Recognising the Early Signs of Bipolar Disorder in Adolescents

Bipolar disorder is a mental health condition characterised by extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). These mood swings can vary in intensity and duration, significantly impacting mood, energy levels and behaviour.

There are two main phases of bipolar disorder:

• Depressive Phase: Depressive episodes are characterised by feelings of sadness, hopelessness, worthlessness and loss of interest or pleasure in activities that were once enjoyed. Other symptoms may include changes in appetite and sleep patterns, fatigue, difficulties concentrating and thoughts of self-harm or suicide.
• Manic Phase: During manic episodes, individuals may experience elevated mood, increased energy, racing thoughts and a decreased need for sleep. They may also engage in impulsive or risky behaviours, such as excessive spending, reckless driving or substance abuse.

Hypomania is a milder version of mania that usually lasts for a shorter amount of time. Similar to mania, it is also characterised by excitability, over-activity and high-energy behaviour.

The phases of bipolar disorder can vary in how severe they are and how long they last. They can affect an individual’s energy levels, behaviours, cognitions and ability to function.

Adolescent-Onset Bipolar Disorder

Adolescence is the period of life when people are at greatest risk of developing bipolar disorder. Adolescent-onset bipolar disorder refers to when the onset of the disorder begins during adolescence (typically between the ages of 12 and 18). During adolescence, the individual may begin to experience symptoms, such as severe emotional highs and lows. The symptoms of bipolar can have a significant impact on an adolescent’s life and can impact their:

• Daily functioning.
• Education.
• Relationships with their peers.
• Relationships with their family members.
• Overall quality of life.

Bipolar disorder can make it difficult for an adolescent to maintain healthy relationships with their friends, family members and teachers and they may find it difficult to engage with school and follow school rules. Manic and depressive episodes can affect classroom behaviour, make it difficult to concentrate, cause an adolescent to be more impulsive and irritable and can cause sleeping difficulties, all of which can affect their education.

Adolescents with bipolar disorder are also at significantly higher risk of engaging in self-harm, substance abuse and high-risk behaviours. They are also more likely to experience suicidal thoughts and commit suicide. 

Bipolar disorder can be more difficult to diagnose in adolescence because of the hormonal changes that occur during puberty. Hormonal fluctuations during puberty can exacerbate mood swings and emotional volatility and make it harder to differentiate between normal hormonal changes and typical adolescent behaviour and the symptoms of bipolar disorder. This can lead to a misinterpretation of the symptoms and a delay in diagnosis.

Additionally, adolescents may be less likely than other age groups to self-identify or self-report their symptoms. They may be hesitant to seek help for mental health issues due to the stigma or a lack of awareness about bipolar disorder. This can mean that unless symptoms are correctly identified by family members or teachers, the disorder goes undiagnosed, meaning the adolescent has no access to appropriate support and treatment. Bipolar disorder also often coexists with other mental health conditions such as ADHD, anxiety disorders or substance abuse disorders in adolescents. The presence of comorbid conditions can obscure the underlying bipolar symptoms and make diagnosis more challenging.

The presentation of bipolar disorder symptoms may vary depending on the stage of adolescent development. For example, younger adolescents (ages 12-14) may exhibit more externalising behaviours such as irritability and aggression, may be more impulsive and may demonstrate academic and behavioural problems. Middle adolescents (ages 15-17) may have increased mood swings, engage in more risk-taking behaviours and have more social and relationship difficulties, whereas older adolescents (ages 18 and above) may display more classic symptoms of bipolar disorder such as mood swings and depression and may be more aware of their symptoms, compared to younger adolescents.

Early Signs of Mania

Identifying the earlier signs of mania can help an individual to access appropriate treatment and support and prevent the manic episode from progressing and symptoms from worsening. 

