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Autism and Bipolar: What is the Connection?

April 6, 2022


Parents concerned about their autistic child’s mood swings often ask if autism and bipolar disorder co-occur and whether symptoms overlapping mean the disorders are related.

Autism and Bipolar: What is the Connection? 
https://www.autismparentingmagazine.com/autism-bipolar-connection

Autistic adults, diagnosed later in life, often talk about their struggle to get diagnosed. Far too many share details of being misdiagnosed, and suffering severe side effects of medication that did little to improve challenging autism symptoms. Because the autism spectrum is so wide, and symptoms manifest differently in each individual, some of these adults were erroneously diagnosed with a mental disorder like bipolar disorder or schizophrenia before eventually being accurately diagnosed with autism spectrum disorder (ASD).

Many autistic individuals have a comorbid condition like anxiety, attention deficit hyperactivity disorder (ADHD), or less frequently bipolar disorder, which means diagnosis becomes even more complicated—especially when symptoms of one disorder mask those of the other.

For children and adolescents with autism spectrum disorders, an accurate diagnosis of comorbid mood disorders is crucial. Certain mood disorder medications cause severe side effects, and this is especially dangerous for a population with communication deficits which may render the child incapable of sharing distress. 

If possible, parents should keep detailed notes of mood episodes and consult with a child psychiatrist or other medical expert if any mental health issues—particularly uncharacteristic and extreme mood swings—are observed.

While only experienced, certified medical professionals can diagnose autism and bipolar disorder (especially complicated, comorbid diagnoses in the pediatric population) parents with kids on the spectrum may be interested to find out how autism and bipolar disorder’s symptoms overlap and differ.

Autism spectrum disorder (ASD) and bipolar disorder

Autism is a lifelong neurodevelopmental disorder with symptoms appearing in the early developmental period of a child’s life. The spectrum condition is characterized by social, behavioral, sensory, and communication issues. Autistic individuals engage in repetitive and restrictive behaviors; these symptoms and characteristics should be serious enough to interfere with daily living and should not be better explained by another diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013).

Bipolar disorder is a mental health condition or mental disorder that causes atypical shifts or changes in an individual’s energy level, mood, and ability to function. Bipolar disorder occurring in the pediatric population is the topic of much debate. A meta-analysis suggested prevalence of pediatric bipolar disorder of approximately 3.9% (Van Meter et al., 2019). 

But, findings suggesting the heterogeneous community surveys were unsuitable for statistical meta-analysis resulted in a narrative analysis (Parry et al., 2021) concluding that bipolar disorder is very rare in childhood—in fact the article suggests abandoning the term pediatric bipolar disorder.


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Contrasting research aside, parents may be concerned about dramatic shifts in their autistic child or adolescent’s moods. Bipolar disorder is characterized by extreme mood swings: from episodes of intense highs (mania) to dismal lows (depression/depressive episodes). These episodes may last for days, but usually span several weeks or months. A person may experience highs and lows at the same time or episodes may follow in quick succession.

Hypomania or mania is associated with elevated energy and mood, increased impulsivity, overconfidence, sleep disturbances (sleeping little but not feeling tired),  talking a lot (rapidly) and jumping from one conversation to the next. 

An individual experiencing a manic episode may deny that anything is wrong, they may feel a sense of grandiosity, their self esteem and confidence may be raised significantly. But, while feeling like they can do and achieve anything, they may actually underperform. At work or school they may be easily distracted, and dealing with racing thoughts and feelings of extreme restlessness. 

Within weeks of a manic episode the same person experiencing such feelings of euphoria, elevated energy or perhaps unusual irritability and restlessness may experience a depressive episode. This period may be characterized by feelings of worthlessness, low mood, lack of energy and feeling unusually tired. Depressive episodes may result in suicidal thoughts; autistic individuals struggling with communication may be especially vulnerable in such circumstances.

The connection between bipolar disorder and autism

A study (Joshi et al. 2013) investigated the clinical and familial correlates of bipolar disorder when it occurs with and without autism. The study found a significant minority of youth with bipolar disorder had comorbid autism spectrum disorders. In the presence of autism comorbidity, familial correlates of bipolar disorder were commonplace.

The genetic link between autism and bipolar disorder is the topic of complicated research but it does seem as though autism and bipolar disorder share specific genetic expression patterns. A study (Guan et al., 2019) identified eight gene sets with dysregulated expression shared by autism, schizophrenia, and bipolar disorder. Results from research like this contribute to the study of etiological overlap between autism and bipolar disorder.

Conditions like autism, bipolar disorder, schizophrenia seem to activate genes in star-shaped brain cells called astrocytes, which perform many important functions in the central nervous system (Gandal et al., 2018). This could contribute to the overlap in symptoms—like irritability and aggression—between conditions like autism, bipolar disorder, schizophrenia.

While research can tell us more about the genes involved in autism and comorbid bipolar disorder, an accurate prevalence rate may be difficult to obtain as overlapping symptoms and misdiagnosis often skew statistics.

Presentation of bipolar symptoms in ASD

Another question parents concerned about mood disorder in ASD ask is whether bipolar symptoms present differently in someone on the spectrum? A study (Borue et al., 2016) looked at the characterization of mood and psychosocial functioning in children and adolescents with comorbid autism and bipolar disorders. 

The study (Borue et al., 2016) found youth with autism and bipolar disorder display typical bipolar disorder mood characteristics but symptoms appear earlier, with mixed presentation. The disorders occurring comorbidly may also present additional functional impairments. 

