Bipolar disorder in teenagers is not clearly defined as only diagnostic criteria for adult bipolar disorder is set out in the current version of the Diagnostic and Statistical Manual of Mental Disorders. Moreover, the proposed next revision of the DSM still does not contain symptoms of teenage bipolar disorder.¹

However, studies now show bipolar disorder type 1 manifests before age 20 in approximately 20% - 30% of cases and 20% of youths diagnosed with depression later go on to experience a manic episode.²

Symptoms of Bipolar in Teenagers

Early onset bipolar disorder is often defined as occurring before the age of 25. The younger the age of onset of bipolar disorder, the more likely it is to find a significant family history of the condition (read Causes of Bipolar Disorder).

Early onset bipolar disorder most commonly begins with depression and there may be many episodes of depression before the first hypomania. Depression with psychotic features may be a predictor of future full-blown bipolar disorder in the early onset group. Akiskal (1995) has argued that syndromal dysthymia with its onset in childhood, particularly in the presence of a family history of bipolar disorder, may herald a bipolar disorder.

Because the specific set of symptoms of bipolar in teenagers may be different than those in adults, teenage bipolar is commonly misdiagnosed as:

• Borderline personality disorder
• Posttraumatic stress disorder (PTSD)
• Schizophrenia

Risky Behaviors in Bipolar Disorder in Teens

Because symptoms of bipolar disorder include lack of judgment and risky behavior, when these manifest in bipolar teenagers, the results can be deadly. Teenagers may engage in the following types of risky behaviors:

• Frequent, unprotected sex
• Driving while intoxicated
• Substance abuse
• Poor diet, leading to obesity, high blood pressure and diabetes
• Lack of treatment plan compliance

Suicide is another huge concern in teenage bipolar. Suicide is the third leading cause of death between the ages of 15 - 25 in the general population and bipolar disorder increases this risk, but by how much is unknown. In teenage bipolar, males in their first years of treatment are most likely to commit suicide. Lithium drastically reduces the risk of suicide among adults and may reduce the risk of suicide in teenagers with bipolar disorder but specific study data is not available.

Extensive information on suicide thoughts, suicide attempts, and other suicide issues.

Treating Bipolar Disorder in Teenagers

Treatment for teenage bipolar is similar to that of adult bipolar disorder: medication, therapy and support (bipolar self-help and how to help a bipolar loved one). Medications used to treat adults are often helpful in stabilizing mood in teenagers with bipolar disorder. Most doctors start medication immediately upon diagnosis if both parents agree.

Early onset bipolar disorder is more commonly associated with a positive response to the mood stabilizer valproate and relative failure of response to lithium, not only because rapid cycling, mixed states and substance use are common in this group, but also because adolescents and young adults are less tolerant to the side effects of lithium.³

Other treatments, such as psychotherapy, may not be effective until mood stabilization occurs. In fact, stimulants and antidepressants given without a mood stabilizer (often the result of misdiagnosis) can cause havoc in bipolar disorder in teenagers, potentially inducing mania, more frequent cycling and increases in aggressive outbursts.

Treatment of bipolar disorder in teens is a trial-and-error process lasting weeks, months, or longer, as doctors try several medications alone and in combination to find the best treatment for the symptoms of teenage bipolar disorder. Two or more mood stabilizers, plus additional medications for symptoms that remain, are often necessary to achieve and maintain stability.

Medications for the Treatment of Bipolar Disorder in Teens

Few medications are FDA approved for the treatment of teenage bipolar disorder. Psychiatrists often use their knowledge of bipolar treatment in adults and apply it to adolescents. The following medications have Food and Drug Administration (FDA) approval for use of bipolar disorder in teens:²

• Lithium carbonate – often a first-line mood stabilizer and is effective in approximately 60-70% of adolescents and children with bipolar disorder. Approved in patients 12 years and older.
• Valproate / sodium divalproex / valproic acid (Depakote) – an anticonvulsant approved in patients 12 and older.
• Aripiprazole (Abilify) - an atypical antipsychotic approved for bipolar disorder in teens and children aged 10-17 years. It can be used alone or adjunctively with lithium or valproate.
• Risperidone (Risperdal) – an atypical antipsychotic approved for bipolar mania in children aged 10-17 years.
• Quetiapine (Seroquel, Seroquel XR) – an atypical antipsychotic approved for bipolar mania in children aged 10-17 years.
• Olanzapine (Zyprexa) – an atypical antipsychotic approved for use in those 13 and older with bipolar type 1.

See also Bipolar Disorder in Children: Signs, Symptoms, Treatment or Bipolar Depression in Teens: How Parents Can Help

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There is medical debate about whether bipolar disorder should be diagnosed in children as currently, there are no specific symptoms for bipolar disorder in children, only for adult bipolar disorder. Moreover, many clinicians believe bipolar disorder cannot be diagnosed in pediatric patients.

