Bipolar Disorder is a mental health disorder that consists of episodic periods of elevated and euphoric moods and contrasting periods of low or depressed mood. Most people have at least a basic understanding of what depression looks like. In contrast, the symptoms related to hypomania or mania, such as rapid speech or an elevated mood state, can be harder to identify because they often feel positive, especially in the early stages.
What Is Bipolar Disorder?
Bipolar disorder (sometimes called “Manic Depression”) is a set of symptoms that typically present in episodes and includes contrasting periods of euphoric or high mood states (mania or hypomania) as well as down or depressed mood states. At other times, someone with bipolar disorder may have minimal or no symptoms. Bipolar disorder can be hard to accurately diagnose. In fact, on average, there is an 8-year lag between someone’s first mood episode and accurate diagnosis and treatment.1 This is not ideal because, in general, the longer it takes someone to get help, the worse they do with managing their symptoms.
Bipolar Disorder Symptoms
The symptoms of bipolar disorder differ dramatically depending on the type of mood episode someone is experiencing. Symptoms of mania and depression are essentially opposite mood states. When someone is manic, their mood and energy levels are elevated, whereas someone who is depressed is experiencing low energy and depressed or sad mood states.
Generally speaking, “mania” refers to a euphoric psychological state that is accompanied by other symptoms such as heightened self-esteem, increased motor activity, and pressured speech. Sometimes the mood is predominantly irritable rather than euphoric, but in all cases, there is a noticeable mood change, which is abnormal for the individual. To meet the criteria for a manic episode, when the mood is predominately euphoric, it must be accompanied by three additional symptoms. When the mood is predominately irritable, it must be accompanied by four additional symptoms.
In addition to the change in mood, the common symptoms of mania include:
- Heightened self-esteem. While we typically associate self-esteem as being positive, with mania, the levels of heightened self-esteem are highly extreme and unrealistic.
- Decreased need for sleep. Someone might feel like they don’t need as much sleep or feel unusually rested after only small amounts of sleep.
- Rapid speech. An individual may feel unusually talkative and people around them will likely notice that they are talking a lot and quickly.
- Racing thoughts. Thoughts move rapidly and become hard to keep up with when someone experiences racing thoughts, which often contributes to the rapid speech discussed above.
- Easily distracted. When someone is experiencing this symptom, their attention is constantly shifting around making it hard to complete tasks or engage in coherent conversations.
- Increased goal directed activity. This involves someone increasing their goal directed behaviors or activities whether socially, in social/work or sexually.
- Psychomotor agitation. This symptom feels like being antsy or restless and might be observable in someone through behaviors like pacing or fidgeting.
- Engaging in impulsive or risky behavior. Examples of impulsive behaviors during mania include things like excessive spending, promiscuous sexual activity, and unrealistic business decisions.
When the above symptoms last for at least a week or more, the mood episode is referred to as a bipolar manic episode. If the symptoms last for more than four days, but less than a week, it is called a hypomanic episode.
The symptoms of depression that occur in bipolar disorder are the same as those that occur in typical depression (i.e., unipolar depression).
Specifically, a depressive episode lasts for at least two weeks and consists of a sad, low or depressed mood accompanied by at least some of the following symptoms:
- Loss of interest or pleasure. When experiencing this symptom, someone might find themselves unable to become interested in activities they used to enjoy.
- Difficulty sleeping. This may consist of trouble falling asleep, trouble staying asleep, or both.
- Hypersomnia is the clinical term for sleeping too much. In this case someone would be sleeping more than usual and will still feel tired.
- Feeling restless. This symptom is often described as feeling antsy or keyed up.
- Feeling slowed down. This is described as feeling sluggish or as if you are moving through molasses.
- increased fatigue. Oftentimes when someone is depressed they feel more tired than usual, even when getting sufficient sleep.
- Feeling worthless or guilty. The feelings of worthlessness and guilt that are experienced during depression are often excessive and do not match the realities of the situation.
- Difficulty concentrating. Difficulty concentrating during tasks or conversations is common in depression.
- Thoughts of death or suicide. This is the most serious depressive symptom and should be treated accordingly. The severity of this symptom can range widely, from passing thoughts of death to actual suicide plans.
Symptoms of a Mixed Episode of Bipolar Disorder
A mood episode that is characterized by mixed features consists of a combination of symptoms from polar ends of the mood spectrum. Specifically, there must be at least three symptoms from the opposite polarity. For instance, someone may have a depressed mood, along with racing thoughts, rapid speech, and being easily distracted. Someone else might present with an elevated irritable mood, along with feelings of worthlessness or guilt, loss of interest in things they used to enjoy, and thoughts of death.
