Because bipolar disorder is often unrecognized or misdiagnosed, it’s vital to clarify what it is and what makes it unique among other mental health conditions. The key here is to understand mania, both with respect to its symptoms and to its effects on people who suffer from it. What makes bipolar disorder different from any other mental disorder—especially major depressive disorder—is a distinct episode of manic symptoms. The term mania is used both as a specific bipolar mood zone and as a generic term encompassing all three mood zones of hypomania, mania, and psychotic mania.
Diagnosing Bipolar Disorder
These different mood zones are useful in understanding each type of bipolar disorder. For a diagnosis of bipolar I disorder, a person must have a history of at least one episode of mania or psychotic mania. That one episode means they have bipolar I, even if they have had hypomania before, or have never had major depression.
For a diagnosis of bipolar II disorder, a person must have one episode of hypomania and one episode of major depression, but not ever an episode of mania or psychotic mania. Adults with periods of hypomania and dysthymia (minor depression) consistently over a period of two years, or one year if a child, have a type of bipolar called cyclothymia.
Symptoms of Mania and Hypomania
Mania and hypomania have the same symptoms. The essential differences between the two types of episodes involve the duration of the episode and the level of consequences to a person’s overall functioning. However, a correct diagnosis means symptoms are not the direct consequences of drug use, or another medical condition, such as thyroid imbalances or a traumatic brain injury.
Generally, the manic person’s mood can be described as abnormally elevated, euphoric, or expansive (unrestrained). This can be described as euphoric mania. Or, the overall mood condition can be irritable and agitated, and therefore described as dysphoric mania.
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 agitated but not euphoric):
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- More talkative than usual, pressured speech, or pressure to keep talking
- Flight of ideas or racing thoughts
- Increase in goal-directed activity or psychomotor agitation
- Distractibility
- Excessive involvement in pleasurable or risky behaviors that have a high potential for painful consequences1
In a generic sense, any type of mania can be euphoric or dysphoric, or can switch during an uninterrupted episode. This is common for people who may start the episode with a great feeling of inflated self-esteem, but then shift to anger or exhaustion as the episode continues.
Three Types of Manic Episodes
In all three instances of mania, there are likely several events occurring in the brain that are facilitating the episode. One of these neurological changes involved a brain chemical known as dopamine, which is responsible for feelings of pleasure and reward. Simply stated, a brain flooded with dopamine can make the individual feel on top of the world and as if whatever the action is, they’re being “rewarded” for it.
Psychotic Mania
This involves the specific symptoms of mania listed above but is marked by extreme bizarre behaviors during the episode, and typically lasts a minimum of one week unless interrupted by immediate bipolar treatment. Those who have psychotic mania experience periods of delusional thoughts and actions, and at times, hallucinations.
These hallucinations are most often auditory, which means a person can hear voices speaking about them, directly to them, or with indiscernible gibberish. There can be other types of hallucinations, including visual, tactile (physical sensations), or somatic (bodily feelings or experiences).
The themes of both delusions and hallucinations tend to be grandiose, but any psychotic behaviors witnessed by others can be frightening. Psychotic mania can be euphoric or dysphoric, or move from one to the other during the episode. Psychotic symptoms subside once the manic episode has ended, which makes it different from other psychotic disorders such as schizophrenia.
During an episode of psychotic mania, hospitalization is likely required. Having one episode in a lifetime is enough to be diagnosed as bipolar I disorder with psychotic features.
Mania
This type of episode involves the symptoms listed above, but does not have co-occurring psychotic features. It can last for several weeks if not immediately treated. Along with meeting the symptoms for mania, it is marked by significant consequences to a person’s functioning, including threats to overall health, relationships, and other social and occupational needs.
The episode can be euphoric or dysphoric. Hospitalization may be needed, but under certain conditions, mania can be treated adequately in an outpatient setting. One episode in a lifetime is enough to be diagnosed as bipolar I disorder without psychotic features.
Hypomania
This mood zone has the same elements as mania but either is shorter in duration (minimum four days) or has fewer severe consequences than in longer episodes. Hypomania can be euphoric or dysphoric but does not have psychotic features. The changes in behavior during this episode are regarded as out of character to those who know the hypomanic person.