However, research suggests 20% - 30% of adults with bipolar disorder type 1 first showed symptoms before the age of 20. (Read "Childhood Bipolar Disorder: Growing Up A Bipolar Child") Additionally, 20% of youths diagnosed with depression later go on to experience a manic episode.²

Symptoms of Bipolar in Children

Bipolar disorder in children and teens is difficult to recognize because it does not precisely fit the symptom criteria established for adults, and its symptoms can resemble or co-occur with those of other common childhood-onset mental disorders. In addition, symptoms of childhood bipolar may be initially mistaken for normal emotions and behaviors of children and adolescents. But unlike normal bipolar symptoms and mood changes, bipolar disorder significantly impairs functioning in school, with peers, and at home with family.

There appears to be an equal number of male and female children with bipolar disorder but males are more frequently referred for treatment.

In their book The Bipolar Child: The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder, Demitri and Janice Papolos suggest the following symptoms of bipolar disorder in children:

Very common in childhood bipolar:

• Separation Anxiety
• Rages and Explosive Temper Tantrums (lasting up to several hours)
• Marked Irritability
• Oppositional Behavior
• Frequent Mood Swings
• Distractibility
• Hyperactivity
• Impulsivity
• Restlessness/ Fidgetiness
• Silliness, Goofiness, Giddiness
• Racing Thoughts
• Aggressive Behavior
• Grandiosity
• Carbohydrate Cravings
• Risk-Taking Behaviors
• Depressed Mood
• Lethargy
• Low Self-Esteem
• Difficulty Getting Up in the Morning
• Social Anxiety
• Oversensitivity to Emotional or Environmental Triggers

Common symptoms in bipolar children:

• Bed-Wetting (especially in boys)
• Night Terrors
• Rapid or Pressured Speech
• Obsessional Behavior
• Excessive Daydreaming
• Compulsive Behavior
• Motor & Vocal Tics
• Learning Disabilities
• Poor Short-Term Memory
• Lack of Organization
• Fascination with Gore or Morbid Topics
• Hypersexuality
• Manipulative Behavior
• Bossiness
• Lying
• Suicidal Thoughts
• Destruction of Property
• Paranoia
• Hallucinations & Delusions

Less frequent symptoms for children with bipolar disorder:

• Migraine Headaches
• Bingeing
• Self-Mutilating Behaviors
• Cruelty to Animals

It's important to remember a childhood bipolar diagnosis is an expert opinion and not all experts will agree on what fits a child best. As more is learned about bipolar disorder in children, diagnoses and treatments are likely to change.

(Read here: how is bipolar disorder diagnosed in adults?)

How Common is Bipolar Disorder in Children?

The true number is not known as there are no diagnostic criteria defined for bipolar disorder in children and there is insufficient study data. However, one estimate suggests bipolar disorder affects 0.2% - 0.4% of children.²

There is a real concern, however, of the overdiagnosis of bipolar in children. Recent U.S. trends show as much as a 40-fold increase in bipolar diagnosis in youth under the age of 20 and four times the number of inpatient psychiatric hospitalizations of youth with bipolar disorder.³

Other Illnesses in a Bipolar Child

Bipolar kids may be misdiagnosed or have co-occurring illnesses. Even when a child's behavior is unquestionably not normal, correct diagnosis remains challenging. Bipolar disorder is often accompanied by symptoms of other psychiatric disorders. Attention deficit/hyperactivity disorder (ADHD) appears to be the most common in bipolar children with almost 90% of children with bipolar disorder also having ADHD.

Additional diagnoses that mask or sometimes occur along with bipolar in children include:

• Depression
• Conduct disorder (CD)
• Oppositional-defiant disorder (ODD)
• Panic disorder
• Generalized anxiety disorder (GAD)
• Obsessive-compulsive disorder (OCD)
• Tourette's syndrome (TS)
• intermittent explosive disorder
• Reactive attachment disorder (RAD)

Find more information on these and other childhood psychiatric disorders.

Treatment of Bipolar Disorder in Children

A good treatment plan for child bipolar disorder includes:

• Medication
• Close monitoring of symptoms
• Education about the illness
• Counseling or psychotherapy for the individual and family
• Stress reduction
• Good nutrition
• Regular sleep and exercise
• Participation in a network of support.

Utilizing a comprehensive treatment plan leads to the best chance of childhood bipolar recovery. Factors that contribute to a better treatment outcome include:

• Access to competent medical care
• Early diagnosis and treatment
• Adherence to medication and treatment plan
• Flexible, low-stress home and school environment
• Supportive network of family and friends

Medication for children with bipolar disorder is similar to that given to adults with bipolar disorder. Bipolar medication choices include mood stabilizers and antipsychotics for bipolar like:

• Lithium
• Valproic Acid(Depakote)
• Aripiprazole (Abilify)
• Carbamazepine (Equetro)

Medications in bipolar children are generally off-label because very few drugs are FDA approved for the treatment of children.

The good news is with appropriate treatment and support at home and school, many children with bipolar disorder achieve a marked reduction in the severity, frequency and duration of episodes of illness.

