Despite the colloquial use of the term “bipolar” and references to the condition in popular culture, bipolar disorder is often misunderstood by the public. While the disorder does feature alternating moods, it is not simple moodiness or unpredictability. Bipolar disorder is defined by specific mood episodes on opposite poles of the mood spectrum: “manic,” or elevated, and depressed.
These mood episodes come with many additional symptoms beyond changes in mood, including altered cognition, sleep and behavior. Bipolar disorder is a severe mental health condition that sometimes requires inpatient treatment to address life-threatening risks and to stabilize people so that in the future they can manage the condition on an outpatient basis.
What Is Bipolar Disorder?
Psychiatrists have been diagnosing and treating bipolar disorder since the mid-1800s. The condition features alternating mood episodes. It was originally called “manic depression,” a term that persists to this day in popular culture and song, though clinicians no longer use it as a formal diagnosis.
Bipolar disorder is defined by the presence of at least one distinct mood episode. While most people with bipolar disorder have depressive or mixed episodes, the Diagnostic and Statistical Manual of Mental Disorders (DSM) only requires people to have a history of manic episodes to receive the diagnosis.
Manic and depressive episodes cause holistic changes to thinking and behavior. People who are depressed have less mental and physical energy, while people who are manic or hypomanic have more.
The sudden intensity of a manic episode can be unpleasant and dangerous. Manic episodes are sometimes severe enough to lead to hospitalization, especially when they include psychotic features like delusions or hallucinations.
Types of Bipolar Disorder
People can be confused by the different types of bipolar disorder and what is meant by terms like manic bipolar disorder, mild bipolar disorder and bipolar I versus bipolar II.
For many people, these distinctions aren’t important. However, it can help to know that bipolar I disorder is more severe than bipolar II disorder and that the difference between them relates to the severity of associated manic episodes. Severe depressive episodes carry risks, but manic episodes are much more dangerous than hypomanic episodes.
Bipolar I disorder is the most severe form of bipolar disorder. It is defined by the presence of manic episodes. There is no requirement regarding depressive episodes. However, most people with bipolar I disorder experience both manic and depressive episodes.
Severe manic episodes are associated with many risks. These include impulsive behavior like reckless driving, excessive spending and unsafe sex. Sometimes people who are manic also experience psychosis. They may start having auditory hallucinations, such as “hearing voices,” or develop grandiose delusions.
Someone who has bipolar I with psychotic features may believe that they are imbued with supernatural powers and act on those beliefs in ways that put them or others at risk of harm. People experiencing extreme manic symptoms usually require a brief period of inpatient hospitalization until they mentally recover to the point they no longer experience psychosis.
For people to be diagnosed with bipolar II disorder, they must have experienced at least one hypomanic episode and at least one major depressive episode. While it is possible for them to experience psychosis during either kind of mood episode, people with bipolar II disorder are much less likely than people with bipolar I disorder to have a psychotic break.
Hypomanic episodes affect people’s functioning but not to the same degree as manic episodes. People do not require hospitalization for hypomanic episodes. Many people with bipolar II disorder experience them as positive periods of increased energy and creativity.
The pleasurable aspects of hypomanic episodes are what cause many people with bipolar disorder to avoid taking medications that control their disorder. However, hypomanic episodes often also have unpleasant aspects like racing thoughts and agitation.
People with bipolar II rapid cycling type typically experience more mood episodes per year than people with other types of bipolar II disorder.
When considering a diagnosis of cyclothymia versus bipolar disorder, the main distinguishing factor between the two is severity. Cyclothymia is even milder than bipolar II disorder. While people with bipolar II disorder have full episodes of hypomania and major depression, people with cyclothymia only have symptoms of hypomania and depression.
People with bipolar cyclothymia have never had a full mood episode as defined in the DSM. They may not even recognize they have an underlying disorder and might experience their shifts of mood as seasonal or contextual. While untreated cyclothymia is less severe than untreated bipolar I or bipolar II disorder, it can affect relationships and work. It can also drive people to use substances to try to regulate their moods.
People who experience a bipolar mixed episode are at increased risk for impulsive and self-destructive behavior, including self-harm and suicide attempts. While mixed state bipolar disorder might seem like a contradiction, it is actually relatively common for people who are depressed to experience sudden bursts of energy that make them feel irritable or agitated. Similarly, people experiencing manic symptoms can sometimes start feeling hopeless.
What makes mixed episodes more dangerous is that people who are severely depressed often lack the energy or motivation to act on suicidal ideation, while people in a mixed state are more likely to act on depressed or hopeless thoughts. Episodes with mixed features can also include psychotic symptoms that make them even riskier and more likely to require hospitalization.