Some of the early signs of mania in adolescents include:

• A sudden increase in energy levels.
• A reduced need for sleep.
• Excessive talking (including talking non-stop, jumping from one topic to another and speaking rapidly).
• Impulsive behaviour and decision-making.
• Engaging in risky behaviours with little regard for personal safety.
• Feelings of grandiosity or increased self-esteem and delusions of self-importance.
• Feeling euphoric.
• High levels of creativity and activity.
• Reduced appetite and weight loss.
• Racing thoughts.
• Feelings of irritability, impatience or aggression.
• Reduced inhibition.
• Making grand and unrealistic plans.
• Poor concentration and being easily distracted.
• Experiencing delusions or hallucinations.

Early Signs of Depression

The early signs of the depressive phase in adolescents include:

• Persistent feelings of sadness or emptiness that are disproportionate to the situation or have no apparent cause.
• A loss of interest in normal activities, such as hobbies and sports.
• Reduced participation in class activities.
• Reduced academic performance and lower achievement.
• Withdrawing from family and friends and isolating themselves.
• Changes in appetite and weight.
• Disruptions to normal sleep patterns, including difficulties falling asleep, waking up frequently in the night or sleeping excessively.
• Feeling persistently tired or low in energy.
• Feelings of worthlessness or excessive guilt.
• Impaired cognitive functioning, such as difficulties concentrating, memory issues or difficulties making decisions.
• Thoughts of self-harm or suicide.

Cycling Between Phases

Adolescents with bipolar disorder may experience rapid cycling between manic and depressive phases, a pattern characterised by frequent and abrupt shifts in mood. Unlike the more typical pattern of bipolar disorder where mood episodes last for weeks or months, rapid cycling involves four or more mood episodes within a year.

These rapid shifts can be particularly challenging for adolescents as they can disrupt their daily functioning, relationships and overall well-being. During manic phases, adolescents may exhibit symptoms such as elevated mood, increased energy, decreased need for sleep, impulsivity and sometimes even psychotic features like hallucinations or delusions. In contrast, during depressive phases, they may experience sadness, irritability, fatigue, changes in appetite or sleep patterns, feelings of worthlessness or guilt and thoughts of self-harm or suicide.

The unpredictability of these mood swings can make it difficult for adolescents to manage their symptoms and maintain stability in various aspects of their lives, including academic performance, social interactions and family relationships. Treatment typically involves a combination of medication, psychotherapy and lifestyle adjustments aimed at stabilising mood, managing symptoms and improving overall functioning. Close monitoring by mental health professionals is essential to track mood fluctuations and adjust treatment strategies accordingly.

Social and Academic Impact

Bipolar disorder can be a debilitating condition for adolescents and can have a significant impact on both their social life and their education. Some ways bipolar disorder can impact an adolescent’s life can include:

Social Impact:

• Withdrawal from friends
  During depressive episodes, adolescents with bipolar disorder may withdraw from social interactions and isolate themselves from friends and peers. They may feel overwhelmed by feelings of sadness, hopelessness or worthlessness, which can make it difficult to engage in social activities.
• Increased risk of conflict
  During manic or hypomanic episodes, adolescents may experience irritability, impulsivity and difficulties regulating their emotions. This can lead to conflicts with friends and peers. Their behaviour may also become unpredictable or erratic, which can result in more strained relationships.
• Unpredictability
  The unpredictable nature of the mood swings that often occur with bipolar disorder can make it challenging for adolescents to maintain stable friendships. Friends may struggle to understand or cope with the sudden changes in behaviour and mood, which can lead to strain, distancing and the ending of relationships.
• Stigma and misunderstanding
  Adolescents with bipolar disorder may face stigma or misunderstanding from their peers due to the symptoms of the disorder. If their friends or peers do not understand bipolar, this can lead to social rejection, bullying or feelings of isolation, which can further exacerbate social difficulties. An adolescent with bipolar may also feel embarrassed about their diagnosis and worry that other people will judge them, so may try to hide their condition or isolate themselves from others.