This bipolar quiz can help tell you if you're experiencing a bipolar episode. The quiz specifically looks for evidence of bipolar mania but not bipolar depression. You might also want to check out the quiz for bipolar depression.

Bipolar disorder is a serious mental illness that should be diagnosed by a doctor and treated as soon as possible. While no quiz for bipolar disorder can make a formal bipolar diagnosis, if the results suggest you're experiencing a manic episode, you should discuss the results of this bipolar quiz with a healthcare professional as soon as possible.

Quiz for Bipolar Disorder Mania

Please indicate whether or not you experience any of the following:

1. I have a decreased need for sleep.

Yes No

2. I have much more energy than usual.

Yes No

3. My thinking is speeded up.

Yes No

4. I feel unusually euphoric and "high."

Yes No

5. I can't seem to stop talking.

Yes No

6. I can't keep my mind on one thing--I jump from task to task.

Yes No

7. I have a heightened interest in sex.

Yes No

8. I am irritable and short-tempered.

Yes No

9. I have a close blood relative who has had a serious emotional illness or alcohol abuse.

Yes No

10. I think about dying or killing myself.

Yes No

Bipolar Quiz Results

Keep in mind that no online bipolar quiz is definitive. The results of this bipolar disorder quiz should be discussed with a professional if bipolar disorder is suspected.

Add the number of times that you answered "yes" to the test.

If you answered "yes" to question 10, you should seek help immediately, regardless of your answer to any other questions.

Scores between 0 and 4.

Interpretation: These scores generally indicate a normal pattern. However, if the symptoms are severe enough to interfere with your daily routine, consult your doctor or a qualified mental health professional. If you answered "yes" to question 10, you should seek help immediately, regardless of your answer to any other questions.

Scores between 5 and 10.

Interpretation: If you experience five or more of these symptoms for longer than two weeks or if the symptoms are severe enough to interfere with your daily routine, consult your doctor or a qualified mental health professional. If you answered "yes" to question 10, you should seek help immediately, regardless of your answer to any other questions.

Note that this inventory can only give results based on the limited number of questions asked in the inventory. It cannot account for the truthfulness of the answers, only for the self-reporting of each participant. The interpretations given are for informational and educational purposes only, and do not constitute or substitute for any psychological and medical evaluations performed by a qualified professional, nor for any psychological or medical treatment. If you need psychological or medical evaluation or treatment, immediately consult a qualified professional.

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How Bipolar Disorder Affects Everyday Life

Effects of bipolar disorder can be far-reaching, both into the lives of patients and those around them. Bipolar disorder affects work, school, relationships, physical health and many other aspects of everyday life. In fact, in the early 1990s, it was calculated that the loss of productivity due to bipolar disorder cost $15.5 billion annually.¹

The most severe effect of bipolar disorder is suicide. Unfortunately, 25% - 50% of people with bipolar disorder attempt suicide and 11% commit suicide.¹

The best way to lessen the effects of bipolar disorder is an accurate, professional bipolar diagnosis and early, appropriate bipolar treatment.

Psychological Effects of Bipolar Disorder

Bipolar disorder is a mental illness known as a mood disorder (read: what is bipolar disorder). In mood disorders, the patient suffers from severe emotional states. In bipolar disorder, the patient suffers from "highs" known as mania or hypomania and "lows" or bipolar depression.

Psychological effects of bipolar are broken down by the type of episodes the person is experiencing. Symptoms during mania / hypomania may include:

• Auditory and visual hallucinations
• Delusions, including delusions of grandeur and thoughts that objects are sending special messages
• Intense anxiety, agitation, aggression, paranoia
• Obsessive worried thoughts and feelings; feeling the need to check something
• Feeling like life is spinning out of control
• Heightened mood, exaggerated optimism and self-confidence
• Racing thoughts; rapidly changing streams of thought; easily distractible

(Read more information about bipolar manic episodes.)

Vast psychological effects are also seen during depressive episodes:

• Prolonged sadness
• Feeling helpless, hopeless and worthless; feelings of guilt
• Pessimism, indifference; reoccurring thoughts of death and suicide
• Inability to concentrate, indecisiveness
• Inability to take pleasure in former interests

(Read more information about Severe Bipolar Depression: Is There Anything That Can Help?)

When the person is not in either type of episode, it's common for them to feel guilt and shame over what they have done, said or felt during the bipolar episode.

Physical Effects of Bipolar Disorder

The physical effects of bipolar disorder come from both the disorder itself as well as its indirect effects. For example, many people with bipolar disorder also develop substance abuse problems in an attempt to medicate the symptoms of bipolar disorder.

The effects of bipolar disorder can also result in negative productivity - in depressive episodes, but productivity can actually increase during hypomanic episodes.² This irregularity often leads to job loss and emotional instability results in relationship loss. Physical effects of bipolar disorder include:

• Increased physical and mental activity and energy; hyperactivity
• Significant changes in appetite and sleep patterns
• Trouble breathing
• Racing speech
• Social withdrawal
• Loss of energy, persistent lethargy; aches and pains
• Unexplained crying spells
• Poor overall health
• Weight gain; blood pressure and heart problems; diabetes

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What Causes Bipolar Disorder?