Some people experience bipolar rapid cycling type, also known as rapid cycle bipolar disorder. It is important to understand that the term “rapid cycling” does not mean a person has sudden shifts in mood from one day to the next or mood swings throughout the day. That kind of mood lability typically indicates another disorder, such as borderline personality disorder. In bipolar cycling, people alternate between mood episodes that last a few weeks or one or two months instead of typical bipolar episodes that last for several months each.
Some of the people that originally defined bipolar disorder in the late 19th and early 20th century viewed it as a spectrum disorder, with there being stages of bipolar disorder rather than specific or discrete types of bipolar disorder.
While this concept is not reflected in the way bipolar disorder is diagnosed, it can be helpful for some people who are trying to better understand their experience with the disorder. People who have more depressive episodes or symptoms and therefore fall on the depressive end of the spectrum may need different interventions than do people who frequently experience and need to manage manic or hypomanic symptoms.
Symptoms of Bipolar Disorder
Signs of bipolar disorder can be subtle at first. Some people may experience alterations to cognition, such as bipolar memory loss before they experience any mood symptoms. They might notice they are having difficulty recalling words or remembering plans before more distinctive symptoms of depression or mania start to occur. Early bipolar signs often include disruptions in sleep and increased irritability.
Episodes of what some people with the disorder called “bipolar anger” are often a precursor to a full bipolar mood episode. As brain chemistry shifts, increased irritability can spur people to snap or lash out at others.
Bipolar rage attacks can occur in the context of depression or mania. Research shows that increased anger and aggression in bipolar disorder is independent of the polarity of the current mood episode but is more common in acute mood episodes, especially when psychotic features are present.
While some bipolar symptoms are independent of mood episodes, most of the time, symptoms of bipolar disorder are indicative of one of three mood states: depression, mania or hypomania.
Bipolar depression symptoms are generally the same as symptoms of major depressive disorder, except in cases where mixed features are present. While worsening mood and hopeless thoughts are typically associated with depression, the onset of a depressive episode is often first signaled by a loss of energy and changes to appetite, sleep and cognition. People who are depressed have more difficulty making decisions or maintaining the motivation to pursue personally important activities.
The onset of bipolar mania is often indicated by increased energy level and mental activity. In the early stages of a manic episode, people may notice that their thoughts race from topic to topic. They may develop sudden new interests that progress to compulsive behavior as the manic episode develops.
For example, a new interest that develops in the early phase of a manic episode can lead to someone spending thousands of dollars on items related to that interest in the acute phase of a manic episode.
People who have bipolar with psychotic features can experience symptoms of psychosis in the course of depression or mania, though psychosis is more common in manic episodes. Symptoms of psychosis are usually mood congruent, which means that they reflect the underlying mood of the episode.
For example, when they are hearing voices, bipolar patients are more likely to hear blaming or hostile voices when they are depressed. When experiencing a manic episode, they may hear benign voices with messages that they are “special.”
The symptoms of hypomania are similar to the symptoms of mania, just more subtle. Many people experience feelings of inspiration at the onset of a hypomanic episode. They may feel more creative or adventurous and decide that they want to start a major new project.
Pleasant symptoms like these cause some people to embrace their bipolar disorder even if it means accepting less pleasant episodes or symptoms. It’s important to note that not all hypomanic symptoms are benign — people can often feel irritable, anxious or out of control when they are hypomanic.
Causes of Bipolar Disorder
Some people may ask, “Is bipolar genetic?” or “Is bipolar hereditary?” The disorder does have strong genetic components. Research published in Scientific American indicated that someone with a parent who has bipolar disorder is six times more likely than others to struggle with the condition. The risk is even more pronounced if both parents have bipolar disorder.
The most powerful bipolar disorder causes are biological differences that can be inherited. Research suggests that bipolar disorder is caused by changes in brain structure and function, including changes in levels of the neurotransmitters serotonin, dopamine and norepinephrine.
While environmental factors cannot cause bipolar disorder, they can increase the risk that a person will develop the disorder. They can also trigger its onset, causing people to experience bipolar symptoms earlier than they would have otherwise. Bipolar triggers include stress, sleep deprivation, trauma and substance abuse.
How Is Bipolar Disorder Diagnosed?
As with any other mental health diagnosis, professionals make a bipolar disorder diagnosis through a series of clinical interviews. They may use a screening tool or bipolar test with targeted questions to determine if a person meets DSM criteria for a bipolar diagnosis.
Some people might be diagnosed with bipolar disorder for the first time during an episode of inpatient treatment. People with bipolar I disorder are often hospitalized after their first manic episode. Hospital staff makes observations over several days to determine the most appropriate diagnosis for people who exhibit both psychotic symptoms and elevated mood.