Academic Impact:

• Decline in academic performance
  The symptoms of bipolar disorder, such as mood swings, fatigue, difficulties concentrating and impulsivity, can significantly impact academic performance. Adolescents may struggle to focus in class, complete assignments or study for exams during depressive or manic episodes. Students with bipolar disorder typically complete fewer years of education and are less likely to attend higher education.
• Increased absences
  Adolescents with bipolar disorder may miss school or arrive late due to sleep disturbances, emotional distress or difficulties sticking to routines during manic or depressive episodes. Repeated absences and lateness can lead to an adolescent falling behind in their work, lower grades and academic disengagement.
• Difficulties maintaining routines
  Bipolar disorder can disrupt daily routines and habits, making it challenging for adolescents to consistently attend classes, complete homework assignments or participate in extracurricular activities. This can not only negatively affect their education but also their social life and overall mental health.
• Negative feedback from teachers
  Teachers may notice changes in behaviour or academic performance and provide negative feedback or disciplinary action. This can further contribute to stress and anxiety for the adolescent.
• Difficulties concentrating
  Manic and depressive episodes can result in difficulties concentrating, memory difficulties and poor problem-solving skills. Additionally, some bipolar medications can have side effects that impact an adolescent’s education, including slower energy levels, cognitive dulling, increased fatigue and physical symptoms, such as nausea.
• Misdiagnosis
  As mentioned earlier, bipolar disorder is more difficult to diagnose in adolescence. Many adolescents with bipolar disorder are misdiagnosed or undiagnosed which prevents them from receiving appropriate support in school, including interventions and additional time and provisions during exams. Not having an accurate diagnosis can also mean teachers do not understand and make allowances for the individual’s behaviour. For example, they may label them as lazy or disruptive.

Early intervention and support from mental health professionals, school staff and family members can help to address the social and academic challenges associated with bipolar disorder in adolescents. Educating the individual and others about bipolar, implementing an effective treatment plan and making provision in the school environment can help adolescents manage their symptoms, improve social functioning and succeed academically. Creating an understanding, empathetic and supportive network of peers, family members and educators can help reduce stigma and promote acceptance in the school community.

Family History and Genetic Factors

Family history and genetic factors can play a significant role in the development of bipolar disorder in adolescents. Bipolar disorder has a strong genetic component, meaning that adolescents who have a family history of the disorder are at a higher risk of developing it themselves. The risk is even higher if a close family member, such as a parent or sibling, has bipolar disorder.

However, even if you have a close family member who has bipolar disorder, this does not mean you will definitely develop it. Bipolar disorder is a complex disorder influenced by multiple genes. While specific genes associated with bipolar disorder have been identified, the inheritance pattern is not straightforward. It involves interactions between multiple genetic variants and environmental factors. This makes it challenging to predict who will develop the disorder based solely on genetic factors.

While genetics can play an important role in the development of bipolar disorder, environmental factors also contribute to its onset and course. Environmental factors can interact with genetic vulnerabilities to trigger the onset of bipolar symptoms in susceptible individuals. This can include:

• Stressful life events, such as the breakdown of a relationship or the death of a loved one.
• Trauma, for example physical, sexual or emotional abuse.
• Substance abuse.
• Disruptions in early childhood development.
• Chemical imbalance in the brain.
• Exposure to certain infections.
• Complications during pregnancy.
• Traumatic brain injuries.

A family history of bipolar disorder serves as an important risk factor for identifying adolescents who may be at increased risk of developing the disorder. During an assessment for bipolar disorder, doctors usually enquire about family history to help guide diagnosis and treatment decisions. Adolescents with a family history of bipolar disorder may benefit from closer monitoring, increased education about the disorder and early intervention if symptoms emerge.

