Bipolar disorder is frequently unrecognized or misdiagnosed, potentially taking years before an accurate diagnosis is made, therefore it’s important to understand the signs and symptoms of bipolar-related mood changes. Bipolar disorder is most often initially diagnosed as non-bipolar major depressive disorder, sometimes called unipolar depression.
The depressive episodes in bipolar disorder present essentially the same as the non-bipolar variety of depression. However, any history of mania or hypomania ultimately defines the disorder and should always be explored in a clinical assessment.
Types of Bipolar Disorder
Bipolar disorder has three basic types:
Bipolar I Disorder
Bipolar I is marked by current presentation or past history of mania. Bipolar I may be easier to diagnose than the other types, as symptoms last longer or are more intense with more negative consequences, and usually require hospitalization.
Psychotic symptoms, such as hallucinations or delusional thinking, can only be present in Bipolar I. More opportunities are available for treatment of Bipolar I because severe levels of the disorder tend to get more attention. However, consistent participation in care is difficult to sustain. Bipolar I can emerge anytime, but the average age of onset is about 18 years old.
Bipolar II Disorder
Bipolar I was once believed to be worse than Bipolar II, but both forms of bipolar disorder can be devastating. Bipolar II is marked by manic symptoms of shorter duration called hypomania (which literally means “under mania”). The same manic symptoms as in Bipolar I can exist, but the hypomanic episodes tend to last at least four days instead of seven days as in Bipolar I.
Depressive episodes, however, can be just as severe—or even worse—as in Bipolar I. Moreover, hypomanic episodes can be harder to identify. The average onset of Bipolar II is about 25 years old, but the slightly older onset compared to Bipolar I may have more to do with how hypomanic episodes are is generally more difficult to identify.
Since people with Bipolar II disorder with hypomania tend to be highly productive and more “functional” than Bipolar I manic patients, they may not consider mood regulation to their benefit. Some people around the person diagnosed with Bipolar II might disagree. In fact, one criterion for a Bipolar II diagnosis involves at least one other person noticing a distinct change in typical behavior during a hypomanic episode compared to their baseline behavior.
Cyclothymia literally means “cycling emotions.” This form of bipolar is marked by less severe but more frequent changes in mood than other kinds of bipolar disorder. It forms a chronic, consistent pattern that lasts at least two years in adults and one year in children.
Essentially, cyclothymia consists of alternating episodes of hypomanic symptoms (less than in a full hypomanic episode) and dysthymia, without any history of major depression, mania, or hypomania.
There are other forms of bipolar disorder induced strictly by substance use, medication effect, or certain medical disorders. Other medical disorders, such as traumatic brain injury or thyroid conditions, may cause manic or hypomanic presentations as well. The most important thing you can do is seek professional help if symptoms of bipolar disorder are present in yourself or noticed in a loved one.
Mania and Hypomania: What to Look For
The term “mania” is used to describe a particular mood state associated with Bipolar I. However, mania also generically describes a range of manic mood zones that include mania and psychotic mania in Bipolar I and hypomania in Bipolar II. These symptoms apply to manic episodes and hypomanic episodes alike.
Generally, the manic person has abnormal and persistently high energy or activity level together with changes in mood that can be described as abnormally elevated, euphoric, or expansive (unrestrained). Or, mania can be dysphoric (irritable and agitated).
Essentially, the mood state in mania can make people look like they’re on a mind-altering drug that makes them appear “high” or “cranked.” However, in mania, these symptoms aren’t the direct consequence of drug use or another medical problem.
During the period of the manic mood state, three or more of the following must be present (or four if the mania is dysphoric, or irritable, and not euphoric):
Inflated Self-Esteem or Grandiosity
Individuals in a manic episode often see themselves as more special than the people around them. They can experience a surge of energy that makes them feel on top of the world and free from negative consequences, as if they can whatever way they wish. They often feel high and mentally impenetrable. This is known as “euphoric mania.”
Manic individuals also can believe they have a special purpose or message to send to the world. Even if they are talented, while manic, they exaggerate the importance of their projects or ideas. Some manic individuals, however, aren’t quite as talented as their mania leads them to believe. Their grandiosity allows them to create wonderfully imaginative scenarios for their success, even if they lack the skills, discipline, or basic sense of reality to make those ideas come true.
