- There are presentations highly correlated to bipolar development, like teens or young adults with intense, atypical major depression.
- Moodiness is not synonymous with bipolar disorder, and it's poor practice to conclude that a moody youth is developing the illness.
- Researchers are learning more about bipolar disorder genetics, but no blood test exists.
- Catching bipolar disorder early can reduce the number of mood episodes someone experiences, which can intensify with each successive cycle.
Anyone jumping to conclusions that a moody juvenile is bipolar is acting prematurely. In fact, a perusal of the literature (e.g., Stringaris et al., 2009; Duffy et al., 2020; APA, 2022) will uncover information that childhood moodiness is not a good predictor of future bipolar illnesses.
A hot topic of research in recent decades (e.g., Huntley-Jones et al., 2006; Bauer et al., 2008; Correll et al., 2014; Kessing et al., 2017; Rabelo-de-Ponte et al., 2020) both observational and potential genetic evidence have been considered as the silver bullet to catching it early. Despite a growing understanding of the disorder, the general conclusion is that there are no psychiatric crystal balls for bipolar disorders.
Given my work evaluating kids in the juvenile courts, I've been asked more than once if bipolar disorder can be detected early. This is usually because some kids present as inordinately moody, which leads probation officers and parents, succumbing to pop culture ideas about bipolar disorder, to reflexively think the kid is developing it.
My answer is invariably, "It depends."
If the relatively rare instance occurs of a juvenile exhibiting a sharply-defined manic, hypomanic, or mixed episode(s), or if an unfailing genetic test is ever created, we can unquestionably say it's been detected. Barring these situations, as readers will see, we're largely left to be mindful of correlates and remain vigilant observers.
Importance of Early Detection
Like schizophrenia, bipolar disorders are known to harbor a "kindling effect," making early detection an important topic. Kindling effects in psychiatry are like the kindling of fires; a smaller fire is initiated to encourage a more intense one. In affective disorders, this would mean that previous mood episodes set the stage for successive ones to develop faster and perhaps be more intense (e.g., Post, 2021; Goodwin & Ghaemi, 2022), and the sufferer eventually doesn't return to premorbid functioning during remission. Clearly, catching the condition as soon as possible can have immense effects on prognosis. Unfortunately, bipolar disorders are primed for misdiagnosis, adding a layer to the challenge.
Ripe for Misdiagnosis
Bipolar disorders are among the most over-diagnosed (e.g., Ghouse et al., 2013; Zimmerman, 2020) and missed-diagnosis (e.g., Rakofsky et al., 2015; Stiles et al., 2018) conditions in mental health care and it's vitally important that providers understand what constitutes bipolar disorders is if they're to identify it.
Bipolar spectrum illnesses are not simply a pattern of moodiness, as popularly perceived. Socially, we hear, "That's so bipolar," if someone who is normally calm becomes irritable during a bad week. Professionally, I have observed that "ruling out bipolar disorder" is not an unusual preliminary diagnosis, even for kids, simply based on moodiness.
This seems especially true if someone says the kid has an allegedly bipolar family member. While genetic loading is high in actual bipolar disorder (e.g., McIntyre, 2020), just because someone says a family member is bipolar doesn't mean it's true. It could be self-diagnosed or, given the aforementioned misdiagnosis by professionals, just such a case.
It must be realized there is a palette of other, more common conditions with "moodiness" that should be considered. In particular, people with personality disorders, especially borderline, are prone to regularly exhibiting highly reactive moods. In fact, borderline personality is at particular risk of being misdiagnosed as bipolar disorder (e.g., Ruggero et al., 2010; Morgan & Zimmerman, 2014; APA, 2022), followed by trauma sufferers, people with ADHD due to low frustration tolerance, and people with sensory-integrative complications.
In short, bipolar disorders are just that: moods of distinct polarity. There are periods of endogenously-generated depression, followed or preceded by (hypo)mania and/or mixed episodes. This isn't to say that environmental stressors, especially if they engender a stretch of poor sleep (e.g., Mondimore, 2014; Steardo et al., 2019), can't contribute to the evolution of episodes, but it takes more than disappointment in a friend to set episodes in motion.
Further, these mood episodes last for days or weeks, not minutes or hours. Though "ultradian cycling" is a popular idea and possible, providers are encouraged to remain extremely cautious of applying this specifier, as written about in "Thinking twice About Ultra-Rapid Cycling."
Outside of cyclothymia, as written about in "The Bipolar Condition You Don't Hear About," bipolar disorders generally do not provide a baseline, "everyday" pattern of moodiness. Even in cyclothymia, a cycling of "soft" depression and a few hypomanic symptoms every few days, it is distinctly different from someone whose moods are reactive to their environment/interpersonal relating. Thus, it’s essential that providers evaluate for mood episode duration, triggers, and patterns before settling on bipolar disorder diagnoses. Of course, they can be comorbid with other "moody" disorders, but that is not license for using bipolar disorder as a catch-all diagnosis. Many disorders share symptoms, but that doesn't mean they're treated similarly.
Vigilance Is the Best Practice
Though there's no crystal ball, the following are strong correlates of bipolar disorders, and their presence should heighten clinician awareness of the potential emerging illness.
- Bipolar disorders tend to emerge in the teens and early 20s, and the first distinct mood event is apt to be a major depressive episode (MDE). Barring a serious psychosocial stressor (or medical condition mimicking MDE symptoms), given bipolar spectrum illnesses are largely endogenously generated, if someone spontaneously exhibits an MDE, clinicians should monitor for hypo/manic episode development, bearing in mind it could be months or years before emergence.
- Next, the MDE associated with bipolar disorders are often of atypical features (e.g., Lojko et al., 2015; Buzuk, 2016), long-lasting, and intense. This is especially the trend in type 2, as discussed in "The Truth About Bipolar 2 Disorder." Atypical features are MDEs chiefly marked by eating and sleeping more, severe psychomotor retardation ("leaden paralysis"), and mood reactivity (e.g., mood can brighten upon positive news/events/humor).
- The presence of MDE with mixed features can also be a tip-off. As explained in the "Spinning World of Major Depression With Mixed Features," though not everyone who experiences a few hypomanic symptoms during an MDE goes on to evolve into a bipolar disorder, some do. If during an MDE, a patient exhibits some combination of intense restlessness, impulsivity, racing/scattered thoughts, affective lability, and/or appears energized despite little sleep. They are likely suffering from a mixed episode.
- Lastly, hypomania may be subtle. It's, therefore, essential, if bipolar disorder is suspected, to carefully interview the patient and family regarding any history of clearly demarcated days or weeks of hypomanic symptoms. Some individuals, for example, who are not anxious at baseline, report "periods of anxiousness," which to the untrained eye might simply seem nervous. Upon further evaluation, it could be uncovered that this includes not feeling tired despite little sleep, trouble holding thoughts, and bouts of irritability–a package of hypomanic symptoms.
Disclaimer: The material provided in this post is for informational purposes only and is not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care from an individual’s provider or formal supervision if you’re a practitioner or student.
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