To be diagnosed as having bipolar II disorder, individuals must also have had at least one episode of major depression in their life history, along with one episode of hypomania. Many people with hypomania can function adequately and with high productivity, sometimes for many years into adult life. But bipolar II can be a devastating disorder because of the cumulative effects of hypomanic and major depressive episodes. Many individuals with bipolar II only seek treatment when they feel depressed. This can lead to difficulties and delays in getting a diagnosis of bipolar disorder.
What It’s Like to Be in a Manic Episode
Events and experiences during a manic episode can be so accelerated that the person loses track of time and a clear sense of purpose. People in the throes of mania often attempt an activity blitz. The impulse to achieve as much as possible is overwhelming, and denial is used to keep things going for as long as possible. As a result, people with bipolar mania will avoid sleep, good hygiene, and rational thoughts and behaviors.
The more severe the mania, especially when it’s psychotic, the more that behavior reflects a mind acting out its greatest fantasies. These fantasies can reveal desires of great wealth, power, ambition, popularity, and sexual conquest.
People in a manic episode can act as if they are free of consequences. They can believe that any idea they have is a great idea, and will plow through reasonable methods and organization to achieve it. They may try to spend money beyond their limits, or set up businesses, projects, or investments that are doomed to fail. They may wind up in places and with people they don’t know, or engage in behavior that puts their well-being and the well-being of others at risk without any sense of wrongdoing.
But when the episode ends, patients often report failing to recall things they did or said. Those around them might call this amnesia “convenient” or “selective,” but generally, their usual memory process is fractured during the manic episode. Once they enter a different mood state, they often don’t remember everything that happened.
Over time, they might figure out what they did and said by recovering certain memories, but more likely they find out from other sources. Family or friends tell them what happened during mania, but they might meet a full account with skepticism.
Or they might discover the extent of their behaviors after getting arrested or winding up in a hospital—results that are difficult to dispute or reject. Unexpected credit card charges or other strange bills can come due, delivering a shocking chronology of manic exploits. Drug or alcohol binges—especially when ending in a mammoth hangover—can provide undeniable proof of an underlying manic process that could destroy any hope of maintaining a life of sobriety.
Bipolar disorder patients in treatment acknowledge experiencing manic episodes as if watching a movie of someone else instead of living it themselves. They describe a sense of surrealism; it feels intense and super-real in the moment but at the same time not exactly real. That’s partly why people with bipolar can hang on to denial as a defense mechanism—it’s often difficult to fully accept what mania can do to themselves and the people around them.
It might appear that the thoughts of a person with mania are disordered, but instead, the disordered mood state is essentially crowding out any semblance of rational thought. Patients sometimes describe the “feeling-action” response as feeling an impulse that’s influenced by the mood episode and followed by immediate action.
In fact, mania is often a series of these responses. Each action appears justified because the feeling dictates the action without any competing thought to evaluate it. That’s like saying, “I didn’t think what I did was wrong, so it isn’t.” This sequence keeps going without intermittent review, other than the overarching euphoric or dysphoric manic feelings that feed and maintain the repeating pattern.
Mania Keeps People Away from Bipolar Treatment
There may be several reasons why people with bipolar disorder avoid getting help. But the main reason is likely that mania can be an amazing, uplifting experience, and meet various perceived needs. Along with the great feeling, people with mania may defend it through denial.
In a person who has bipolar disorder, mania can be highly arousing and force that person to use every energetic moment to get as much accomplished as possible. This is always true, even if the arousal process produces what many would find uncomfortable, such as the irritability and agitation within dysphoric mania.
For many, mania feels like the only way out of depression and inactivity. Frequently, mania is perceived as the counterweight to depression. And even without a period of depression, just the loss of mania can lead to feelings of frustration amidst a sense of lost productivity.
The bipolar misperception is this: As long as a manic episode can balance out an episode of major depression, everything will work out fine. People with bipolar can employ a kind of irrational thinking as a defense against dealing with the reality of the true consequences of the disorder, especially from mania. This is why the defense of denial frequently develops in people with bipolar disorder.