When psychotic features are present, grandiosity reaches a high level of intensity and disconnection from reality. They may experience hallucinations or delusions that reinforce a grandiose sense of self.
Decreased Need for Sleep
This symptom is different than what we generally think of as insomnia. With insomnia, people can have bouts of sleeplessness when they’ve tried different ways to fall asleep, and are awakened when they don’t want to be.
But unlike people with insomnia, people with mania do not want to sleep. Instead, they desire to keep going with various tasks and feel rested or energized with little to no sleep.. hey frequently defend their lack of sleep by saying, “I don’t need it. I feel great if I get just two hours!”
This symptom of bipolar mania is uniquely important because you can’t really find it in any other mental disorder diagnosis. It not only differs from insomnia, but also when people suffering from anxiety or PTSD avoid sleep simply out of fear of something bad happening as a result. Again, bipolar mania decreases the need for sleep due to excessive energy and activity. People in a manic mood zone rarely look forward to downtime. Besides, for them, downtime may in fact be depression.
More Talkative than Usual, Pressured Speech, or Pressure to Keep Talking
People with mania talk excessively, usually loud, and for some this can be more intense and present as accelerated and scattered streams of speech. It can even be incomprehensible when attempting to communicate with others. They’re typically difficult to interrupt and can be tangential; that is, they can go on about different subjects as if they’re authorities on each. They tend not to speak concisely and are rushed to get as many thoughts out as quickly as possible.
Flight of Ideas or Racing Thoughts
People with mania can go on and on expressing varied and fragmented thoughts, often being in a state of hypercreativity. However, the constant barrage of thoughts can be both overwhelming and disturbing, as it can be so severe that speech is incoherent or difficult.
With euphoric mania, individuals revel in their thoughts, often believing they can formulate new, powerful theories or wildly exciting accomplishments. With high irritability or “dysphoric” mania, they can become frustrated with the intensity of their own thoughts or with how others get “turned off” by their rants.
Some people with mania can begin feeling euphoric, but eventually they become dysphoric toward the end of the episode. They may come to feel that others are doubtful naysayers to their perceived sense of greatness.
Increase in Goal-Directed Activity or Psychomotor Agitation
This, in effect, separates manic thoughts and speech from manic behavior. People with mania can create intense and complex social situations, entangling others in the process. They can become hyperactive or overextend on their various responsibilities. They can enact poorly planned ideas that ultimately sabotage social and occupational achievements. They can also pursue any number of radical and befuddling changes in appearance or affiliation (such as different social groups, political movements, religious beliefs, and so on).
Although this intense drive to get things done may sound appealing, such increases in activity can’t be sustained. Too many “irons in the fire” means people with mania frequently create more chaos than accomplishment. But when coupled with grandiosity, it becomes difficult to interrupt the manic person’s goal-driven activities. A path of destruction is left in the wake of the manic person’s inflated sense of destiny.
Psychomotor agitation refers to a significant type of physical overactivity or restlessness (usually nonproductive) that includes emotional distress or anxiety. Pacing, hand wringing, excessive text messaging, and the inability to stay seated are examples of psychomotor agitation. This can also be a symptom of major depression.
No matter how great their ideas or how goal-directed they seem, people with mania can get easily distracted with unrelated activities in their environment. They also may become hyper-focused on a single thing, to the detriment of important tasks that need to be completed.
If successful people with mania cannot avoid becoming distracted at the height of their creative moments, others in their life typically compensate for their failure to accomplish essential tasks. Otherwise, the manic person will have difficulty maintaining employment and overall reliability with other people.
Distractibility is also found in Attention Deficit Hyperactivity Disorder (ADHD). Distractibility in mania is episodic, while in ADHD it is ongoing no matter the mood state.
Excessive Involvement in Pleasurable or Risky Behaviors
This symptom of mania brings the greatest attention to the disorder and the need for treatment. People with mania often can go on buying sprees, invest impulsively, or gamble away their paychecks. They might go on alcohol or drug binges or act out sexually through promiscuity or other indiscretions.
