What Is Bipolar Disorder?

A mood disorder formerly known as manic depression

Bipolar disorder, formerly known as manic depression, is a group of mental disorders that causes extreme mood fluctuations, from abnormally elevated highs known as mania or hypomania episodes to emotional lows known as depressive episodes. Bipolar disorder is more than just mood swings; it is the recurrent, and sometimes severe, disruption of normal moods that undermines a person’s ability to function, maintain relationships, work, and make sound judgments.

The diagnosis of bipolar disorder is based on behavioral criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Edition 5 (DSM-5), a tool that mental health professionals use to diagnose mental health conditions.

Treatment of bipolar disorder typically involves a combination of psychotherapy, pharmacotherapy (medication), and procedures such as electroconvulsive therapy (ECT) for people with severe and persistent manic or depressive episodes.

How Common Is Bipolar Disorder?

At some point during their lifetime, 2.4% of people worldwide and 4.4% of people in the United States will be diagnosed with bipolar disorder. While the cause of bipolar disorder is unclear, having a first-degree relative with the condition is a recognized risk factor.

Most people with a relative with bipolar disorder will not develop the condition, however. Some families are at greater risk than others, but the exact reason is not known.

Nervous woman at doctor's office

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What Is Bipolar Disorder?

Bipolar disorder is defined by its episodic nature—people with this condition will experience intermittent periods of mania or hypomania and depression, with an absence of symptoms in between.

People with bipolar disorder experience periods of unusually intense emotion, changes in sleep patterns and activity levels, and uncharacteristic behaviors. These distinct periods are called mood episodes. Mood episodes differ greatly from typical moods and behaviors. There is no set pattern of episodes. Duration and severity of each episode also vary from one person to another. 

The different types of mood episodes experienced by people with bipolar disorder include:

  • Manic episodes are defined by distinct periods of abnormally and persistently elevated and irritable mood lasting for at least one week. Manic episodes can cause marked social or occupational impairments when they are severe. The average age for people with bipolar disorder to experience their first manic episode is 18, but a first manic episode can happen anytime from early childhood to late adulthood
  • Hypomanic episodes are also defined by distinct periods of abnormally and persistently elevated and irritable moods, but hypomanic episodes last for at least four consecutive days and present at most hours of the day nearly every day. Hypo means "under," and it is used in hypomania because this mood state is under, or less manic, than mania. Unlike mania, these episodes are not severe enough to lead to hospitalization or impair social or occupational functioning
  • Major depressive episodes are periods of emotional and energy lows that persist for two weeks. Typical symptoms include a mix of intense and severe feelings of despair, hopelessness, sadness, and worthlessness or guilt; appetite changes, sleep disturbances, agitated behaviors, including pacing or hand wringing; frequent thoughts of death or suicide; and difficulties in making decisions and concentrating
  • Mixed episodes (or mixed affective states) are periods where mania and depression occur at the same time. For example, someone may experience the extreme agitation and restlessness associated with mania and the suicidal thinking more attributed to depression at the same time during a mixed episode

Mood Disorder

Bipolar disorder is a type of mood disorder, which is defined as a mental health condition that primarily affects a person's emotional state. People with a mood disorder can experience long periods of extreme happiness, extreme sadness, or both. Mood disorders can cause changes in behavior and affect a person's ability to deal with routine activities, such as work or school. Depression is another common type of mood disorder.

The frequency, duration, and kind of episodes are what defines the type of bipolar disorder that a person has, including bipolar I disorder, bipolar II disorder, and cyclothymia.

Bipolar I Disorder

Bipolar I disorder is characterized as having had at least one manic episode last at least seven days or be so severe that hospitalization is required. Depressive episodes may also occur in bipolar I disorder, but they are not necessary for the diagnosis of the condition. Periods of normal moods often occur between manic and depressive states. 