Substance Use and Self-Medication

Many adolescents with bipolar disorder are at an increased risk of turning to substance use as a form of self-medication, to help them cope with their mood swings and associated symptoms. Adolescents with bipolar disorder are at a higher risk of developing comorbid substance use disorders compared to their peers. Substance use can worsen the symptoms and prognosis of bipolar disorder and increase the likelihood of the adolescent experiencing complications such as psychiatric hospitalisations, dangerous behaviours and suicidal thoughts.

The behaviours associated with substance use can complicate the diagnosis and treatment of bipolar disorder, particularly because substance use can mask or mimic the symptoms of bipolar disorder and make it challenging to differentiate between the effects of substance use and the underlying mood disorder. Adolescents with co-occurring bipolar disorder and substance use disorders often present with complex clinical presentations that require integrated treatment approaches. Dual diagnosis treatment involves addressing both bipolar disorder and substance use disorder concurrently, which may necessitate specialised care from mental health and addiction professionals.

Substance use can exacerbate symptoms of bipolar disorder and trigger mood episodes. For example, stimulant drugs like cocaine or methamphetamine can induce manic or hypomanic symptoms, while depressant drugs like alcohol or opioids can worsen depressive symptoms. This can lead to a cycle of substance use and mood instability, further complicating diagnosis and treatment.

Substance use can also interfere with the effectiveness of medication and psychosocial treatments for bipolar disorder. Adolescents who misuse substances may have difficulties taking their medication regularly, attending therapy sessions or engaging in healthy coping strategies, which can make their treatment plan less effective in their response to treatment and their recovery. 

To address the risk of substance use in adolescents with bipolar disorder, it is essential for clinicians to conduct thorough assessments, including screening for substance use and addressing any co-occurring substance use disorders. Treatment should be comprehensive and tailored to the individual’s specific needs. Additionally, education about the risks of substance use and the importance of following their treatment plan can help empower adolescents and their families to make informed decisions about their health and well-being. 

Seeking Professional Help

If you are a parent or caregiver and notice any persistent and concerning mood changes in your adolescent, seeking professional help is important for early detection and more successful management of bipolar disorder. If you are concerned your child may have symptoms of bipolar disorder, your first step will be to visit your GP. Your GP will likely ask about their symptoms and may look at their medical history and family history. If they think they may have bipolar, your child will be referred for a specialist assessment, most likely with a psychiatrist. A psychiatrist can differentiate between normal mood fluctuations and symptoms that indicate bipolar disorder, ensuring an accurate diagnosis.

If you receive a diagnosis, a psychiatrist can recommend appropriate interventions and treatment, including medication management, psychotherapy and psychoeducation. Early intervention is key to improving outcomes and preventing complications associated with untreated bipolar disorder. Mental health specialists tailor treatment plans to meet the specific needs of each adolescent with bipolar disorder. When creating the treatment plan, they will consider factors such as: 

• Symptom severity.
• The age of the adolescent.
• Any co-occurring conditions.
• Family dynamics.
• Cultural considerations.

Psychiatrists and other mental health specialists can also conduct thorough risk assessments to identify any potential risks of self-harm or suicide in adolescents with bipolar disorder. They can develop safety plans and provide support to mitigate these risks and ensure the safety and well-being of the adolescent.

Mental health specialists provide ongoing monitoring and follow-up care to track the adolescent’s response to treatment, adjust interventions as needed and address any emerging issues or concerns. Regular appointments with a mental health specialist are essential for managing bipolar disorder effectively and preventing relapse.

Seeking professional help for a child or adolescent with bipolar disorder can be overwhelming for parents and caregivers. However, mental health specialists can offer support, guidance and education to caregivers, which can empower them to navigate the challenges of caring for a loved one with bipolar disorder. 

Treatment Options 

Without effective treatment, the manic phase of bipolar disorder can last for between three and six months and a depressive phase can last as long as 12 months. Bipolar treatment aims to reduce the severity of the adolescent’s symptoms and the frequency and duration of manic and depressive episodes. This helps to improve daily functioning, for example at school, at home and in social situations, and improve the quality of life.