Mood episodes with mixed features are common, potentially occurring even more frequently than purely euphoric mania.2 Sometimes referred to as agitated depression, mixed features can increase suicide risk because of the dangerous combination of depression, hopeless, and/or thoughts of death, along with impulsive behavior and increased energy and goal directed activity.3
Types of Bipolar Disorder & Their Symptoms
The types of mood episode(s) an individual has experienced in their lifetime in combination with their most recent mood episode determines which type of bipolar disorder they would meet criteria for. This diagnosis can also change across a lifespan if someone experiences a new mood episode. For instance, many individuals who are initially diagnosed with depression, later meet criteria for a bipolar disorder after experiencing mania.
Bipolar I Disorder
If someone experiences a full manic episode, lasting one week or more, at any point in their lives, they meet criteria for bipolar I disorder. A manic episode consists of a distinct period of abnormally elevated, expansive or irritable mood, accompanied by increased goal directed activity that lasts for at least a week. If the mood shift does not last a full week, the episode is classified as hypomania and the individual likely meets criteria for bipolar II.
When someone’s mood is elevated or expansive during mania, they must also exhibit at least three additional symptoms listed above in the section on symptoms of mania (e.g., inflated self-esteem, being more talkative, and engaging in impulsive or risky behaviors). If their mood is predominately irritable, they need to exhibit an additional four symptoms of mania (e.g., decreased need for sleep, racing thoughts, distractibility, and psychomotor agitation). In severe cases of the illness, individuals may also experience psychotic features (i.e., hallucinations or delusions) while manic. Finally, the mood shift must be significant and severe enough that it impacts the individual’s social or occupational functioning or requires a psychiatric hospitalization to prevent harm to self or others.
Most often, individuals with bipolar I disorder also experience depressive episodes or symptoms of depression, but it is not technically required for the diagnosis. Additionally, it is common to experience episodic mania and depression, as well as periods in their lives without any noticeable symptoms. The severity and frequency of the mania and depression varies and is impacted significantly by how consistent the individual is with treatment.
Bipolar II Disorder
Bipolar II disorder is the correct diagnosis when an individual is currently exhibiting or has exhibited a hypomanic episode and has a history of depression. Similar to mania, hypomania is a period of abnormally elevated mood and increased energy or activity for most the day for at least four consecutive days. The symptoms that may accompany the mood shift in hypomania are exactly the same as the symptoms listed for mania, but are often less severe.
So the primary differentiator between hypomania and mania (and bipolar II versus bipolar I) is the length and severity of the elevated mood and manic symptoms. Because this is the primary differentiator between the two diagnoses, it is not uncommon for someone to initially be diagnosed with bipolar II disorder and then later in life exhibit more severe mania, in which case the diagnosis would shift. Treatment recommendations are generally the same, so this does not necessarily mean a corresponding change in treatment.
Cyclothymia is a disorder characterized by the same symptoms we have been discussing thus far. However, in the case of cyclothymia, the symptoms have never reached the threshold for a full depressive or hypomanic episode. This might be because the individual exhibits less than the three to four symptoms accompanying the mood shift or the periods of depression and hypomania/mania do not last for the specified time frames (i.e., two weeks for depression and four days or hypomania). Otherwise, the illness looks similar day to day. The highs and lows may be less severe, but the symptoms still cause distress or impairment in their lives. For a diagnosis of Cyclothymia, the periods of hypomania and depression symptoms must have persisted for at least a year in children and adolescents and for at least two years in adults.
Late-Onset Bipolar Disorder
Late-onset bipolar disorder describes the onset of bipolar disorder symptoms that occur later in life, typically after age 50. Late-onset bipolar disorder can be challenging to diagnose, as symptoms may be attributed to other medical or psychiatric conditions commonly found in older adults, such as dementia or depression.
Bipolar Disorder Symptoms in Females vs. Males
Although women and men are diagnosed with bipolar disorder at similar rates, there are some notable gender differences. For instance, women typically experience more depressive episodes and different comorbidities.4 The increased rates of depressive episodes can also lead to delayed accurate diagnosis (because it is assumed to be unipolar depression). Women can also face additional medication complications. For instance, there are many problematic drug interactions between mood stabilizers and hormonal contraceptives.
