Bipolar Disorder in Adolescents

Mood swings are often considered a typical part of adolescence – just ask any parent with one or more teenagers at home. However, typical teenage mood swings are different from the intense mood swings of associated with bipolar disorder. Bipolar disorder is a serious, lifelong psychiatric illness. Formerly classified as a mood disorder called manic-depressive disorder, bipolar disorder is now its own category in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and includes three separate conditions: bipolar I, bipolar II, and cyclothymic disorder. Although onset frequently occurs in early adulthood, all three types of bipolar disorder can also develop in childhood or adolescence.

As a parent, it can be challenging to determine what’s normal and what’s not when it comes to adolescent emotional health. This brief guide is designed to help you know the signs to watch for and the steps to take if you believe your teen may have bipolar disorder.

Adolescent Bipolar Disorder: Facts and Figures

Some people think that bipolar disorder only affects adults, and that it’s not an illness that can develop in childhood or adolescence. This is incorrect. Symptoms of bipolar disorder and other mood disorders can and often do first appear during the teen years.

Here are some important statistics regarding adolescent bipolar disorder:

  • Approximately 1 in 5 teens who have major depression develop bipolar disorder within 5 years of the onset of their first depressive episode
  • A nationwide survey of over 10,000 teens between the ages of 13 and 18 found that 2.9% met the criteria for bipolar disorder within a given year
  • There are gender differences in the rate of bipolar disorder in adolescents:
    • 3.3% for females
    • 2.6% for males
  • The rate of bipolar symptoms increases with age:
    • 1.9% of adolescents age 13-14 reported symptoms of bipolar disorder
    • 4.3% of adolescents age 17-18 reported symptoms of bipolar disorder
  • Nearly 6 out of 10 teens who develop bipolar disorder during adolescence are also diagnosed with ADHD
  • As many as 33% of children and teens with depression may actually have early onset bipolar disorder

Though the overall prevalence rates for bipolar disorder and other mood disorders is relatively low, it’s important not to discount the seriousness of bipolar disorder and other mood disorders. When we translate the percentages above into population level figures – which is acceptable with sample sets as large as 10,000 adolescents – we get numbers that may resonate more than the small percentages we see above. For instance, if we round the overall prevalence of bipolar disorder up to three percent and assume a population of around 25 million adolescents in the U.S., we arrive at a figure that indicates there may be as many as 750,000 adolescents with bipolar disorder at any given time.

Types of Bipolar Disorder

Although bipolar disorder is often used as a catch-all phrase, it includes three distinct disorders. Each one involves some degree or combination of manic, hypomanic (similar to, but less intense than mania), and depressive episodes. The different types of bipolar disorder are:

  • Bipolar I Disorder is characterized by periods of mania, major depression, or mixed episodes that:
    • Last for at least a week
    • Are so severe that they affect sleep or typical daily functioning
    • Occur immediately before or immediately after a depressive episode that lasts or lasted two weeks or more
  • Bipolar II Disorder is characterized by periods of mania, hypomania depression, or mixed episodes that are less intense than the episodes experienced by adolescents with bipolar 1. The milder manic episodes typical of bipolar II are called hypomanic or hypomania.
  • Cyclothymic Disorder is characterized by numerous periods of depressive symptoms and hypomanic symptoms, but adolescents with cyclothymic disorder do not experience the full hypomanic or major depressive episodes seen in bipolar I or bipolar II.

Bipolar Disorder in Adolescents: Signs and Symptoms

Knowing what to look for and how to recognize symptoms of bipolar disorder in your teen will enable you to intervene sooner than later. There are two main things to remember:

  • Watch for and pay close attention to any extreme changes in their mood, personality, and behavior.
  • Symptoms of mania and depression don’t always look the same in teens as they do in adults.

What to Watch For:

Mania and Hypomania

Manic episodes or moods can cause elation, euphoria, or the opposite: anger or extreme irritability. In children and teens, irritability is more common than elation. Another hallmark symptom of mania is a limited need for sleep, which can last for days.

During a manic episode, adolescents have a high risk for engaging in destructive and/or risky behavior.

Other signs of mania may include:

  • Temper tantrums/outbursts of anger
  • Pressured or rapid speech
  • Racing thoughts
  • Intrusive thoughts
  • Very high energy levels
  • Difficulty sleeping
  • Difficulty concentrating
  • Unusually high level of optimism
  • Excessive multitasking
  • Grandiosity, i.e. an exaggerated sense of self-importance
  • Reckless behavior
  • Hypersexuality/risky sexual behavior
  • Recklessness, i.e. driving erratically or going on spending sprees
  • Impatience
  • Aggression
  • Having lots of exciting new ideas
  • Hallucinations, i.e. hearing voices
  • Delusions (beliefs that are irrational, false, or illogical)

It’s not uncommon for individuals experiencing their first manic or hypomanic episode to think everything is okay, even though others can see something is definitely not okay. A teen experiencing a manic episode may become annoyed or upset if a parent or family member mentions their concerns, or attempt to point out that something seems atypical or irregular about their behavior.