Treatment plans are usually tailored to the individual person but can include:

Medication:

Lithium:

Lithium is the main type of medication used in bipolar treatment in the UK. Lithium can be effective in treating bipolar and preventing episodes of mania, hypomania and depression. It can also help to reduce self-harming behaviours.

Mood stabilisers:

Mood stabilisers should be taken every day on a long-term basis and can help to regulate mood swings and prevent episodes of mania or depression. Mood stabilisers may be prescribed if the adolescent experiences rapid cycling. 

Antipsychotics:

This medication may be prescribed to help manage and reduce the symptoms of mania or psychosis associated with bipolar disorder. Some popular antipsychotic medications include:

• Haloperidol
• Olanzapine
• Quetiapine
• Risperidone

Anticonvulsants:

Anticonvulsants are similar to long-term mood stabilisers and are often used to treat mania and hypomania. Common anticonvulsant medications include:

• Valproate
• Carbamazepine
• Lamotrigine

Antidepressants:

In some cases, antidepressant medications may be used to treat depressive symptoms. However, because taking antidepressants alone can lead to a relapse, they will likely only be prescribed alongside mood stabilisers or antipsychotics to prevent inducing manic episodes.

Taking medication as prescribed and regularly monitoring any side effects is essential. You will likely have regular medication reviews to check you are taking the correct dose and that your medication is working effectively. 

Psychotherapy: 

Cognitive behavioural therapy (CBT): 

CBT can help adolescents with bipolar disorder learn coping skills, how to recognise and challenge negative thought patterns and how to develop strategies for managing stress and mood symptoms. CBT for bipolar disorder can help to: 

• Increase the adolescent’s understanding of their diagnosis.
• Learn how to identify links between their thoughts, feelings and behaviours.
• Identify and restructure negative patterns of thought.
• Identify potential triggers.
• Develop coping strategies.

Family-focused therapy: 

Family-focused therapy is a type of talking therapy that can help to improve family relationships and the individual mental health of each family member. It involves educating families about bipolar disorder, improving communication and problem-solving skills and creating supportive family relationships to improve the adolescent’s treatment outcomes.

Psychoeducation: 

Providing adolescents and their families with education about bipolar disorder, including information about symptoms, treatment options and strategies for managing the disorder, can empower them to actively participate in treatment and make informed decisions about their care.

Lifestyle Interventions:

Lifestyle interventions and self-help techniques can be effective, alongside formal treatment, in helping adolescents with bipolar disorder and their family members to manage their symptoms, reduce the impact of bipolar on their everyday life and improve their quality of life. 

Some lifestyle changes you can make include:

Healthy lifestyle habits 

Following a healthier lifestyle can help to reduce the symptoms of bipolar disorder. Encouraging adolescents with bipolar disorder to follow healthier habits can help to stabilise their mood and improve their overall well-being. This can include: 

• Follow a regular sleep schedule.
• Engage in regular physical activity.
• Eat a balanced diet.
• Avoid alcohol and recreational drugs.

Stress management techniques 

Teaching adolescents relaxation techniques, mindfulness and stress reduction strategies can help them cope with triggers and stressors that may worsen their mood symptoms. Some stress management techniques include:

• Yoga.
• Meditation.
• Mindfulness.
• Deep breathing.
• Guided imagery.

Talking 

Talking about their diagnosis can be extremely beneficial in helping an adolescent realise they are not alone and that they have a support network to help them. Some adolescents prefer to talk to their family and friends about their diagnosis and the effects of bipolar on their lives, whereas others prefer to talk to other people with the same diagnosis. They may choose to join a support group to connect with other people with bipolar disorder and educate themselves more on their diagnosis. Some support groups and charities they can contact include:

• Bipolar UK.
• Young Minds.
• Rethink Mental Illness.
• Action for Children.