In this study, participants with autism and bipolar disorder exhibited significantly greater friendship impairments throughout the study’s follow-up. A conclusion of the study pertaining to early recognition and treatment of mood disorder in ASD to improve clinical outcomes deserves more attention.

Antipsychotic or mood stabilizing medication to treat bipolar disorder

Since significant amelioration of symptoms occurred in the study referred to above (Borue et al., 2016) the author’s conclusion, relating to treatment of mood disorder in ASD improving clinical outcomes, makes sense. Unfortunately this may be a complicated feat as mood disorders are difficult to diagnose in a pediatric population with communication deficits and symptoms masking and overlapping with those of other mental disorders. Even when a child is accurately diagnosed with ASD and comorbid bipolar disorder, the medication described for mood disorders has many side effects that may be especially severe in children.

With doctors increasingly recommending multiple medications to effectively treat autism and comorbid bipolar disorder, safety concerns are amplified. Considerations focused on safety are crucial, and should encourage further studies to establish outcomes of long-term use of antipsychotics and mood stabilizers in children, especially when such medication is combined with other medicine prescribed for ASD symptoms. 

Research suggests youth with comorbid ASD and bipolar disorder may experience more severe symptoms, and pharmacological intervention (like anit-depressants and other medication) may improve quality of life. The safety concerns of prescribing multiple mood altering medication for young children means parents should seek diagnosis and intervention from medical experts with extensive experience in the complicated manifestation of comorbid psychiatric conditions.

Bipolar disorder is very rare in childhood and rare in adolescence (Parry et al., 2021) therefore, it is important to consider that some mood fluctuations may be because of symptoms associated with ASD, puberty and sensory issues related to the child’s environment. If, however, parents observe any dramatic shifts in mood in their autistic child they should keep a careful record and consult their child’s pediatrician, psychiatrist or health care provider as soon as possible. 

Signs and symptoms to look out for include but are not limited to :

  • Mood swings including euphoric happiness or out of character silliness (Parents know their child best, mood swings may be a normal part of childhood and may be the way autism presents in some children, but severe shifts in mood that seem uncharacteristic should not be ignored)
  • Talking very fast and switching topics at random; not to be confused with the unusual speech patterns often observed in ASD
  • Risky, inappropriate, or impulsive behavior. Angering quickly or aggressive behavior not normally observed in the child 
  • Sleep disturbances. Autism is characterized by sleep issues, but take note when your child suddenly gets up a lot at night, becomes completely disinterested in sleep or sleeps a lot more or less than usual
  • Symptoms that warrant immediate medical attention include suicidal ideation and when your child mentions seeing or hearing things that are not there

Autistic children may experience worsening or more intense ASD symptoms due to a number of factors including illness, puberty and the demands of living in an environment unsuitable for the autistic mind. Sometimes, however, sudden mood changes indicate a comorbid mental issue that deserves the immediate attention of an experienced medical specialist.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Borue, X., Mazefsky, C., Rooks, B. T., Strober, M., Keller, M. B., Hower, H., Yen, S., Gill, M. K., Diler, R. S., Axelson, D. A., Goldstein, B. I., Goldstein, T. R., Ryan, N., Liao, F., Hunt, J. I., Dickstein, D. P., & Birmaher, B. (2016). Longitudinal Course of Bipolar Disorder in Youth With High-Functioning Autism Spectrum Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 55(12), 1064–1072.e6. https://doi.org/10.1016/j.jaac.2016.08.011

Gandal, M. J., Haney, J. R., Parikshak, N. N., Leppa, V., Ramaswami, G., Hartl, C., Schork, A. J., Appadurai, V., Buil, A., Werge, T. M., Liu, C., White, K. P., CommonMind Consortium, PsychENCODE Consortium, iPSYCH-BROAD Working Group, Horvath, S., & Geschwind, D. H. (2018). Shared molecular neuropathology across major psychiatric disorders parallels polygenic overlap. Science (New York, N.Y.), 359(6376), 693–697. https://doi.org/10.1126/science.aad6469

Guan, J., Cai, J. J., Ji, G., & Sham, P. C. (2019). Commonality in dysregulated expression of gene sets in cortical brains of individuals with autism, schizophrenia, and bipolar disorder. Translational psychiatry, 9(1), 152. https://doi.org/10.1038/s41398-019-0488-4

Joshi, G., Biederman, J., Petty, C., Goldin, R. L., Furtak, S. L., & Wozniak, J. (2013). Examining the comorbidity of bipolar disorder and autism spectrum disorders: a large controlled analysis of phenotypic and familial correlates in a referred population of youth with bipolar I disorder with and without autism spectrum disorders. The Journal of clinical psychiatry, 74(6), 578–586. https://doi.org/10.4088/JCP.12m07392

Parry, P., Allison, S., & Bastiampillai, T. (2021). ‘Pediatric Bipolar Disorder’ rates are still lower than claimed: a re-examination of eight epidemiological surveys used by an updated meta-analysis. International journal of bipolar disorders, 9(1), 21. https://doi.org/10.1186/s40345-021-00225-5

Van Meter, A., Moreira, A., & Youngstrom, E. (2019). Updated Meta-Analysis of Epidemiologic Studies of Pediatric Bipolar Disorder. The Journal of clinical psychiatry, 80(3), 18r12180. https://doi.org/10.4088/JCP.18r12180

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