Depression

Depressive episodes or moods are often characterized by irritability, negativity or pessimism, persistent sadness or feeling down, somatic complaints such as headaches or stomachaches, low energy or fatigue, and increased withdrawal from family and friends.

Other symptoms may include:

  • Feelings of worthlessness
  • Heightened sensitivity to rejection
  • Feelings of hopelessness
  • Frequent crying
  • Feeling empty
  • Decreased self-confidence or self-esteem
  • Excessive sleeping
  • Difficulty falling or staying asleep
  • Changes in appetite
  • Temper tantrums
  • Apathy
  • Agitation or restlessness
  • Difficulty starting or completing tasks
  • Lack of motivation (often confused with laziness)
  • Loss of interest in favorite activities
  • Trouble concentrating or making decisions
  • Irritability
  • Excessive guilt or self-blame
  • Decline in academic performance
  • Neglecting personal hygiene
  • Talking and/or writing about death or suicide*
  • Giving away prized possessions*
  • Suicide attempts*

*Even if there are no other signs of depression, suicidal thoughts or behaviors should never be ignored. Don’t assume this is just your teen being dramatic or manipulative. If your teen talks or writes about suicide, have them evaluated by a mental health professional as soon as possible. If you think your child is in immediate danger, call 911 or the National Suicide Prevention Lifeline: (800) 273-8255*

It’s not uncommon to observe many, if not most, of the above symptoms in teens at one time or another. The intense mood swings of bipolar disorder, however, persist for several days or even weeks at a time and will include many symptoms at once, not just one or two. For a teen at high risk of bipolar disorder, stress or over-stimulation can trigger a manic episode, while a significant loss or disappointment may trigger a major depressive episode.

The First Steps Toward Healing

If you think your teen is starting to exhibit signs of bipolar disorder (or any mood disorder), there are three crucial initial steps you must take to help him or her*:

1. Talk to your teen.

Sit down and have a candid, compassionate talk with your teen. Express your concerns about the various symptoms you see.

Ask your teen if there’s anything going on that’s bothering them. Teens aren’t always forthcoming with parents, especially if they’re experiencing something confusing, uncomfortable, or embarrassing. Don’t pressure them to speak, and if they do, don’t over-react. Let your teen know that you want to help in any way you can, that you are willing and able to listen, and that you support and love them unconditionally, no matter what.

2. Set up an appointment for an evaluation.

Your family doctor or pediatrician is one option for an initial evaluation, but they’re not a mental health professional trained to recognize the nuanced differences in mood and mental health disorders. They can perform a physical examination to rule out any medical issues that may cause your teen’s symptoms, determine that there is a mental health issue present that needs attention, and then refer you to a psychologist or psychiatrist.

You can go to your family doctor or pediatrician first, but a child and adolescent psychologist or psychiatrist will have the specialized training and experience to identify and understand the more challenging and often subtle indicators of bipolar disorder in this age group. It may save time and energy to go straight to a mental health specialist, unless you and your family think you can benefit from the input of your family doctor or pediatrician.

Since both talk therapy and medication are typically recommended for managing bipolar disorder, a psychiatrist may choose to manage only the medication aspect of treatment, while a psychologist or other experienced licensed therapist provides therapy.

3. Get your teen into treatment.

Once your child receives an evaluation and diagnosis, the assessing psychiatrist or therapist will most likely recommend treatment. As mentioned above, treatment for bipolar disorder in teens typically involves a combination of medication and psychotherapy (talk therapy).

  • Medication. Medication is often necessary to manage the various types of bipolar disorder, particularly in the case of bipolar I disorder, in which the mood episodes can be extreme. Typical medications for bipolar disorder in teens include mood stabilizers such as lithium or Depakote, and/or atypical antipsychotics such as Risperdal. Medication can help prevent depressive episodes and decrease the frequency and severity of manic episodes.
  • Psychotherapy. Psychotherapy can help your teen understand bipolar disorder, including the challenges it creates and how to manage it more effectively. Talk therapy can also help them with the difficult relationship and self-esteem issues that often accompany bipolar disorder

Note: If your teen is experiencing a full-blown manic episode, your first step should be to get them to the nearest hospital or psychiatric ER for an evaluation and likely admission to a psychiatric inpatient unit. Attempting to have a conversation while they’re manic probably won’t be productive and may cause your teen to become more agitated.