Denial: A Common Defense Mechanism for Mania
In bipolar mania, denial represents a consistent means by which an individual avoids facing personal responsibility, serious flaws in the self, and otherwise difficult changes necessary to accept a painful reality. It’s no coincidence that bipolar disorder and addictions can go hand in hand.4 That’s especially true considering a manic high can resemble a drug high, and that both often share the common defense mechanism of denial.5
Similar to substance abuse treatment, addressing denial is a part of the first step of bipolar treatment. No one wants to fear that whatever makes them feel good is exposed as something bad and possibly taken away. People with bipolar disorder feel that way about their mania just as addicts feel about their drug of choice (remember, mania is experienced as a defense against depression).
Moreover, a manic episode often is marked by grandiose self-image, hyper-creativity, and productivity. The need to defend these as positive attributes of bipolar disorder makes it difficult to repackage them as personal flaws—or worse—symptoms of a chronic mental disorder.
People who have felt the rush of euphoric mania don’t want to give that up, especially when they’ve also felt the pain of depression. But their perception of having a special purpose to fulfill through their manic abilities and energy is even harder to break through when trying to confront it.
Bipolar’s High Rate of Suicide—Even During Mania
Bipolar disorder is among the most lethal of mental disorders. It’s believed that bipolar may account for one-fourth of all deaths by suicide.1 One of the unfortunate aspects of this reality is that some people may think a person with bipolar disorder is only at risk for suicide when depressed. However, anyone with untreated bipolar disorder is at risk in any mood state, including mania.
It’s important to know that only proper treatment for bipolar disorder can reduce the risk of suicide in all its forms.
Treatment for Mania
The treatment for any form of bipolar disorder may appear similar, and in fact, can follow a typical course after an initial bipolar crisis. When people come to treatment, they are evaluated for their current or most recent episode. This tends to dictate the initial course of treatment in the pre-stabilization phase.
If someone is currently in a manic episode or has recently experienced one, treatment with medications is usually based in mood stabilizers and/or antipsychotic medications that focus on the reduction and prevention of manic symptoms, especially if psychotic symptoms have been present.
If someone enters treatment with a current or more recent bipolar depressive episode, medications would tend to favor depressive symptoms over manic ones. But even in this situation, the treating physician must be careful for any emerging manic symptoms to ensure a balanced approach to bipolar mood swings. Most current clinical research suggests treating patients with bipolar depression with mood stabilizers and/or antipsychotic medications rather than antidepressants.
Once manic symptoms are under reasonable control, medications can be adjusted to better prevent both mania and depression in a long-term maintenance plan. As a bipolar patient experiences greater mood stability, therapy can address some of the effects and consequences of prior manic episodes.
This strategy can help heal damage to relationships, finances, and overall health. And for those with a co-occurring substance abuse disorder, improved stability can go a long way to avoiding a drug or alcohol relapse. Also, therapy can be useful in developing improved organizational methods so people can enjoy their creative talents without the potential destruction caused by manic impulses.
Mental Disorders That Can Be Confused with Mania
Symptoms of different disorders can cross over with some of the manic symptoms associated with bipolar disorder, which often creates confusion in establishing a solid diagnosis and treatment plan.
When separating bipolar mania from other disorders, the first thing to know is that bipolar disorder is disorder of mood. Why is this important? Because in bipolar disorder, mood episodes will eventually subside or change. This means the symptoms of mania and depression will change, too.
Bipolar symptoms, including mania, are described as “episodic”—that is, they present in episodes that come and go over time. For disorders that get confused with bipolar disorder, the symptoms don’t change through their course, unless they are treated. The symptoms of those disorders are “pervasive” in that they continue through the duration of the respective disorder.
The following common mental illnesses are often mistaken with mania in bipolar disorder:
Mania vs ADHD
Distractibility, agitation, increased activity, and hyper-focus are attributes usually found in both bipolar mania and attention deficit hyperactivity disorder (ADHD). While bipolar disorder and ADHD can exist together, they are frequently confused for one another, especially in children. In fact, these children could also be suffering from a major depression or an anxiety disorder, but their agitation and excessive emotional upset can result in acting out behaviors that appear manic.
The main point to look for is the difference between symptoms that are episodic and those that are pervasive. When mania subsides in someone with bipolar, concentration tends to improve with the improving mood, while the activity level stabilizes. In ADHD, these symptoms persist no matter the mood state.
