Thursday, 7 September 2017

Bipolar Spectrum Disorder Comorbid with Autism Spectrum Disorders

Very few studies have investigated the characteristics of individuals with Bipolar Disorder (BD) comorbid with Autism Spectrum Disorders (Austism, Asperger's Syndrome, and Pervasive Developmental Disorder). Both conditions are independently associated with a high degree of morbidity; combined they represent some of the most challenging conditions faced by clinicians, educators and caregivers. Challenges exist not only in differentiating psychiatric symptoms from characteristics of the developmental disorder but also in the identification of effective strategies to help support students diagnosed with these conditions.

Bipolar disorder affects about 1% of children and is characterised by severe mood swings between mania and depression. Some of the symptoms, such as irritability and aggression, are also common in autism. While many large-scale research studies of bipolar disorder exclude ASD patients for methodological reasons, a study in the June issue of the Journal of Clinical Psychiatry suggests that as many as 30% of children diagnosed with BD may also have autism. Other studies have found that as many as 27% of those with autism also have symptoms of bipolar disorder. By contrast, its prevalence in the general population is around 4%.

Autism Spectrum Disorders (ASD) are characterised by significant impairment in communication, and social interaction, and are associated with stereotyped, repetitive, and idiosyncratic behaviors, interests, and activities. Psychiatric comorbidity is often present, particularly disruptive behavior disorders and learning disorders.

Frazier et al highlights the difficulty involved in ascertaining the rate of comorbidity between AS and BD since the diagnosis of AS has been used rather indiscriminately, referring to a heterogeneous group, and the actual incidence of pediatric BD is probably underestimated until the definition of bipolarity in children is more fully agreed upon. Another challenge is that BD often begins in childhood or early adolescence with the clinical features of unipolar depression, acute psychosis, or comorbid disorder (e.g., ADHD, obsessive-compulsive disorder (OCD), panic attack, or eating disorder), while manic symptoms appear later. As a consequence, the rate of bipolar diagnosis, can increase with the mean age of studied population. The current classification of mood disorders has poor reliability and validity. It has been suggested that the differential diagnosis between unipolar depression and BD should be based on the lifetime presence of four days of hypomania. Information on mild symptoms overlapping with manifestations of well-being is subject to recall bias, unreliable evaluation, misinterpretation, incoherence. Furthermore, the source of information (patient, relatives, social institutions) can suggest different conclusions. Notwithstanding such gray area, growing evidence suggests that PDD and BD frequently co-occur.

Interestingly, a family history of BD may influence the phenomenology of students with PDD. In students with autism spectrum disorder and a family history of BD, many features of childhood BD have been observed, including affective extremes, cyclicity, obsessive traits, neuro-vegetative disturbances, special abilities, and regression after initial normal development. On the other hand, students with autism spectrum disorder and without a family history of BD showed less florid agitation, fearfulness, and aggression, and were of lower functioning.

The American Psychiatric Association (2000) describe the Criteria for Manic Episodes as a distinct period of an abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week. While depression can be quite obvious, it can be more challenging to recognise mania in a student with Autism.

Gary Heffner has identified what the Criteria for Manic Episodes may looks like in a student with a comorbid diagnosis of BP and ASD. During periods of mood disturbance, the following criteria may be present to a significant degree:

Inflated self-esteem or grandiosity 
When a student cannot talk or has a communication disorder, it may be hard to identify this symptom. Many children act like they are in charge of the world anyway. What you may see in a student with autism is a marked improvement in the child's usual mood. The student may seem overly happy, silly, or laugh inappropriately or even hysterically. A student who once feared certain situations may show no fear. The student may show irritability rather than a good mood. Behavior may become more aggressive than usual. Tantrums may increase dramatically. The student may act like the rules no longer apply to him or her. The student may act as if he or she has "super powers". The student may say he or she will report others to the principal or to the police, etc.

Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 
Many children with autism have sleep issues to begin with so this may be a difficult symptom to track. What you may see in a student with autism is that the child may not sleep at all or their normal sleep times are decreased significantly. Alternatively, since sleep is usually a pleasurable activity, the student may sleep too much in the beginning of a manic cycle. Many children and adults with Bipolar Disorder have a "crash" after a manic phase and may not want to get out of bed at that time.

More talkative than usual or pressure to keep talking 
For students who have a communication disorder this symptom would not seem to apply. However, many children and adults with autism and Bipolar Disorder show an increase in their speech and vocalizations during a manic cycle. Many parents report the "good news" that their child is suddenly more verbal only to later report that the child is driving them crazy with the accompanying manic behavior. Children with autism may use more words, talk/vocalize faster than normal, be difficult to stop or interrupt, and/or may talk through the night.

Flight of ideas or subjective experience that thoughts are racing 
The child's interest in activities may increase dramatically. The student will be restless, bombard you with "requests" for activities or other things, and will flit from one activity or thought to another. If the student is verbal he or she may be able to talk about their many conflicting thoughts and interests. Their speech may make no sense, may be a series of unrelated sentences or words, or may be songs or rhymes that have little relation to what is going on. They may be expressed as extreme hyperactivity.

Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) 
Attention is too easily drawn to unimportant or irrelevant external stimuli. Many children with autism and ADHD have this symptom already. However, in a manic cycle the distractibility would be more than usual. May focus on unusual aspects of objects that are different from their usual interests.

Increase in goal-directed activity (socially, at work or school, or sexually) 
It may be impossible to redirect ritualistic behaviors. Once the student starts an activity he or she is almost impossible to stop. He/she may repeat activities over and over (with more intensity than usual). The student may masturbate or engage in other sexual activity to an extreme degree.

Excessive involvement in pleasurable activities that have a high potential for painful consequences
Examples involve unrestrained buying sprees, sexual indiscretions, or foolish business investments in an adult context. As above, sexual activity/interest may be taken to the extreme. The child may sleep excessively, self stimulate excessively, eat excessively, toilet excessively, or engage in any other pleasurable behavior with more frequency and intensity.