Supporting and Encouraging Your Child

Bipolar disorder can be challenging for both you and your teen. You can encourage and support them in the following ways:

  • Educate yourself about bipolar disorder, which will enable you to have greater empathy for and understanding of what your teen is experiencing
  • Be patient and understanding
  • Pay attention to mood patterns over time so you can recognize the warning signs and help your teen manage their bipolar disorder. A chart or calendar can be helpful to track sleep, behavior, and other relevant patterns.
  • Minimize stress and over-stimulation in the home environment as much as possible
  • Help your teen find ways to effectively manage his or her stress
  • Be available and willing to listen to your teen
  • Actively participate in your child’s treatment, including family therapy if possible
  • Spend quality one-on-one time with your teen
  • Don’t ridicule, shame, or minimize their mental health disorder
  • Keep weapons, alcohol, and medications locked in a safe place
  • Respect your teen’s privacy and dignity with regards to their diagnosis.
  • Respect what your teen is experiencing, even though you may not understand it
  • Strive to stay calm even if (especially if) you feel frustrated or scared
  • Check-in with your teen to see how things are going, if treatment is helping, and to find out if there’s anything you can do that may be helpful
  • Monitor any side effects related to their medication, and make sure these are conveyed to their psychiatrist or other treatment provider

What to Do When Things Escalate

The extreme mood swings associated with bipolar disorder can be unpredictable and scary for both the person experiencing them and anyone who witnesses them. During a severe mood episode, your teen’s judgment will be seriously impaired. During a manic phase, they may engage in risky behavior that can have serious consequences, go several days with little to no sleep, become hostile and violent, increasingly disorganized, or psychotic. These erratic behaviors can put your teen, your family, and others at risk. During a depressive phase, your teen may become actively suicidal. There’s also a greater risk of drug or alcohol misuse or abuse during a depressive phase.

If your teen spirals out of control, you need to take steps to ensure everyone’s safety. A brief hospital stay may be necessary to keep your teen safe and get manic or depressive symptoms under control. Don’t hesitate to reach out for help. You can:

  • Contact your child’s treatment provider
  • Enlist the help of a close family member or friend
  • Call an emergency hotline (some mental health agencies have a mobile unit that can assist you)
  • Take your child to the nearest hospital emergency room (if you can do so safely)
  • Call 911   

When Individual Therapy Isn’t Enough

Sometimes medication and individual therapy aren’t enough to manage bipolar disorder. You may want to consider a more intensive level of treatment than weekly outpatient therapy if your child:

  • Experiences mania and/or depression even with medication
  • Becomes increasingly sleep deprived
  • Threatens, actively plans suicide, makes suicidal gestures, or attempts suicide
  • Becomes unable to function at all or without frequent assistance

More intensive levels of treatment may involve:

Here are the details about these levels of care:

Intensive Outpatient Programs (IOP)

This level of treatment is a step above weekly therapy or counseling. The amount and timing of treatment depends on the program. Teens typically participate in treatment 3 times a week for 3 hours per session, live at home, and attend school during an intensive outpatient program.

Partial Hospitalization Programs (PHP)

This level of treatment is a step up from intensive outpatient treatment. As with IOP treatment, the amount and timing of treatment depends on the specific program. Adolescents go to treatment daily, usually for 4 hours per day, and attend school at least part time. Most teens in PHP programs for mental health disorders continue to live at home.

Residential Treatment Centers (RTC)

Residential psychiatric treatment, also often referred to as inpatient psychiatric treatment, involves having your teen live full time at a non-hospital treatment facility. This intensive level of treatment may last from 30 to 120 days, depending on your child’s treatment needs and clinical progress. In addition to receiving full-time psychiatric treatment, one of the greatest advantages of residential psychiatric rehab is being in an environment that is designed specifically for teenagers with mental health disorders. This enables them to focus one hundred percent on recovery, without worrying about other factors in their life such as school, family, and peer relationships.

Inpatient Psychiatric Hospitalization

Hospitalization may be necessary if your teen is a danger to themself or others (e.g. suicidal or psychotic), or in need of 24/7 medical monitoring. Medical monitoring may be recommended for teens who are a danger to themselves or others due to mania, suicidal ideation, suicidal behavior, or severe depression.

More About Levels of Care

These levels of care – excluding psychiatric hospitalization, during which immediate safety and psychiatric stability are the primary goals – typically involve some combination of the following therapeutic approaches:

  • Individual therapy and counseling
    • Once a week or more, depending on the treatment center and treatment plan
  • Group therapy and counseling
    • This typically happens every day
  • Family therapy and counseling
    • Family therapy commonly occurs once a month, and in some cases, once a week
  • Experiential activities such as exercise, mindfulness, music, or art
    • These activities often happen every day, with longer experiences on weekends
  • Community support

The exact combination of treatment depends on the treatment center and the level of care your teen needs.

Take Care of Yourself

Helping a loved one with bipolar disorder is hard. The extreme mood swings can take quite a toll over time. Also, your teen will look to you for guidance, emotional support, and reassurance. Therefore, it’s important that you take care of yourself so you can be fully present to support them. Several things you can do include:

  • Get support for yourself through an online or local support group. Locate your local NAMI Chapter (National Alliance on Mental Illness) to find support groups. Also, you can talk to a therapist, members your church, and your family and friends
  • Get sufficient rest
  • Make time for yourself
  • Find effective ways to manage your own stress, such as yoga, meditation, or regular exercise

The most important thing you can do is stay positive and hopeful – for your teen, your family, and yourself. Never give up. Bipolar disorder is a serious illness, but it does not mean your teen will live an unhappy life. With proper treatment and support, your teen can learn to manage the symptoms of bipolar disorder and look forward to a bright and fulfilling future.