There may be no single cause of bipolar disorder. Instead, scientific research indicates the causes of bipolar disorder are probably a combination of biochemical, genetic and environmental factors that may trigger and perpetuate the chemical imbalances in the brain.

Biochemical Changes May Cause Bipolar Disorder

In trying to uncover the causes of bipolar disorder, scientists have used brain imaging scans and other tests. From these tests, researchers have discovered that some people with bipolar disorder share the following traits:

• biochemical imbalances of hormones and certain neurotransmitters in the brain; especially dopamine, serotonin, norepinephrine, and acetylcholine.¹
• an over-secretion of cortisol, a stress hormone.
• a super-fast biological clock that may disrupt the sleep-wake cycle. Sleep abnormalities have been linked to triggering symptoms of bipolar depression and bipolar mania.

Genetics: A Primary Cause of Bipolar Disorder

In searching for the answer to what causes bipolar disorder, scientists report genetics may be one of the key culprits, as bipolar disorder seems to run in families. Here are some important statistics on bipolar genetics:

• First-degree relatives of people with bipolar disorder type 1 are seven times more likely to develop bipolar 1 over the regular population.
• Children of a parent with bipolar disorder have a 50% chance of having a major psychiatric illness. Children remain at an increased risk even if they are raised in the home of parents without the illness.
• Identical twin studies show if one twin has bipolar 1, the other twin has between a 33% - 90% chance of also having bipolar type 1.

Multiple genes, involving several chromosomes, have been linked to the development of bipolar disorder.

Causes of Bipolar Disorder and Schizoaffective Disorder

What causes bipolar disorder may also be involved in schizoaffective disorder. Researchers have been investigating whether common biologic factors are involved in the cause of bipolar disorder and schizophrenia, schizoaffective and manic syndromes, as schizophrenia and bipolar disorder are similar in many respects. These disorders share the following charactertistics:²

• Age of onset
• Lifetime risk
• Course of illness
• Worldwide distribution
• Risk for suicide
• Genetic susceptibility

Scientists are also identifying a number of common genetic and biologic pathways shared by both schizoaffective and bipolar disorders. Commonalities between disorders include:

• Genetic abnormalities have been found in the genes for specific brain cells (oligodendrocyte-myelin-related) (also present with major depression)
• Abnormalities in the white matter in parts of the brain (also present with major depression)
• Genetic abnormalities for both diseases appear on many of the same chromosomes.
• Pathways of the neurotransmitter dopamine appear to be important in both illnesses.

Causes of Bipolar Disorder and Epilepsy

For many years, medications used to treat epilepsy have also been used to treat bipolar disorder, leading to research into the shared causes of bipolar and epilepsy. One explanation is that those who are susceptible to bipolar disorder overreact to normal "neurological assaults" like those from drug abuse or stress. Over time, this acts like the same kind of brain damage seen in those with certain types of epilepsy.

Bipolar Linked to Substance Abuse

Those with bipolar disorder also have a higher rate of substance abuse than in the average population. In 2003, the CLOCK gene, which works to regulate the circadian rhythm, was also shown to be linked to the cause of bipolar and substance abuse in animal studies.³

See Also:

What Causes Bipolar Depression

What Does Bipolar Depression Feel Like

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How is bipolar disorder diagnosed? This is one of the first questions most people ask when they’re showing bipolar symptoms. Unlike with other, more common, mental health conditions like depression and anxiety, you cannot walk into your doctor’s office and leave with a bipolar disorder diagnosis.

Bipolar disorder is complex, and it shares traits with other conditions such as major depressive disorder and borderline personality disorder. Misdiagnosing bipolar disorder, and consequently mistreating bipolar disorder, can be dangerous, so how do you know you've got the right diagnosis? Find out how bipolar disorder is diagnosed and who is qualified to make the call.

How Is Bipolar Disorder Diagnosed, and How Long Does It Take?

For bipolar disorder to be diagnosed, your symptoms must meet the diagnostic criteria set out by the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), published by the American Psychiatric Association. In addition to comparing your symptoms to this criteria, your doctor may also perform other tests (try this online bipolar test).

A bipolar disorder diagnosis consists of a thorough evaluation, usually taking place over several appointments. No one test can detect bipolar disorder, but an assessment of your symptoms may include:

• Physical exam: Your doctor may perform a physical exam and run blood tests to rule out any medical issues that could be causing or contributing to your symptoms.
• Mood charting: You may be asked to record your moods over a period of weeks or months so that your doctor can chart your symptoms of mania/hypomania and depression.
• Psychiatric assessment: You will most likely be referred to a psychiatrist who will assess your behavioral patterns, ask questions about your and your family’s history of mental illness and examine any other contributing factors.

If a child or teenager is suspected of having bipolar disorder, the diagnostic process may be different. In this case, a referral to a child psychiatrist and specialist treatment is usually recommended.