Bipolar II Disorder

In bipolar II disorder, depressive episodes shift back and forth with hypomanic episodes, but a full manic episode that is typical of bipolar I disorder never occurs. While hypomania is generally considered less serious than mania, it can still prevent people from functioning in their daily life.

Cyclothymia

Cyclothymia, or cyclothymic disorder, refers to a chronically unstable mood state in which people experience hypomania and mild depression. It involves cyclical bouts of major depression and hypomania with less severe symptoms than bipolar I disorder and bipolar II disorder.

Cyclothymia has been reported to occur at rates from 0.4% to 1% in the general population, although researchers think it is often under- or misdiagnosed due to its overlapping symptoms with other mental health disorders, including borderline personality disorder.

Symptoms

Manic and Hypomanic Episodes

Manic and hypomanic episodes share largely the same symptoms, including: 

  • Exaggerated self-esteem or grandiosity (feeling unusually important, powerful, or talented)
  • Decreased need for sleep
  • Talking more than usual, and talking loudly and quickly
  • Easily distracted
  • Doing many activities at once, scheduling more events in a day than can be accomplished
  • Increased risky behavior (e.g., eating and drinking excessively, spending and giving away a lot of money)
  • Uncontrollable racing thoughts or quickly changing ideas or topics

Major Depressive Episodes

A depressive episode is a period during which a person experiences at least five of the following (including one of the first two):

  • Intense sadness or despair, including feelings of helplessness, hopelessness, or worthlessness
  • Loss of interest in activities once enjoyed
  • Feeling worthless or guilty
  • Sleep problems, sleeping too little or too much
  • Feeling restless or agitated, or having slowed speech or movements
  • Increase or decrease in appetite
  • Loss of energy, fatigue
  • Difficulty concentrating, remembering, or making decisions
  • Frequent thoughts of death or suicide

The severity, duration, and disabling nature of depressive episodes vary from episode to episode and from person to person. Researchers say some people have only one or two episodes during their lifetimes, many have frequent recurrences, and still others will experience less severe but chronic depressive symptoms.

Symptoms in Children and Teens

The National Institute of Mental Health says symptoms of bipolar disorder may present differently in children and teens. For example, adolescents experiencing mania may show intense happiness or silliness for long periods of time; have trouble sleeping and not feel tired; or have a very short temper. During a depressive episode, children and teens may experience stomach aches, headaches, increased sleeping hours, appetite changes, little energy and interest in activities, and unprovoked sadness.

Catatonia and Psychosis

Catatonia (inability to move normally) and psychosis (occurrence of hallucinations or delusions) are also potential symptoms of bipolar disorder. Catatonia has been reported to occur in more than 10% of patients with acute psychiatric illnesses. It can present during a manic episode in bipolar I disorder.

Psychosis is a common feature, with more than half of people with bipolar disorder experiencing at least one symptom of psychosis over the course of their illness.

Bipolar disorder commonly occurs alongside other psychiatric conditions, making it difficult to diagnose and treat. These conditions include obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), eating disorders like anorexia and bulimia, substance abuse disorders, and borderline personality disorder. Anxiety disorders are especially common in people with bipolar disorder, with some studies suggesting that as many as 71% have a dual diagnosis.

Some medical conditions, such as thyroid disease, can also mimic the mood swings and other symptoms of bipolar disorder.

When to Seek Help

The Depression and Bipolar Support Alliance says hospitalization should be considered if someone with bipolar disorder has one or more of the following:

  • Thoughts of hurting themselves or others
  • Seeing or hearing things (hallucinations)
  • Having bizarre or paranoid ideas (delusions)
  • So revved up or impulsive that they are doing dangerous or harmful things
  • Feel too exhausted or depressed to get out of bed or take care of themselves or their family
  • Can’t stop using alcohol or other substances in harmful ways
  • Have not eaten or slept for several days
  • Have tried outpatient treatment (therapy, medication, and support) and still have symptoms that interfere with their life
  • Need to make a major change in their treatment or medication under the close supervision of a doctor

If you are concerned about someone’s behavior or feel they are a potential danger to themselves or others, intervene by contacting their doctor. In the case of emergency, contact the police. 

