Irritability & Bipolar Disorder

Question: My child gets so oppositional and defiant sometimes. His therapist tells me this is a symptom related to his bipolar, but I don’t understand. How is that connected?


Answer: This is a question people ask all the time about kids and bipolar. The truth is that in the DSM (Diagnostic and Statistical Manual of Mental Disorders) the symptoms listed for bipolar disorder reflect the way the disorder impacts adults. There isn’t any specific criteria written in there for children except for two small “notes”:

    • Note: In children, consider failure to make expected weight gain,” accompanies the criteria about weight changes, and
    • Note: In children and adolescents, can be irritable mood,” in relation to depressed mood. 


This brief notation minimizes the degree to which irritability plays a significant role in the depressive, manic, and hypomanic mood states of bipolar disorder as well as in anxiety. 


The short answer is that kids and teens with bipolar disorder often don’t have the capacity to understand what is happening to them when symptoms hit. This can cause them to be reactive and irritable with an elevated stress response when they are symptomatic. 


    • Irritability in a depressive episode, generally speaking involves increased irritability accompanying low energy levels. It can look like reluctance to comply with requests, defying or ignoring instructions, refusal to participate in activities, argumentativeness, low frustration tolerance, or an inability to complete assigned tasks, with  
    • Irritability in an manic episode, generally speaking involves increased irritability accompanying high or escalating energy levels. It can look like a quick temper, argumentativeness, rapid escalation of energy, focusing on a frustration or something distressing, or an inability to “let something go” or be redirected. All of these behaviors apply to a hypomanic episode as well, only they are somewhat less intense. 
    • Irritability from anxiety, generally speaking does not involve changes in energy levels, although it can accompany energy increases or decreases depending on the mood state. It can look like an inability to be redirected, refusal to consider alternatives, fixation on their own desires, argumentativeness, or self-absorption. 


From the outside, to adults who are present, this may seem to be irrational or can be perceived as willful, intentional, disrespectful, or manipulative chosen behaviors. But this is most certainly not the case. For the child or adolescent with bipolar disorder, ‘FOH’, or other mood disorders they are actually the victim of their illness and the active flare-up of symptoms over which they have no control. Treating this symptomatic irritability as a choice, and meeting it with discipline or punitive consequences does nothing to support the child, nothing to reduce the symptom flare-up, and nothing to modify the so called “behaviors”. Additionally, it actively damages the child or adolescent’s self-esteem, reinforcing the misperception that they are a “bad kid” because they have an illness. 


The longer answer involves understanding the exhausting and spiraling impact of the stages of the stress response and the fact that individuals with bipolar disorder are constantly being thrown into this stress response due to their overly-taxed stamina reserves. 

    • Alarm
    • Resistance
    • Exhaustion


The Alarm Stage triggers the fight-flight-freeze response which can cause any of those three responses to occur. This can happen regardless of whether or not the trigger is perceived or understood by others. 


The Resistance Stage starts as the fight-flight-freeze response starts to diminish. But the body is still on high alert, waiting for any other threats that might be on the heels of the first. If threats (even misperceived ones) are happening one after the other, and have overlapping recovery periods, then the body stays on high alert all of the time and continues to produce stress hormones that keep the cycle going. Signs of an ongoing resistance stage are:

    • Irritability,
    • Low frustration tolerance, and
    • Low concentration levels.


The Exhaustion Stage is the logical consequence of the previous two stages. In this stage the avalanche of ongoing stress drains the child or adolescent’s mental, physical, and emotional resources. At this point stress tolerance drops even further, with an inability to cope with even the smallest of setbacks, and levels of anxiety, fatigue, and depression all rise. 


It’s easy to see how these factors combine to make irritability a hallmark, and often misunderstood, feature of bipolar disorder and its symptom presentation. 


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