Perhaps the most significant difference between females and males with bipolar disorder is that reproductive events, including miscarriages, pregnancy, and the postpartum period are typically a challenging time for bipolar-related symptoms.5 Due to the unique combination of dramatic hormonal changes, sleep and routine disruption, as well as role and identify shifts it is common for women with bipolar disorder to experience more severe mood symptoms, as well as reemergence of symptoms that may have been previously well managed, sometimes receiving a postpartum bipolar disorder diagnosis. It is also common for severe mood symptoms to occur for the first time during these significant reproductive events.
Early Warning Signs of Bipolar Disorder
Bipolar disorder most typically emerges during the early twenties, so you might see some early warning signs of bipolar in adolescence. The first signs of mania might include getting less and less sleep, having more difficulty paying attention to others in conversations, speaking more rapidly, and sporadic impulsive behavior or irritability. Because typical adolescent development also includes some of the above, warning signs can be difficult to catch before they progress to symptoms.
Once someone has had a hypomanic or manic episode, a large portion of the illness management plan involves developing an understanding of the individual’s own personal warning signs that precede a mood episode. Changes in sleep patterns is a very common warning sign and one that is easily tracked. Similarly, individuals who are receiving treatment for bipolar disorder typically learn to pay close attention to subtle shifts in their moods, activity levels, and behavior patterns as a way to better manage their illness. If someone can anticipate a mood episode coming, they can typically put safeguards in place to reduce the negative impact of the episode. This might look like increasing contact with loved ones and treatment providers and putting safeguards in place for risky or impulsive behavior, like removing credit cards or car keys from their possession.
How Bipolar Disorder Is Treated
Medication is the first line of treatment for bipolar disorder, especially when someone is exhibiting acute symptoms, because medication will be the fastest route to bring the person’s mood back to baseline. However, in the long run, research consistently demonstrates that it is the combination of medication and therapy that helps individuals with bipolar disorder most effectively manage their moods and live a rich and full life with bipolar. It’s possible that bipolar brain scans will also help assist in diagnosing bipolar disorder and developing effective treatment plans.
Mood stabilizers are typically the first line of medication treatment for bipolar disorder because of their effectiveness in reducing the recurrence of mood episodes, especially manic episodes. For example, lithium reduces the rate of mania recurrence by around 50% when examining 1-2 year periods.6 To be classified as a mood stabilizer, medications must effectively treat mania and hypomania, as well as depressive episodes, without causing additional mood cycling.
The types of mood stabilizers include lithium, as noted above, as well as multiple medications initially used as anticonvulsants, such as Valproate (Depakote), Lamotrigine (Lamictal), and Carbamazepine (Tegretol, Carbatrol, or Atretol). Second Generation Antipsychotics, otherwise referred to as atypical antipsychotics, are also increasingly used for their mood stabilizing properties. Some medications in this category include olanzapine (Zyprexa), quetiapine (Seroquel), lurasidone (Latuda), clozapine (Cloazaril), and paliperidone (Invega). Finally, antidepressants are sometimes used to treat depressive symptoms, in combination with a mood stabilizer.
Unfortunately, all psychiatric medications have potential side-effects, ranging from mild stomach irritation or dry mouth to more severe and even lethal symptoms. For instance, lithium, arguably the most effective mood stabilizer, requires regular blood tests in order to monitor dosage because lithium toxicity can be lethal. Additionally lithium should not be taken if pregnant. Fear of side-effects and/or actual side-effects often plays a role in medication noncompliance, which is directly related to worse disease outcomes. Because of this, it is important for individuals with bipolar disorder to communicate with their providers about medication fears and side-effects.
Psychosocial treatments, including therapy and psychoeducation, are also efficacious in the treatment of bipolar disorder and become particularly critical when medication options are limited, such as when a woman is pregnant or breastfeeding, or when medications are not yet optimized due to problems with side-effects. Psychosocial treatments also help improve rates of medication adherence, which is critical in reducing the severity and frequency of mood episodes.
Cognitive Behavioral Therapy
Cognitive Behavioral Therapy (CBT) for bipolar disorder operates from the assumption that our thoughts, behaviors and emotions are interrelated, so making changes in one area of this triad will have a ripple effect. CBT is well established for the treatment of depression and has also been found to be effective in treating bipolar mood dysregulation.7 Common tools used in CBT for bipolar disorder would include identifying and modifying the thinking errors that are common to mania and depression, such as minimizing the risk of impulsive decisions when manic or the tendency to focus on your flaws and struggles when depressed.