Diagnosis 

Like many other mental health conditions, there are no lab or imaging tests for diagnosing bipolar disorder. A mental health professional will use the latest criteria in the DSM-5 to make a formal diagnosis of bipolar disorder. The person will also report symptoms based on self-observations and those made by coworkers, friends, and family members. Bipolar disorder is most commonly diagnosed between 18 and 24 years of age.

Each type of bipolar disorder has its own specific set of diagnostic criteria.

Bipolar I Disorder

Two criteria must be met for a diagnosis of bipolar I disorder, according to the DSM-5:

  • Had at least one manic episode, which may have been preceded by and may be followed by hypomanic or major depressive episodes
  • The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder or other psychotic disorders

Major depressive and hypomanic episodes may occur, but are not required for the diagnosis of bipolar I disorder. Clinicians will also specify notable features of the person’s experience of bipolar disorder, including:

  • Anxious distress
  • Mixed features
  • Rapid cycling
  • Melancholic features
  • Atypical features
  • Mood-congruent psychotic features
  • Mood-incongruent psychotic features
  • Catatonia
  • Peripartum onset
  • Seasonal pattern

Bipolar II Disorder

Diagnosis of bipolar II disorder occurs after a person meets the following four criteria as defined by the DSM-5:

  • Had at least one hypomanic episode and at least one major depressive episode
  • Has never had a manic episode
  • The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder and other psychotic disorders
  • The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

The doctor will specify if the current or most recent episode was hypomanic or depressive. They will also note:

  • Anxious distress
  • Mixed features
  • Catatonia
  • Mood-congruent psychotic features
  • Peripartum onset
  • Seasonal pattern (applies only to the pattern of major depressive episodes)
  • Rapid cycling

Cyclothymia 

The diagnostic criteria for cyclothymia listed in the DSM-5 include:

  • Have had many periods of hypomania and periods of depression for at least two years, or one year in children and adolescents
  • Stable moods should last for less than two months at a time
  • Symptoms do not meet the criteria for bipolar disorder or another mental health condition
  • Symptoms are not caused by another medical condition or by substance misuse
  • Symptoms significantly affect day-to-day life

There is now also a fourth diagnosis: bipolar disorder not otherwise specified (NOS) or not elsewhere specified (NES). This category includes people with symptoms of mania or hypomania are too short or too few to meet the DSM-5 definition of bipolar disorder. Bipolar disorder NOS is a wait-and-watch diagnosis to ensure that early cases of bipolar or associated psychiatric illness are not missed.

Other Causes of Mood Swings

Clinicians may also perform tests to rule out other causes of mood swings, which can be the result of physical illness rather than mental illness, including:

Causes

The exact cause of bipolar disorder remains unknown. Researchers have, however, identified several genes associated with this condition and environmental stressors and triggers that play a role in one’s susceptibility to developing bipolar disorder. A study suggests that biologic pathways that include hormonal regulation, calcium channels, second messenger systems, and glutamate signaling, may be involved.

Experts believe that people with bipolar disorder have an underlying problem in their brain circuitry (how nerve signals are transmitted) and the balance of neurotransmitters (chemicals that deliver the nerve signals). Three main neurotransmitters associated with bipolar disorder are serotonin (mood regulator), dopamine (motivation and reward), and norepinephrine (regulates the fight-or-flight response). 

Genetics

Bipolar disorder is highly hereditary, and family history is a strong risk factor. Twin studies have found that 31% to 90% of identical twins will both have bipolar disorder. Because identical twins share 100% of their DNA, the fact that the numbers vary so greatly suggests that environmental factors also play a role and that carrying genes associated with bipolar disorder does not necessarily mean someone will develop this condition.

Environment 

Psychosocial factors can trigger and worsen depressive or manic symptoms in people with a predisposition for bipolar disorder. Lack of social support, family dysfunction, and negative life events influence or predict the course of bipolar disorder. Early childhood trauma and abuse are associated with a more severe illness course.