Who Can Provide a Bipolar Diagnosis?

Now we've examined how bipolar disorder is diagnosed, let's look at who is qualified to provide a diagnosis.

Your primary care provider is unlikely to be able to diagnose bipolar disorder. Because bipolar is relatively uncommon, affecting only 2.8% of the population, and because treatment is so specific, it should only be diagnosed by a medical doctor who specializes in mental health. In most cases, a psychiatrist or psychologist is most qualified to assess whether you meet the bipolar diagnosis criteria.

Bipolar Misdiagnosis: Why Does It Happen?

Bipolar disorder is frequently misdiagnosed. According to recent medical research, around 20% of people with bipolar disorder may be mistakenly diagnosed with depression. This occurs because the symptoms of bipolar II disorder are similar to those of major depressive disorder, with most people experiencing more depressive episodes than periods of hypomania.

What's more, unlike full-blown mania, hypomania is easy dismissed as someone being "normal" or seeming more productive and sociable than usual. Some people misunderstand the symptoms of bipolar disorder and think they can't possibly have the condition because their mood changes don't follow a regular pattern.

Bipolar disorder doesn’t always present as we see it in movies and on television. If you think you’re experiencing symptoms of bipolar disorder, such as episodes of depression and mania or hypomania, you must consult your doctor, who will refer you for help and treatment.

Is Bipolar Under or Over-Diagnosed?

Many people believe that bipolar II is under-diagnosed and that more people have the condition than we realize. On the other end of the spectrum, some researchers believe that bipolar disorder is over-diagnosed because of the pressures put on doctors not to “miss” symptoms. Aggressive marketing of mood-stabilizing medications by pharmaceutical companies could also be to blame, according to a 20-year research review that was published in 2016.

Misdiagnosis can be dangerous, not simply because of unmanaged symptoms of mania or depression. If you are misdiagnosed with depression and prescribed antidepressants when you actually have bipolar disorder, for example, your medication may trigger symptoms of mania. What's more, someone who believes that they have treatment-resistant depression (TRD) may never receive appropriate treatment for what is actually bipolar disorder.

Bipolar Self-Diagnosis: Is It Possible?

Meeting the symptom criteria for a bipolar diagnosis is not enough to determine that you have the disorder. The only way to know for sure that you have bipolar disorder is to be diagnosed by a trained and qualified mental health professional; even then, it’s important to keep a check on your symptoms and be referred back for regular check-ups. Bipolar disorder is easy to misdiagnose, and its symptoms do change and evolve over time.

The dangers of bipolar self-diagnosis include:

• Going untreated: Most people with bipolar disorder are treated with a combination of mood stabilizers, antipsychotic medications and talk therapy. If you are not correctly diagnosed and your symptoms remain untreated, you could put yourself at risk – particularly if you experience mania and/or major depression.  
• Substance abuse: Many people with bipolar I or II avoid alcohol and non-prescription drugs to avoid triggering manic or depressive episodes. Without proper treatment, however, mania often leads to alcohol and drug misuse, which can be fatal.
• Relationship challenges: Bipolar disorder can cause behavioral symptoms such as hypersexuality, poor decision-making and erratic, impulsive speech and actions. If you don't treat these symptoms, they can lead to relationship problems that in turn isolate you from your support network.
• Financial stress: Impulsive spending is one of the hallmark symptoms of a manic or hypomanic episode. Left unmanaged, this symptom can leave you in financial jeopardy and cause you to lose assets, such as your house, car or savings.
• Other physical and mental health challenges: Aside from the short-term effects of a bipolar self-diagnosis, there are also long-term risks, such as more frequent episodes, ongoing delusions, worsening of symptoms and other related illnesses like alcoholism, insomnia and even cardiac symptoms.

The process of a bipolar diagnosis is long and complex precisely because the risks of misdiagnosis and self-diagnosis are so great. Although you may come across tests or questionnaires online claiming to provide a bipolar diagnosis, there is only one way to access the right diagnosis and treatment, and that is by consulting your doctor and requesting a psychiatric referral.

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Manic episodes are a period of extremely elevated mood and are required for a diagnosis of bipolar disorder type 1. Bipolar manic episodes are not just feeling "good" or "high," they are moods that are beyond reason and cause major distress and life impairment. Some of the symptoms of a manic episode include:

• Extreme, grandiose self-esteem; a perceived connection with god; belief in god-like powers
• Extreme elation or irritability
• Spending or gambling sprees, drug use, dramatic increase in sexual behavior
• A rapid stream of ideas thought to be brilliant
• Either behavior with extreme focus on goals or complete distractibility
• Not sleeping, or sleeping very little

(More comprehensive information on bipolar mania.)

This mood must be present for at least one week and not be explainable by drug abuse or any other illness in order to be diagnosed as a manic episode. Manic episodes may be brought on by stressful life events, lack of sleep, drug use, medication changes or nothing at all.

What Do Manic Episodes Feel Like?