Additionally, a CBT therapist would help someone identify their individual warning signs and triggers for depression and mania, such as sleep disruption or periods of schedule change. Finally, when working with depression, the CBT intervention of behavioral activation is highly effective and simply involves the therapist and client working together to increase the individuals’ level of engagement in activity, which is an antidote to depression.
Dialectical Behavior Therapy
Although not developed for the treatment of bipolar disorder specifically, Dialectical Behavior Therapy (DBT) offers some helpful skills for managing mood dysregulation, not acting upon impulse alone and developing increased tolerance of difficult emotions. Although there is limited research in this area, the available studies suggest promising results.8 Additionally, interviews with experts in the field indicate routine use of DBT when treating bipolar disorder.9
Acceptance and Mindfulness-Based Therapies
Acceptance and mindfulness-based interventions, like mindfulness-based cognitive behavior therapy (MBCT), mindfulness-based stress reduction (MBST) and acceptance and commitment therapy (ACT), have all shown strong efficacy in regards to treating depression. Women who are diagnosed with bipolar disorder typically experience more depression than mania, so these skills can provide significant relief, although the approaches do not appear to be effective as a standalone treatment for bipolar disorder.
Additionally, mindfulness-based therapies, and specifically mindfulness-based stress reduction (MBST), are very helpful in managing stress. Research indicates that even brief periods of mindfulness and efforts made to reduce stress can translate into dramatic reductions in physiological markers of high stress, such as heart rate and cortisol levels. This is important for individuals who experience significant mood dysregulation, because high stress is often a trigger for mood episodes, including mania.
Finally, the concept of acceptance, which not surprisingly plays a central role in acceptance and commitment therapy, is critical in the management of bipolar disorder. Learning to accept that you are living with a chronic mental illness is naturally difficult, but it is often a lack of acceptance that underlies the more damaging aspects of bipolar disorder.
Family-focused therapy (FFT), which was developed by Dr. David Miklowitz, is based on the premise that family stress can impact the course of bipolar disorder. This skills-based therapy seeks to help family members improve communication and learn how to best support their loved one who experiences bipolar disorder. FFT has proven to be highly effective, especially when combined with medication, in reducing symptom severity and rates of relapse.10 Additionally, the improvements have been observed for years after treatment was received. The concepts and strategies from FFT can be applied with a spouse or other family members.
Interpersonal and Social Rhythm Therapy
Finally, Interpersonal and Social Rhythm Therapy (IPSRT), developed by Dr. Ellen Frank, helps individuals with bipolar disorder to identify and solve interpersonal problems and to maintain consistent daily routines and rhythms. The fact that this therapeutic modality has demonstrated effectiveness in the management of bipolar disorder is not surprising, given that the foundation of the therapy is based on the research which has consistently demonstrated that stressful life events and circadian rhythm disruption often triggers mania and depression.11
How to Get Help for Bipolar Disorder
If you are already working with a general practitioner, like an MD or Nurse Practitioner, you can start by raising your concerns with them. If they think it is likely that you are experiencing bipolar disorder you will be referred to a Psychiatrist or Psychologist, both of whom can diagnose a potential bipolar disorder. If you are already receiving treatment for depression and notice that you may also be experiencing signs of mood elevation or mania, discuss what you are experiencing with your provider. As noted previously, some antidepressant medications can worsen mania.
The earlier someone is accurately diagnosed with bipolar disorder, the better the prognosis is for long-term illness management. A huge factor in successfully managing mania is simply recognizing what is happening when it hits and consistent therapy is the best way to do this. Finding a therapist for bipolar disorder can be achieved using an online therapist directory or through referrals from your primary care doctor. However, because medication plays such a critical role in the treatment of bipolar disorder, you will likely benefit the most from seeing a therapist in combination with long-term medication management with a psychiatrist. There are online psychiatrists available to help you seek treatment.
Carrie Fisher is best known for playing Leia in the Star Wars franchise. The actress was also open about her diagnosis of Bipolar Disorder throughout her lifetime. She once said that Bipolar Disorder can be a great teacher. It’s a challenge, but it can set you up to be able to do almost anything else in your life.” What she is describing is how the tools for managing Bipolar Disorder, like maintaining a balanced and consistent schedule, reducing stress, knowing the signs when you are doing well and not doing well, and accepting help when you need it, are also skills that contribute to life satisfaction. There are many effective treatments for Bipolar Disorder, so it is critical to be open about what you are experiencing in order to allow providers to accurately diagnose any potential mood condition.