This pattern of poor judgment can also involve reckless behaviors such as driving at extreme speeds, unprotected sex, and other activities that could put themselves and others in danger. Severe irritability can result in hostile or even violent behaviors against self or others.
No matter what pleasurable or risky behaviors people with mania indulge in, there is little to no reasonable judgment or insight into the long-term effects of their decisions, and is behavior that is not typical for the individual outside of a manic episode. The results of these actions could mean legal or medical emergencies, bankruptcy or homelessness, and most often, broken relationships. These are referred to as the “functional consequences” of bipolar disorder.
Bipolar Depression: What to Look For
The depression end of the bipolar cycle can be just as devastating as the manic side—sometimes even more so. Here, the mood is intensely sad, dark, and overpowering. The depressed person often experiences the painful functional consequences of the manic episode, and the previously inflated self-esteem has turned into shame and despair.
Alcohol and drug abuse have turned away from a manic-style party, and toward coping for the intense emotional pain or continued use from dependence on these substances. Suicidal thoughts, self-harm, or the potential to harm others are of great concern during bipolar depression.
When depressed people with bipolar are admitted to inpatient or outpatient treatment, their history of mania isn’t always evident. They may be diagnosed initially with non-bipolar major depressive disorder. That misdiagnosis typically occurs when the bipolar person is experiencing a major depressive episode but has no known history of mania or hypomania. Precise treatment choices require a full history to assess if the person has ever had a manic or hypomanic episode.
When a depressed person is evaluated by a mental health professional, the clinician should know the patient’s history. If the question isn’t asked about mania or the patient fails to mention it or the patient doesn’t realize what it is, a diagnosis of major depression is typically the only diagnosis made. This is important because certain medications for depression, when taken alone, could be a catalyst for a manic episode, thus worsening the situation.
Symptoms for a major depressive episode in bipolar disorder include at least five of the following over the same two-week period:
Depressed Mood for Most of the Day, Nearly Every Day
This is more than feeling down from time-to-time or having “the blues.” A depressed mood is a serious, consistent reduction in feeling, often without a sense that anything can make it feel better.
Diminished Pleasure or Interest in Usual Activities
This symptom is measured against the individual’s usual profile of occupational, recreational, social or sexual activities. The person starts to find less enjoyment in the things they would always love to do or avoid trying new, adventurous pursuits. Even if they attempt their typical activities, they find it difficult to experience the same joy or pleasure as before the depressive episode. They may instead feel a sense of blandness and reduced energy when they try.
Significant Change in Appetite, or Weight Gain or Loss
Oftentimes, people in a major depressive episode lose their appetite and eventually lose weight without trying to. Or, they may overeat due to increased appetite or trying to feel better, resulting in weight gain.
Insomnia or Hypersomnia (Oversleeping)
Sleep patterns commonly change during depression. Insomnia can take different forms, from the inability to fall asleep within a reasonable time, to waking up too early without falling back to sleep. For some, however, they may sleep too much during the night or day.
In both circumstances, people will not feel rested with any additional energy for usual daily tasks. Note: Sleep problems associated with depression are different from the decreased need for sleep associated with mania. In that instance, the individual has a decreased need for sleep and persists in manic activity.
Psychomotor Agitation or Slowing
This presents in physical behaviors that are a change from routine ones. Agitation can include pacing, hand wringing, verbal outbursts, and the inability to sit still. With psychomotor slowing, there is a reduction in physical activity or body movements, causing the person to appear listless or dull. Agitation can also be noted in mania, but there it is accompanied by other manic symptoms.
Fatigue or Loss of Energy
Like other depressive symptoms, fatigue or loss of energy is persistent, even when a person tries to push themselves into activity. These feelings are not just experienced emotionally, but physically as well.
Feelings of Worthlessness, or Excessive or Inappropriate Guilt
These symptoms are often considered to be “inappropriate” to the true nature of the person and his or her situation. That is, they may feel guilt in matters for which they have little or no actual responsibility, or feel that they are worthless people, though others around them would disagree. Overall self-esteem is frequently reduced in bouts of depression.