Because manic episodes can cause great elation or great irritability, manic episodes can be perceived as pleasant or unpleasant. For some with a grandiose, elated mood, a manic episode is a pleasurable experience. They feel very good about themselves and engage in pleasurable behavior, like spending money or having sex. They believe they are extremely creative and intelligent and can constantly create with no need for sleep. They feel above all others.

For some though, and sometimes within the same manic episode, a person feels extremely irritable with all those around them. They may feel special and brilliant but be extremely annoyed with others for not understanding their genius. Someone in a manic episode may be particularly angry if their goal-directed behavior is interrupted. The longer someone is in a manic episode, the more likely they are to become irritable. This irritability feels uncontrollable and can increase to rage.

In both cases, the person's behavior feels "right," obvious and makes very clear sense, even if it makes no sense to those around the patient or is extremely risky. Those in a bipolar manic episode often endanger themselves because of these behaviors and require emergency intervention. After a manic episode, it may be possible for the patient to see how unrealistic, unreal and out-of-touch with reality they were, but this isn't possible during a manic episode.

What Do Bipolar Manic Episodes Look Like?

The energy felt inside a manic episode is seen on the outside too. People in bipolar manic episodes are often "buzzing" about the room, moving and talking quickly, often going from one idea, or one person, to another. They can be seen laughing and smiling without cause.

Three-quarters of manic episodes involve delusions¹ wherein the person truly believes in ideas beyond reason or logic. This is often seen as they brag about impossible abilities, god-like power or creative genius. They may be so sure of their grandiose powers that they demand others follow and obey them, and become enraged, even violent, if they don't. They may defend themselves violently if they feel threatened. Manic episodes may even, very rarely, result in homicide.

Other outward cues of a manic episode include:

• Clothes put on in haste, disheveled
• Unusual clothing that attracts attention
• May be openly combative and aggressive with no tolerance for anyone
• Hyper-vigilance
• Making bad decisions in all aspects of life; no insight

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Manic symptoms are some of the most devastating in bipolar disorder and often land patients in the hospital. Bipolar mania is the elevated mood, or the highs, associated with bipolar disorder.

What Are Some Manic Symptoms?

Bipolar mania is associated with bipolar I, where the person experiences both the highs and depressed lows. The diagnosis of a manic episode is defined as being at least one week long, and severely impacting someone's daily life. Bipolar manic symptoms include:

• extreme elation
• irritability
• expansiveness (acting in a larger-than-life manner)

Other manic symptoms required for diagnosis include at least three of the following:¹

• A large sense of self; overwhelming and unrealistic self-esteem
• Reduced need for sleep
• Rapid, incessant, excessive talking
• Rapid and rapidly changing thoughts
• Being easily distracted
• Excessively engaging in pleasurable activities like sex, spending sprees, gambling; often with negative consequences
• Increase in goal-focused activity at home, at work, or sexually

In order to be diagnosed with bipolar disorder mania, these manic symptoms cannot otherwise be explained by substance abuse or another illness.

Impact of Manic Symptoms

Some manic symptoms sound pleasurable and can even be perceived that way by the person with bipolar disorder. However, the problem with bipolar disorder mania is that the behaviors and thoughts are taken too far to the extreme and result in dangerous consequences.

It is common for bipolar manic symptoms to include the feeling of god-like power. The person feels that they can control everything around them or have a direct line to God. The person may start preaching his perceived powers or do things to prove his powers such as attempt to fly by jumping from a roof. Gambling and spending sprees, as a result of bipolar mania, often leave a person with huge bills and no way to pay them. Bipolar mania is often intercepted by police when the patient's behavior becomes so risky as to endanger others, such as driving while intoxicated. It's at this time, the person with bipolar disorder is often taken to the hospital for emergency bipolar treatment.

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Rapid cycling bipolar disorder can be a dangerous condition and carries a high risk of suicide. When a person with bipolar experiences four or more manic, hypomanic, or depressive episodes in any 12-month period, it's defined as rapid cycling bipolar. While the term rapid cycling may make it sound as if the episodes occur in regular cycles, episodes actually often follow a random pattern. Because of the rapid mood swings associated with this type of bipolar disorder, the individual may feel as if they're on an emotional roller coaster; swinging from the highs of mania to the depths of depression -- all in the course of a few days or even hours.

Any type of bipolar disorder can be rapid cycling. It is thought between 10% -20% of people with bipolar disorder rapid cycle.²

Understanding Rapid Cycling Bipolar Disorder

Bipolar disorder is characterized by episodes of bipolar depression and either mania or hypomania, as in the case of bipolar type 2. Episodes must last a minimum length of time:

• Four days for hypomania
• One week for mania
• Two weeks for depression

While those are minimum lengths of time, many people with bipolar disorder spend more, sometimes considerably more time in an episode. On average, people have between 0.4-0.7 episodes per year, lasting three to six months.¹ Between episodes, there may be periods of normalcy (without an elevated or depressed mood). Rapid cycling bipolar disorder is the dramatic speeding up of these cycles.

