Date Published: September 22, 2021
Jonathan’s mood took a dark turn in his 20s. Jonathan, who has autism and intellectual disability, began talking a lot about fires and death. He struggled to complete tasks that he used to perform easily. He put forks and dishes in the trash, instead of the dishwasher, and put his dirty napkin in the refrigerator.
Then, he had little sleep for days, and he stopped talking. When he later saw his mother, he was happily surprised that she was alive, although he had no reason to think otherwise. His doctor referred him to a clinic that specializes in developmental disabilities. The diagnosis: bipolar disorder.
Jonathan’s story, which was described in a research article,1 is not unique. Compared to other people, adults with autism are at higher risk for bipolar disorder, a serious mental health condition that often begins in a person’s teens or 20s. Bipolar disorder affects about 1 in 10 adults with autism spectrum disorder (ASD).2,3 That rate is from three to six times greater than found in people who don’t have autism, according to studies.
What is Bipolar Disorder?
Bipolar disorder involves “dramatic shifts in mood, energy, and activity levels” that affect someone’s ability to complete daily tasks, according to the U.S. National Institute of Mental Health. The person may experience manic episodes, in which he does not sleep, becomes overactive, and has unusual thoughts, along with episodes of depression. Some people with bipolar disorder have delusions.
“In its classic form, bipolar disorder is one of the most severe psychiatric disorders that can co-occur in persons with autism spectrum disorders (ASDs),” wrote two child psychiatrists at the University of Michigan.4
The suicide rate for people with bipolar disorder is 15 times higher than in the general population, according to the diagnostic manual used by American psychiatrists.
Nonetheless, bipolar disorder has received “relatively little attention” in autism research articles, compared to other conditions, autism researchers wrote in the International Review of Psychiatry. They noted that bipolar disorder, which is less common in children than in adults, affects from 1 to 2 percent of youth with autism.5
Although about 10 percent of autistic adults have bipolar disorder, many more have other psychiatric conditions. A study of 2,900 autistic adults in the SPARK research study found that 41 percent have an anxiety disorder, 39 percent have attention deficit hyperactivity disorder (ADHD), 24 percent have obsessive compulsive disorder, and 20 percent have depression.3
Fewer participants, almost 4 percent, have schizophrenia, a condition that often includes delusions or hallucinations. The SPARK study involved adults who have legal guardians.
“There is increasing evidence that the risk of psychiatric disorders in general is raised among individuals with ASD and that applies to both common psychiatric disorders ― anxiety, ADHD ― and other neurodevelopmental disorders,” says the study’s lead researcher, Eric J. Fombonne, M.D., a child psychiatrist and professor at Oregon Health and Science University.
Diagnosing Bipolar Disorder
Doctors may face challenges when diagnosing a psychiatric condition in patients with autism, particularly if they cannot describe their symptoms or feelings. Doctors often have to figure out which behaviors are part of autism and which are caused by something else.
“When evaluating the prevalence or incidence of bipolar disorder among individuals with ASD, it is also important to be aware of the dangers of misdiagnosis,” Fombonne says.
People with autism may have periods of irritability, aggression, pacing, hyperactivity, and loss of sleep that can look like symptoms of bipolar disorder. A psychiatrist reviews a person’s symptoms and examines whether there is a cycle of changing moods over time.
Having distinct periods of irritable or overactive behavior and sleeplessness, and other periods of depression, may suggest bipolar disorder. But if the irritable behavior and sleep problems, for example, are “chronic and persistent,” they may be related to autism, according to some researchers.5
Psychiatrist Robert Wisner-Carlson, M.D. says that he asks about symptoms that might point to bipolar disorder when he is evaluating adults who have both autism and depression.
“There’s some evidence that the incidence of bipolar disorder may be higher in people with autism, so you also have to be looking at that. Has the person had periods that meet the criteria for mania or that partially meet those criteria? And is there a family history of bipolar disorder? That’s important information to get,” he says. Wisner-Carlson, who was interviewed in 2020, is chief of the Autism and Neurodevelopmental Outpatient Program at Sheppard Pratt psychiatric hospital in Towson, Maryland.
Some studies suggest that bipolar disorder may be genetic, and it may run in families. In addition, autism, bipolar disorder, and schizophrenia may occur in different members of the same family, according to some studies.
People with autism were more likely than others to have a parent, sister, or brother with bipolar disorder or schizophrenia, according to a study of families in Sweden and Israel.6
Genetic studies have found several genes that are linked to bipolar disorder, autism, and schizophrenia.7,8
How is Bipolar Disorder Treated?
Bipolar disorder is treated with medication and therapy. Psychiatrists often prescribe drugs that stabilize a person’s mood, along with “second-generation” antipsychotic drugs. Some of those antipsychotics are also approved to treat irritable and aggressive behavior in autism.
Antidepressants can trigger manic episodes in some people with bipolar disorder, so they may be combined with a mood stabilizing drug to treat depression in those people, according to the National Institute of Mental Health.
Diagnosing Youth Carefully
A bipolar diagnosis in youth needs to be made carefully, Fombonne says. “In the last 20 years, the diagnosis of bipolar disorder has been, to some extent, used very liberally among youth, leading to a number of youth being incorrectly labeled as ‘bipolar’ and treated as such. The last thing we want for the ASD population, is to be overdiagnosed and treated with complex medications that would not be necessary,” Fombonne says.
Read about Bradley, a young SPARK participant with bipolar disorder and a genetic diagnosis.
- Rysstad A.L. et al. Int. J. Dev. Disabil. Epub ahead of print (2020) Article
- Croen L.A. et al. Autism 19, 814-823 (2015) PubMed
- Fombonne E. et al. J. Autism Dev. Disord. 50, 3679-3698 (2020) PubMed
- Ghaziuddin M. and N. Ghaziuddin Child Adolesc. Psychiatr. Clin. N. Am. 29, 433-441 (2020) PubMed
- Rosen T.E. et al. Int. Rev. Psychiatry 30, 40-61 (2018) PubMed
- Sullivan P.F. et al. Arch. Gen. Psychiatry 69, 1099-1103 (2012) PubMed
- Goes F.S. et al. JAMA Psychiatry 73, 590-597 (2016) PubMed
- O’Connell K.S. et al. Mol. Cell Neurosci. 88, 300-307 (2018) PubMed