It can be harder to diagnose bipolar disorder when a person is experiencing a depressive episode. Mental health professionals engage in a careful process of differential diagnosis to determine if a person who has symptoms of depression has also ever had symptoms of mania or hypomania. They must determine whether a person experiences the distinct mood episodes that indicate bipolar disorder or shorter-term mood instability, which may indicate another kind of disorder, such as a personality disorder.
Who Is at Risk of Bipolar Disorder?
The risk factors for bipolar disorder include the following:
- A family history of bipolar disorder or other mood disorders
- Early experiences that affect brain function, such as head trauma
- Childhood trauma or growing up in an unstable or violent home
- Substance abuse in late childhood or early adolescence
- Sleep deprivation, especially when chronic
- Long periods of elevated stress
substance abuse can cause changes in the brain that can trigger the onset of bipolar disorder. However, it is unlikely that anyone without genetic or biological risk factors will develop the disorder, even when several environmental risk factors are present.
Bipolar Disorder Statistics
Bipolar statistics include the following:
- About 3 percent of the United States population has bipolar disorder in a given year.
- People with bipolar disorder suffer from the most severe functional impacts of any mood disorder, with 83 percent of people experiencing serious impairment.
- About 65 percent of people with bipolar disorder have a manic or hypomanic episode before they have a depressive episode.
- From 25 to 50 percent of people with bipolar disorder attempt suicide at least once.
- Suicide is the cause of death for over 15 percent of people with bipolar disorder.
- This means that the bipolar suicide rate is 25 times higher than the suicide rate in the general population.
Bipolar Disorder by Age and Gender
Bipolar disorder usually emerges for the first time in early adulthood but can also arise in adolescence. There are some differences in how the disorder manifests based on the age and gender of the person with bipolar disorder.
Bipolar in Men
While rates of bipolar disorder are similar for women and men, bipolar symptoms in men differ from bipolar symptoms in women. Men with bipolar disorder have higher rates of comorbid substance use disorders and social and legal problems than women do. They also tend to experience the onset of the disorder at a younger age than women.
Bipolar in Women
Women with bipolar disorder experience rapid cycling and mixed episodes more frequently than men do. They also have higher rates of comorbid eating disorders, sleep problems and changes to appetite and weight than men. Women are more likely to experience seasonal patterns of mood episodes and to have co-occurring medical conditions like migraines and thyroid problems.
Women who experience bipolar and pregnancy at the same time are generally not more or less likely to experience severe symptoms. However, they do face risks if they have to discontinue the bipolar medication they are taking while they are pregnant. They are also at increased risk of severe symptoms and the onset of a mood episode during the postpartum period.
Bipolar in Children
Diagnosing bipolar disorder in children remains controversial but ongoing research and treatment support the concept of pediatric bipolar disorder. Attempts have been made to distinguish bipolar in children from the way the disorder manifests in adulthood.
Disruptive mood regulation disorder (DMRD), which was added to the DSM in 2013, is now used in some instances for children instead of a bipolar diagnosis. Temper outbursts that are excessive and inconsistent with a child’s level of development are the primary factors used in determining a DMRD diagnosis.
Signs of bipolar disorder in children are different than they are in adults. Children do not typically have discrete mood episodes but instead experience abrupt and frequent shifts in their moods and energy levels. This makes them more irritable and prone to temper tantrums and defiant behavior than other children. They may exhibit alternating hyperactivity and lethargy.
A careful process of differential diagnosis is required to rule out alternative diagnoses like anxiety, conduct disorders or attention-deficit/hyperactivity disorder in children with these symptoms.
Bipolar in Teens
People who experience early-onset bipolar disorder during childhood or adolescence are at a significantly increased risk of severe depression and mania. They are also at risk of having fewer days symptom-free as adults.
This may have more to do with the amount of time between the onset of their symptoms and when they start treatment than with factors specific to age. This is a reason why it is important for bipolar disorder in teens to be diagnosed and treated as soon as possible.
Symptoms of bipolar disorder in teenagers can resemble childhood or adult symptoms — or both. Unlike children, adolescents can experience manic, hypomanic or depressive episodes. Conversely, they may experience subtler shifts in mood and energy levels as precursors to a first mood episode.
Bipolar in Adults
Does bipolar get worse with age? Mood episodes do not necessarily worsen as people with bipolar disorder get older, but they do get worse if a person stops pursuing treatment for the disorder.
If people spend years dealing with untreated bipolar symptoms, they are much more likely to experience increasingly worse mood episodes until they receive treatment. They are also at an increased risk of developing co-occurring conditions like substance use disorders.
If you or someone you know grapple with untreated bipolar disorder along with an addiction to drugs or alcohol, help is available. The Recovery Village operates treatment centers across the United States that provide integrated treatment options for people with comorbid mental health and substance use disorders. Contact a representative at The Recovery Village to learn about specialized treatment options and how you can get started on the road to recovery.