hypomania (low level mania). The other 10% of the time will be spent cycling between mania (elevated mood) and depression.
So those with Bipolar Type 1 Disorder typically present to their doctors with complaints of depression (because half the time they feel normal but then 30% of the time they are depressed). Their mania will last at least 7 days if left untreated and typically can lead to issues with the law, hospital admissions and/or bodily injury.
For Bipolar Type 2, you do not have episodes of mania. Instead you have episodes of hypomania. So these individuals are low level exceedingly happy and hyperactive which might go unnoticed. This only happens about 1% of the time, so the hypomania is typically missed and they are never clearly diagnosed. They are depressed half the time and the other half of the time they are fine. At base line they experience more depression than those with Type 1 bipolar.
What do symptoms of mania/hypomania look like?⁴
So to clarify, both Bipolar Type 1 and Type 2 can present with mania/hypomania symptoms above.
How we tell them apart is that in Bipolar Type 1, there needs to have been an episode of mania, so all the below 7 symptoms ( in diagram), that lasted for at least one week. There may or may not have been a hypomanic episode (defined as 3-4 of the below 7 symptoms lasting at least 4 days) and overall the episode is 'mild' and doesn't really impact their day to day in that it doesn't get them into trouble with the law or end with a hospital visit.
For Bipolar Type 2, there needs to have been at least one major depressive episode and at least one episode of hypomania. In Bipolar Type 2 disorder you don't get mania. Mania only occurs in Bipolar 1 Type.
The devil's in the diagnostic details
Accurately diagnosing both Bipolar Type 1 and Bipolar Type 2 is so important because giving the wrong medication can really impact an individual's behavior and health. For example, if an antidepressants are used by someone with Bipolar Disorder it can tip them into a manic or hypomanic episode.
The problem with being in an episode of full blown mania is that you're not sleeping (for at least 7 days) and you're probably not eating or hydrating. As a result your body is under a huge amount of stress and deprivation which requires you to be treated in a hospital. That, combined with risk taking and goal directed behaviors (financially and sexually) means that socially and money-wise you could really do damage to your relationships and economic security.
Therefore before starting a child on an antidepressant it is always important to screen for both a family, and personal history of bipolar disorder and continually assess for symptoms of mania/hypomania to make sure the medication is not unmasking an undiagnosed Bipolar Disorder that was sitting there otherwise undetected.
What are the treatment options?
Treating Bipolar disorder is tricky. For this reason it is probably best left to Psychiatry.
The reason that it is so difficult to manage well is that you need to be able to identify what phase the condition is in, i.e. if the child has mania, hypomania, depression, is instead cycling between the two states, or is currently without symptoms, called euthymia.
Phases of Bipolar Disorder (over simplified):
The other reason that it is a difficult diagnosis to manage and treat is that the symptoms overlap with ADHD often, and it is difficult the tease the two apart and figure out whether symptoms are due to Bipolar Disorder or ADHD, or both. For a long time a condition called DMDD was being clinically confused with the Bipolar spectrum⁵ displaying how fraught and tricky accurate diagnosis has been in the past.
Therapy options
The first line option is therapy, namely Functional Family therapy (FFT). It emphasizes the role of family dynamics in shaping a child's behavior and emotional well-being. By involving the entire family in therapy sessions, FFT helps to improve communication, reduce conflict, and foster a supportive home environment. This can be crucial for children with Bipolar Disorder, as a stable and understanding family backdrop can help the management of mood swings and other symptoms. FFT also equips family members with strategies to effectively support the child during both manic and depressive episodes, enhancing the child's ability to cope with their condition and reducing the overall impact on their mental health.
Should FFT not be enough then there are medication options available to address both the manic and depressive phases of bipolar disorder called 'mood stabilizers'.
These medications encompass a select group of medication drug classes, namely antipsychotics (which are very effective and super versatile as they can be used in depression and anxiety that is otherwise not response to antidepressants) and anticonvulsants (also used to treat seizures).
Medication options
The choice of which mood stabilizer to use comes down to which phase of the Bipolar you are trying to treat.