(Read more on the diagnosis of bipolar disorder.)

Rapid Cycling Bipolar Disorder Symptoms and Effects

While the DSM-IV-TR only defines one type of rapid cycling, particularly short cycles are also known to occur. Ultra-rapid cycling denotes episodes only lasting days and ultradian indicates multiple episodes per day.

Rapid cycling bipolar disorder can be more difficult to detect than standard bipolar disorder as patients, particularly those with a short hypomanic cycle, may see the hypomania as simply a rare "good mood" rather than an actual mood episode. Since they spend more time depressed, they are often misdiagnosed with depression.

The hallmark symptoms of rapid cycling bipolar are mood and energy changes that are out of control and disabling. The person may experience severe irritability, anger, impulsivity, and uncontrollable outbursts.

Treatment of Rapid Cycling Bipolar Disorder

People who experience rapid cycling bipolar are hospitalized more often and their symptoms are usually more difficult to control over the long term.

Rapid cycling is more common in people with type 2 bipolar disorder and people with bipolar 2 have been shown to spend 35 times more time depressed than hypomanic. Because of this, rapid cycling treatment tends to be focused around relieving the depression.

While antidepressants would seem to be the logical choice for treatment of a depressive episode, antidepressants can often make rapid cycling worse. Antidepressants for bipolar depression can induce cycling, create more rapid cycling or even induce a manic episode.

Mood stabilizers are the preferred treatment for rapid cycling bipolar disorder with the aim to stop the cycling and then bring the mood up if needed. Common mood stabilizers used in the treatment of rapid cycling bipolar disorder include:³

• Anticonvulsants like valproic acid (Depakote) or Carbamazepine (Tegretol)
• Antipsychotics, normally newer generation antipsychotics like Quetiapine (Seroquel) or Aripiprazole (Abilify)
• Lithium

Anticonvulsants are typically the first choice mood stabilizers as both valproic acid and carbamazepine have been shown effective in treating rapid cycling bipolar disorder. If an antidepressant is used, it is used in combination with a mood stabilizer to prevent further cycling. Antidepressants are typically tapered once the depression is under control.

One medication, Symbyax, is a combination of Olanzapine (Zyprexa) and fluoxetine (Prozac). This combination of an antipsychotic and an antidepressant may be useful in improving depressive symptoms without destabilizing mood.

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Detailed info on side effects of antipsychotic medications..

What is Tardive Dyskenesia (TD)?

I'd like to define this antipsychotic side-effect first, as all discussions of antipsychotic drugs make reference to tardive dyskinesia. Tardive Dyskinesia, or TD, is a side-effect that was especially prevalent in the older antipsychotics described below. TD involves involuntary repetitive movements often in and around the mouth such as moving the tongue around. It's a serious side effect as it can be permanent. Over many years of taking the older antipsychotics described below, 25% develop TD. Tardive means the side-effect can show up even after the drugs are stopped. Dyskinesia refers to the movement itself.

History of Antipsychotics: From Thorazine to Atypical Antipsychotics

Before the 1950's, psychiatric hospitals were not as they are today. Patients, especially those with psychosis, were often strapped down to beds and wheelchairs in the halls of overflowing psych wards. They were given strong sedatives, as there were no effective medications for psychosis. Though this does sound, and often was cruel, psychosis was so little understood and the behavior was often so agitated that the patients had to be either restrained or calmed in some way.

In 1954, the drug Thorazine (chlorpromazine) was the first medication specifically targeted for the treatment of psychosis. The effect of Thorazine on psychosis treatment simply cannot be overemphasized. It revolutionized the mental health world and hundreds of thousands of those treated with the drug went from living in institutions to returning to the public world. Thorazine helped clear the mind, increased emotional responsiveness and even worked for those who had been psychotic for years.

Of course, there is always a cloud over any revolutionary breakthrough. The side-effects of Thorazine were intense for many and sometimes permanent due to tardive dyskinesia. And furthermore, what is known as the 'deinstitutionalization' of psychiatric hospitals after the introduction of Thorazine actually put many people on the street who were not able to survive on their own. This is a problem that exists today.

Similar Thorazine-type antipsychotic drugs such as Haldol and Trilaphon soon followed. Once again they worked but the side-effects, including tardive dyskinesia, restlessness, sedation, and blunted emotions, were strong. It wasn't until the 1990s with the introduction of Zyprexa (olanzapine), Risperdal (respiridone), and Seroquel (quetiapine) that the risk of tardive dyskinesia was reduced. In the early 2000s, two new drugs Geodon (ziprasidone) and Abilify (aripiprazole) were introduced soon followed by Invega (paliperidone) and the newest from 2009 called Fanapt. These new antipsychotics were called 'atypical' in order to differentiate them from the older (typical) medications.

It was originally thought that the creation of the atypical antipsychotics meant that they were not only superior in terms of side-effects due to less TD, but that they were actually more effective than the older drugs. The findings of a recent study by the National Institute of Mental Health called the CATIE study disputes these beliefs. (CATIE stands for Clinical Antipsychotic Trials in Intervention Effectiveness.)