One potential point of confusion hinges on different treatment approaches. A primary treatment for ADHD involves medications known as “psychostimulants.” Even though they stimulate certain aspects of brain functioning, psychostimulants in a person with ADHD improve attention and focus, helping patients calm themselves.
But caution must be used in treating ADHD when bipolar is suspected. Mood stabilization should occur first before adding psychostimulant medication specifically for ADHD.2 These two disorders require careful attention so that a proper treatment plan doesn’t put the patient at undue risk.
Mania vs OCD
Obsessive-compulsive disorder (OCD) involves frequent and intrusive repetitive thoughts (obsessions) and/or behaviors (compulsions). Fundamentally, people with OCD attempt to stave off their intense anxiety or fears, which usually are irrational or unconscious. They eventually realize their recurring thoughts and actions are creating problems in their lives, but they can’t stop OCD symptoms by using will alone. In time, the symptoms will overwhelm them.
People with entrenched, persistent compulsions can go about these behaviors in a ritualized way that requires considerable drive and energy. Thus, compulsive behaviors can appear to be manic in nature, particularly if the compulsions keep a person completely occupied day and night. Like major depression, OCD is frequently treated with antidepressant medications, which by themselves can induce mania in people who have bipolar disorder.
Mania vs Personality Disorders
Some personality disorders mimic signs of mania. At times, they’re referred to as “characterological disorders” because they reflect severe, pervasive impairments in the individual’s psychological makeup. Borderline, narcissistic, and antisocial personality disorders can have some of the closest similarities to bipolar mania.
Borderline Personality Disorder
Borderline individuals typically display stark emotional changes, turbulent relationship patterns, and irresponsible or risky personal behaviors. A key component of borderline personality is called idealization/devaluation or “splitting.”3 This means a borderline person can idealize another person in a relationship as “all good” or a “perfect soul mate.” Later, and usually without provocation, that same amazing person will be devalued as “all bad” or “useless.”
These harsh instabilities in mood, relationships, and social behavior can appear manic. This is complicated by the fact that those with borderline personality disorder can suffer severe depression with suicidal thoughts and actions just like with bipolar disorder.
Narcissistic Personality Disorder
Narcissistic personality disorder is marked by inflated self-esteem, grandiose self-regard, and unrealistic standards about love and achievement. Again, these features can appear to be manic, especially if narcissistic individuals are feeling frustrated. They often respond with high levels of irritability and anger. By comparison, people with borderline and narcissistic personalities typically have a low tolerance for frustration. Both tend to blame others for their failures in life.
Antisocial Personality Disorder
Antisocial personality disorder includes not only severe impairments in relationships but also a callous disregard for rules, laws, and social norms. People with antisocial personality disorder begin showing these disturbances during adolescence. Their behavior tends to be consistent, even if mood patterns change over time. Antisocial activity can result in constant run-ins with authority figures, just as people with bipolar mania can display irresponsible behaviors.
Bipolar disorder and a personality disorder can coexist in the same person; however, one is often confused for the other, resulting in delayed or ineffective treatments. Bipolar disorder is driven by episodic mood swings, and those drastic mood shifts do not by themselves reflect the total, pervasive character of a bipolar individual. When in baseline, the qualities of a bipolar individual are often different than the characteristics described in personality disorders.
Mania vs Schizophrenia
Like psychotic mania, schizophrenia involves delusional or disorganized thinking, and frequently involves hallucinations that can be auditory (“hearing voices”), visual, tactile, or somatic.
Typically, no psychotic symptoms are evident if the individual with bipolar mania is between mood episodes, otherwise known as a baseline zone. People with schizophrenia, however, rarely have vast mood changes or an abatement of psychotic symptoms along with a mood change as seen in bipolar disorder.
Identifying what drives the psychosis in its origin helps distinguish between the psychotic features of schizophrenia and that of bipolar I disorder. Schizophrenia is regarded as a “thought disorder,” meaning that a disorganized pattern of thoughts drives the psychosis. And because thoughts tend to be more consistent than feelings, and evolve (or devolve) over time, the untreated psychotic features would be pervasive.
By comparison, in bipolar disorder, poorly regulated mood patterns—not thoughts—drive psychotic symptoms. And because the moods change drastically, the psychosis comes and goes with the moods. That means it is episodic.