Environmental factors like temperature and seasonal effects can be managed. A person with chronic mental health conditions like bipolar disorder should work with their doctor to identify triggers and individual patterns of relapse and recurrence.

Risk Factors of Bipolar Disorder

  • Genetics and family history
  • Stressful life events 
  • Social rhythm disruptions like job loss, divorce, or moving
  • Sleep-wake and circadian rhythm dysfunctions and disruptions

Treatment

Bipolar disorder is a chronic mental health condition and requires long-term management. Appropriate treatment options vary from person to person depending on the severity of symptoms.

Psychotherapy

Psychotherapy employs talk therapy and other therapeutic techniques to equip someone with bipolar disorder with the skills and coping mechanisms necessary to recognize and change troubling emotions, thoughts, and behaviors. 

Common types of therapy include cognitive behavioral therapy, interpersonal and social rhythm therapy, and psychoeducation to provide the person with coping strategies. Psychotherapy is commonly paired with other treatment options like pharmacotherapy and select procedures.

Medication 

Drug therapies are considered key to treating bipolar disorder. Typical medications for bipolar disorder may include antidepressants, mood stabilizers (anticonvulsants, lithium, and atypical antipsychotics like Vraylar), dopamine agonists, and NMDA-receptor agonists.

Selective serotonin reuptake inhibitor (SSRI) antidepressants are used for treating depression, but tricyclic antidepressants should be avoided because of the possibility of inducing rapid cycling of symptoms. Mood stabilizers are used to manage mania and can reduce suicide risk. Targeted medications for symptoms of anxiety and sleep disturbances may also be prescribed.

Side effects vary by medication, with weight gain, metabolic dysregulation, sedation, and akathisia (restlessness) being the most common. People who take bipolar medications may also experience diarrhea, nausea, and the risk of dehydration. Positive clinical responses to medications may be reduced by endocrine and metabolic comorbidities, weight gain, and obesity.

Procedures

If psychotherapy and medications fall short of providing adequate treatment, procedures may be recommended. 

  • Electroconvulsive therapy (ECT) is a brain procedure for treatment-resistant conditions or in cases where rapid response is required. One study has found ECT to be an effective and safe treatment for drug-resistant bipolar disorder, showing improvement in approximately two-thirds of participants
  • Transcranial magnetic stimulation (TMS) is a newer, noninvasive therapy that utilizes the power of magnetic energy to stimulate nerve cells associated with depression. It can be used in cases where ECT is not appropriate due to potential side effects on memory and cognition. Approximately 50% to 60% of people with depression who did not receive benefit from medications experience a clinically meaningful response with TMS
  • Ketamine infusion therapy has gained interest over the past decade for treating bipolar depression. One study showed those taking ketamine had a statistically significant improvement in symptoms over placebos. Ketamine infusion therapy can be used when a person has exhausted other available options

Severe cases of mania or depression may require hospitalization or admission to day treatment programs. Outpatient programs are also available for less severe cases and can be used as part of a more comprehensive treatment plan.

Coping

People with bipolar disorder can improve their quality of life by taking actions to reduce environmental stressors and triggers, including:

  • Soliciting family and social support, including support groups
  • Vigorous exercises, like jogging, swimming, or running
  • Self-management strategies like keeping drug diaries, setting up reminders, and learning to recognize the onset of manic and depressive symptoms
  • Mood charting, which means recording moods, emotions, and triggers
  • Participating in prayer and faith-based activities
  • Stress reduction activities, including mindfulness meditation

If you or a loved one needs help with bipolar disorder or the associated signs and symptoms, contact the SAMHSA National Hotline for treatment and support group referrals at 1-800-662-HELP (4357).

How to Seek Help


If having suicidal thoughts, call the National Suicide Prevention Hotline at 1-800-273-8255. If you or a loved one is in immediate danger, call 911.

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