Dr. Preston explains:

"There is now controversy over whether the new atypical antipsychotics are actually more effective than the older drugs. The CATIE study found that the older drugs were just as good. The only difference between the two is the side-effect profile and especially the risk of tardive dsykenesia. The atypicals definitely have a lower risk of TD, but the two classes of drugs actually share many side-effects. So it often comes down to what a person can tolerate. Research clearly shows that if one antipsychotic doesn't work or the side-effects are too difficult to tolerate, it's essential that the person try other medications. Even if they are from the older class of drugs. "

Antipsychotics: Approved and Off-Label Use

Even though all of the antipsychotics available on the market can be used to treat bipolar psychosis, none are specifically approved for bipolar psychosis treatment by the Food and Drug Administration. Instead, certain antipsychotics are approved for either mania, depression or maintenance (relapse prevention.) Of course, antipsychotics are regularly prescribed for bipolar psychosis treatment. This is called off-label use and is very common and simply means that the drugs are prescribed, but are not officially approved by the FDA for psychosis. Thorazine (1973), Zyprexa (2000), Risperdal (2003), Seroquel and Abilify (2004) and Geodon (2005) have FDA approval for mania. Seroquel was approved for bipolar depression in 2007. Zyprexa and Abilify were approved for maintenance treatment in 2004 and 2005 respectively.

Antipsychotic Medication Side-Effects

There is no question that antipsychotics can be life-saving and life altering drugs for people with bipolar psychosis. The problem is that antipsychotic medications can cause significant side-effects. The most common being akathisia (extreme physical agitation), lethargy, dulled thinking and weight gain. Fortunately, many of these side-effects can be lessened and even prevented by the correct drug choice and dosage.

Unfortunately, as a few of these new drugs have now been on the market for almost ten years, a new side-effect pattern has emerged called metabolic syndrome. This syndrome involves weight gain around the middle as well as diabetes, heart disease risks and other related symptoms. All people on antipsychotics need to be monitored for metabolic syndrome as the effects can be very serious. On a positive note, unlike with TD, metabolic syndrome can be caught early and reversed once the person goes off the antipsychotic.

Antipsychotics and Weight Gain

While TD and metabolic syndrome-related diabetes and heart problems may be the biggest side-effect concern for health care professionals, it's usually the weight gain that upsets people with bipolar disorder the most. For example, Zyprexa is a very effective antipsychotic, but studies show that the average weight gain is 20 pounds! Once again, it's a trade-off. For some, the trade-off is weight gain vs. not being able to work or having to go to the hospital. It's not an easy choice. It may be that the person can change from a drug that causes weight gain to one that has less weight gain tendencies. It's all about working with a healthcare professional to find what works for you.

Important Note on Antipsychotic Medication Side-Effects

Antipsychotic drugs are very strong drugs. Many say that the drugs make them feel like a zombie and, in some cases, a very agitated zombie. As always, it's a trade-off.

I have a friend who has been on a high dose of antipsychotic medication for three years. When she goes down on the dose, the manic psychosis comes back. It's a dilemma. She is significantly dulled by the drugs and gained a lot of weight around her stomach- but the manic psychosis is far more serious. She tried other antipsychotic medications until she found the one that works the best. But now her doctor is worried about TD.

I am not telling this story to scare you. She is doing better every day, but it's important not to sugar coat what we go through due to these medications.

I have another friend who has been on mood stabilizers for years. When she added an antipsychotic medication to the mix, she told me she felt normal for the first time in her life- and she had no side-effects. It's truly an individual process.

Here is a note from Dr. Preston on how antipsychotic drugs affect each person differently:

"Antipsychotics have different side-effect profiles. Abilify is known to cause agitation with little weight gain while Zyprexa can be very sedating and cause significant weight gain. And yet, they are both very effective drugs for managing bipolar psychosis. If one antipsychotic doesn't work, it's important to try another and then microdose onto a new one by trying a small amount of the medication until it works and you can tolerate the side-effects. It would be a shame to try one antipsychotic and have a bad reaction and then not try another. It's very hard to treat bipolar psychosis without medications."

Antipsychotic Treatment in Bipolar Disorder

The main use of these drugs is in combination with other bipolar disorder treatment drugs (eg: Lithium, Depakote, Tegretol or Lamictal). Antipsychotic medications are more commonly used to treat Bipolar I due to the high incidence of psychosis with full-blown mania, though people like myself who have Bipolar II with a lot of mild to moderate psychotic depression often take antipsychotics as well. It usually takes a cocktail of medications for most people to successfully manage bipolar disorder and antipsychotics are an important part of the mix.

We truly have come a long way since the 1950's medication management of bipolar psychosis. With the advent of new medications, there is even more hope that psychosis can be managed easily and effectively. When you combine this information with a strong and healthy lifestyle, psychosis management and prevention are truly possible.