Psychiatric Disorders: Bipolar Disorder
Amanda Surdock, M.A.

This is the first in a series of articles discussing the symptoms of certain psychiatric disorders in adults with intellectual disabilities (ID). In this series, we will discuss the symptoms and behavioral effects of specific psychiatric disorders.

Bipolar disorder is a mood disorder with one or more episodes of highly elevated or irritable mood (mania) which usually alternate with depressed episodes. As with all psychiatric disorders, this is only diagnosable if it is a change from current level of functioning, or is interfering with life functioning. Many people will show some signs of mania or depression at certain points, but that does not necessarily mean they have a psychiatric disorder. It is also important to note that bipolar disorder has a cycle, which means that individuals typically move between manic, depressed and normal moods, so someone who presents with constant symptoms with no change, is not necessarily bipolar.

The featured symptom of bipolar disorder is the elevated or irritable mood. In individuals with ID, elevated mood may present as inappropriate laughing or singing, excessive silliness or smiling, and intrusion into others' personal space. Irritable mood may present as aggression, property destruction, or screaming and swearing with little provocation.

Bipolar disorder is more than just a mood disorder; it has other features which significantly impair functioning in the individuals it affects. These symptoms include inflated self-esteem, decreased need for sleep, excessive talkativeness, racing or incoherent thoughts, distractibility, increased goal-directed activities, and excessive involvement in pleasurable activities with potential for painful consequences. We will address each of these symptoms in turn.

In individuals with ID, inflated self-esteem may be difficult to identify. This is usually present when individuals make exaggerated claims about their skills or life circumstances. For example, the individual may claim they have a car or driver's license when they do not, or to be dating or getting married to someone when they are not in a relationship. The important thing to remember is that these claims are different from those they make when not in a manic episode. So someone who makes constant exaggerated claims would not likely be in a manic episode.

Decreased need for sleep is one of the most common manic symptoms seen in individuals with ID and bipolar disorder (Gonzalez & Matson, 2006). This would typically present as someone who only sleeps for 3-4 hours per day, and reports feeling refreshed. This change in sleep is different from their normal sleep patterns, and is not provoked by environmental causes, such as a noisy or restless roommate, or other sleep disturbance, such as excessive napping during the day.

Excessive talkativeness is a symptom of bipolar that can be present even in individuals with limited verbal communication. For those individuals, they may have an increase in screaming, vocalizing or other noise-making activities. For verbally fluent individuals, the excessive talking may be characterized by frequently interrupting others or excessive laughter. In a similar manner, racing thoughts can be difficult to identify in individuals with limited insight into their own thoughts or limited verbal abilities. Observers may notice that the individual jumps quickly from topic to topic in conversation or makes statements that do not make sense. This may also be a sign of increased distractibility, which is another symptom of bipolar disorder.

When an individual demonstrates increased goal-directed behavior, they may appear to be "hyperactive". The individual may walk rapidly, be unable to sit still for long, or pace around. Again, it is important to note that this has to be a change from previous behavior. Some people just naturally walk faster than others or have difficulty sitting still; it is when this behavior is unusual for that individual that we suspect a problem.

The final symptom of bipolar disorder is excessive involvement in pleasurable activities. This is seen less often in ID populations, since many individuals are in controlled environments with restricted access to these types of activities. In the general population, this may be represented by excessive spending, gambling, sexual indiscretions or risky business investments. In the ID population, you might see excessive masturbation (especially in public) or other inappropriate sexual behaviors, shoplifting, or impulsive decision making.

As staff and family members, we spend a lot of time with the residents and have a good idea of what is "typical" behavior for each person. If you notice behavior that is unusual for a particular resident it is important that you notify someone who can help. You can contact clinic staff, the case managers, the behavior specialist, or E&R staff for assistance and information.