So, in acute mania or a mixed episode you might use a second generation antipsychotic such as Risperidone, Olanzapine, Ariprzaole, Quetiapine, Asenapine or Lithium, or anticonvulsant Valproic acid. There are far more treatment options available to treat Bipolar Mania than Bipolar depression⁵.
For Biploar depression you might reach for second generation antipsychotics such as Lurasidone, Quetiapine, Olanzapine/Fluoxetine (aka Symbyax) or Lithium or the anticonvulsant Lamotrigine⁵.
For maintenance treatment (not currently in mania/hypomania, and not depressed but wanting to protect against future mood swings) the options are Lithium, anticonvulsants Valproic acid or lamotrigine and second generation antipsychotic, Apriprazole⁵.
The second generation antipsychotics are considered 'first line' or what you would consider using first in pediatric Bipolar Disorders. The other mood stabilizers listed above such as Lithium and the anticonvulsants carry more side effects so would be considered in cases where a child does not tolerate antipsychotics or does not do well with them.
Is there anything we can use instead of medications for Bipolar disorder?
So, I do not recommend trying to treat Bipolar disorder 'naturally'. Left under-managed it can be severely disabling and even cause suicidality, so it is not a diagnosis to be taken lightly.
For Bipolar Mania, in addition to the FDA approved recommended mood stabilizers above, parents can use 'Dark Therapy'. Essential what this means is putting your child down for bed around 6pm in a pitch black room, with absolutely no light source. What this does is help reset their sleep-wake cycle and control mood swings. If 6pm seems a little too early to get to bed then blue light blocking glasses (like amber tinted safety glasses) can be worn at night around the house. What we are doing here is shielding the eyes (and brain) from blue light so that darkness itself can act as a mood stabilizer⁶.
For Bipolar depression the converse is recommended: Bright Light Therapy (BLT) as an adjunctive treatment, i.e. a treatment given in addition to medication management to control depressive symptoms. Overall it is found be a helpful treatment for reducing depressive symptoms in those with Bipolar Disorder⁷,⁸ with the caveat that it may help some, but not every single person who tries it. But given the fact that it does not carry risks or side effects, it is worth trying.
Supplementation options for Bipolar depression include Omega 3 fatty acids⁹. N-acetylcysteine¹⁰ is also recommended, though large trials do not currently exist. Finally making sure that the Thyroid is working properly is also important. This can be tested by your child's healthcare provider with blood testing. If the Thyroid is over- or under active, medications can be prescribed to help rebalance the Thyroid. A healthy functioning Thyroid plays an important a role in mood stabilization in Bipolar Disorder¹⁰.
Conclusion
Bipolar Disorder is a complex condition and a part of a mood disorder spectrum, with mitochondrial dysfunction potentially playing a role presentation.
Bipolar Type 1 Disorder involves severe mania lasting at least seven days, while Bipolar Type 2 is characterized by less intense hypomanic episodes.
Accurate diagnosis is crucial, as the misuse of antidepressants can exacerbate symptoms, highlighting the challenge of distinguishing between similar psychiatric conditions such as ADHD.
Treatment approaches include a combination of mood stabilizers and antipsychotics, tailored to the phase of the disorder, with family involvement and therapy such as Functional Family Therapy playing supportive roles in managing the condition effectively.
Alternative options can be used side by side with medications and include both light and dark therapy (depending on the phase of the bipolar you are trying to treat), Omega 3 and NAC supplementation and correcting any Thyroid dysfunction.
This site is for general informational purposes only and does not constitute the giving of medical advice. The contents do not constitute the practice of medicine, nursing, or other professional health care services. No provider–patient relationship is formed. Please consult with your child's healthcare provider when considering supplementation for children.
⁴DSM-5-TR; Diagnostic and Statistical manual of Mental Disorders. Fifth Edition. American Psychiatric Association. American Psychiatric Association Publishing.
⁵Feder, J., Tien, E & Puzantian, T. (2023) Child Medication Fact Book for Psychiatric Practice. Second Ed. Carlat Publishing
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