Diminished Ability to Think or Concentrate
Feeling overwhelmed with depression, loss of self-esteem and surrounding life problems can seriously affect the depressed person’s ability to think, concentrate, or stay on task compared to their ability when not depressed. This is slightly different than the distractibility noted in mania, mostly due to mania’s intense energy that pushes the individual to think more and do more than can be attempted while depressed.
Recurrent Thoughts of Death, or Suicidal Thoughts or Actions
People who are depressed become at risk for suicidal thoughts or actions. Even if they have no intent or plan to harm themselves, they may ponder death or wonder if they or the world would be “better off” without them. These thoughts and potential actions should always be treated seriously and shared immediately with a mental health professional.
Spectrum of Mood Presentation
Understanding all bipolar disorder symptoms is vital in recognizing the disorder in its individual parts. This helps distinguish it from other psychological problems while isolating problem areas for the ensuing conversations about treatment. Some people diagnosed with bipolar disorder appreciate knowing about the spectrum of presentations. They often cite these to better identify and explain different mood episodes in the context of their day-to-day lives.
Understanding that people with bipolar disorder live in various mood presentations can help explain bipolar disorder as a single, lifelong mental health condition.
These common mood descriptors are listed from the top of the manic high to the bottom of the depressive low. The top three are considered the manic zones; the bottom three are the depressive zones:
- Psychotic mania
- Major depression
- Psychotic depression
This represents a severe form of mania. Extreme bizarre behaviors accompany other manic symptoms, along with hallucinations and delusional thoughts, including severe paranoia or grandiosity. The episode can be euphoric or dysphoric. The psychotic symptoms subside once the manic episode has ended.
During an episode, hospitalization is usually required. Having one episode in a lifetime is diagnosed as Bipolar I, with psychotic features.
This mood presentation lasts at least one week, but may continue for many weeks. It meets the mania criteria mentioned above and comes with severe functional consequences. The episode can be euphoric or dysphoric. Hospitalization may be needed. One episode in a lifetime is diagnosed as Bipolar I, but without psychosis.
This mood presentation has the same features as mania but is shorter in duration, with a minimum of four consecutive days. Hypomania can be euphoric or dysphoric. The changes in behavior during this episode are regarded as out of character to those who know the hypomanic person.
To be diagnosed as Bipolar II, they must also have had at least one episode of major depression in their lifetime along with one episode of hypomania. Many people with hypomania can appear to function adequately and with high productivity.
This is the mood state most people describe as “normal.” But “normal” can mean different things to different people. Individuals can have different mood baselines, and even then, their baseline may not feel like any particular type of emotion. It’s mostly identified as the mid-range between the bipolar mood extremities, and can appear differently in each individual.
Oftentimes, people with bipolar disorder and their loved-ones may feel relief during this time, and thus ignore the ongoing problem of extreme mood changes. However, this mood state can be a great opportunity to discuss bipolar disorder and seek treatment.
This is best described as an episode of minor depression. It represents reduced mood (sadness, anxiety, and so on) below the person’s baseline. All of the symptoms for major depression listed above may apply in dysthymia, but they are considered less severe.
Patients diagnosed with cyclothymia usually have episodes of dysthymia and hypomanic symptoms that alternate consistently over two years or more. If people have periods of dysthymia without a history of mania or hypomania, they don’t have bipolar disorder.
An episode of at least two weeks of significant sadness, agitation, feelings of worthlessness, sleep and appetite impairments, reduced energy and activity, loss of ability to experience pleasure, and possible suicidal thoughts or actions mark this mood presentation. Hospitalization might be needed depending on the extent of the depressive symptoms but especially when suicidal intent is present.
Severe major depression is marked by constant thoughts and/or actions around death or self-harm but can also include disturbance in experiencing reality. Delusions and/or hallucinations can often include dark, deprecating, or frightening themes. The psychotic symptoms subside once the depressive episode has ended. During the episode, however, hospitalization is often required.
It is important to consider that a person with bipolar disorder could suffer related problems in any mood state, including suicidal thoughts or actions. Patients and family members can look forward to returning to baseline as a respite from the chaos and anxiety of the other mood states, but that isn’t the time to do nothing. In fact, it may well be the best time to initiate action before the next turbulent mood presentation.