Happy, sad, excited, angry—our moods swing like a pendulum, reflecting the everyday ups and downs in our lives and how we cope with them. It’s perfectly normal and healthy to experience a range of moods throughout the course of a day. For some people, though, the pendulum swings to extreme. Moods seesaw between profound lows and soaring highs. These symptoms signal the classic presentation of Bipolar Disorder.
Mania is hard to miss. People in this state can’t focus. Their thoughts race. They talk fast. They live on very little sleep and engage in risky behaviors like speeding, overspending, or hypersexuality. They may think they are invincible or possess an inflated sense of self, which leads to reckless decisions. They are frequently impulsive and irritable, and are likely to hurt themselves or others. Unfortunately, people in this state are also very resistant to treatment. Mania is the hallmark symptom of Bipolar Disorder type I.
Hypomania is a tamer form of mania and is not nearly as disabling. People in a hypomanic state might function pretty well. They can be creative, energetic and goal-oriented—behavior easily characterized as normal. Hypomania and depression alternate in Bipolar Disorder type II. Depressive episodes mimic major depression with drained energy, low mood, altered sleep and appetite, and suicidal thoughts or behavior.
Although hypomania is a milder form of mania, Bipolar II is not a milder form of Bipolar I. In fact, in Bipolar II, the depressive symptoms are the most concerning and most disabling, and the hypomania is recognized later and is much less problematic. The depressive symptoms of Bipolar II create a more long-term type of impairment while the manias of Bipolar I lead to more periodic issues.
Bipolar I usually starts around age 18, while Bipolar II starts later, in the mid 20s. When parents suspect Bipolar Disorder in young children, they should also consider the possibility of Disruptive Mood Dysregulation Disorder. Bipolar I comes to light because of the manic episodes. However, depression is usually the first symptom of Bipolar II, and those patients are diagnosed with Major Depressive Disorder until a hypomanic episode occurs. In fact, 12% of people who are initially diagnosed with Major Depressive Disorder have their diagnosis changed to Bipolar Disorder II.
Causes and Risk Factors
Rates and intensity
About 1% of Americans deal with Bipolar I at some point in their lives, and Bipolar II is only slightly less frequent. However, for over 80% of patients, the disorder’s intensity is severe, which means they suffer many more symptoms than the bare minimum needed to make the diagnosis. This means that the vast majority of patients with Bipolar Disorder suffer very distressing and debilitating symptoms that significantly disturb their ability to function.
Both disorders occur in similar rates in men and women. However, women are more likely to experience mixed episodes, depressive episodes, and rapid cycling. Women are also at higher risk for co-occurring Alcohol Use Disorder.
Having other family members with Bipolar Disorder is one of the most reliable and powerful predictors of developing the disorder. The degree of risk increases with increased number of affected relatives and can increase the risk by up to ten times.
Anxiety Disorders are the most common mental disorders that occur alongside Bipolar Disorder I and II, appearing in 75% of these cases. Attention Deficit/Hyperactivity Disorder, Disruptive, Impulse-Control, and Conduct Disorders, and Substance Use Disorders strike more than half of people with Bipolar I. Thirty-seven percent of people with Bipolar II also have a Substance Use Disorder, and alcohol is the most common substance of abuse for these patients.
About a third of people with Bipolar I and II attempt suicide at some point during their illness. Their risk of suicide is 15 times the average, and suicides related to Bipolar Disorder make up almost 25% of all suicides. Additionally, patients with Bipolar II have a much higher risk for completed suicide compared to those with Bipolar I, possibly because of the greater tendency for depression in Bipolar II. For Bipolar II, this increased risk extends even to patients’ first-degree family members (parents, siblings, and children) who do not have Bipolar Disorder themselves. These relatives have over six times the risk of suicide as relatives of patients with Bipolar I.
Diagnosing Bipolar Disorder I and II
Mania vs. Hypomania
These are episodes of excessively euphoric, emotional, or irritable mood accompanied by significantly increased energy that last at least one week for mania and at least four days for hypomania. People with Bipolar Disorder experience at least three of the following symptoms (four if their mood is irritable).
- Greatly increased self-esteem or feelings of superiority
- Reduced need for sleep
- Rapid and increased speech
- Racing thoughts
- Decreased attention span
- Increased energy put towards multiple new projects (as part of work, school, or hobbies) or physical agitation
- Increased participation in risky activities, like impulsive business decisions, shopping binges, and unrestrained sexual activity
While both mania and hypomania cause noticeable changes in functioning, only mania impairs performance in social or work domains. Manic episodes can also require a stay in a psychiatric hospital (to prevent them from harming themselves or others). They may include psychotic symptoms like hallucinations or delusions, but hypomanic episodes do not.
To be diagnosed with Bipolar Disorder I, a person needs to have at least one manic episode. However, for Bipolar Disorder II, both a hypomanic episode and a major depressive episode have to occur.
The criteria for a major depressive episode are similar to those for Major Depressive Disorder. This requires at least two weeks of at least five of the following symptoms, including either #1 or #2.
- Depressed mood (sad and hopeless most of the time on most days)
- Lack of interest in previously enjoyed activities
- Significant decrease or increase in appetite
- Increase or decrease in sleep
- Physical agitation or slowed movement
- Decreased energy
- Hopelessness or guilt
- Difficulty concentrating
- Recurrent thoughts of dying, planning suicide, and suicide attempts
Mixed episodes are a combination of symptoms from a major depressive episode and either a manic or hypomanic episode. These can be either full mania/hypomania with partial symptoms of depression or full depressive episodes with a few symptoms of mania/hypomania.
This denotes when at least four complete altered-mood episodes occur in a single year. These can be mania for Bipolar I and either hypomania or major depression or Bipolar II.
Depressive episodes can have atypical features, which describes a depressed mood that improves in a positive environment. Melancholic features specifies a depressive episode that includes a complete lack of ability to feel pleasure or enjoyment. People with catatonic features do not respond much to the environment. They have slowed, rigid movement, fail to speak or respond, and can have repetitive movements or staring. Peripartum onset includes mania, hypomania, or major depression that starts during pregnancy or within four weeks following childbirth. A seasonal pattern is when a majority of the mood episodes of at least one type (mania, hypomania, or depression) begin and end in characteristic times of year for at least two years.
Treating Bipolar Disorder I and II
Treating Bipolar Disorder has two parts: addressing mood episodes when they happen and preventing new ones from reoccurring.
The most common first choice medication for new-onset mania is lithium. Depakote (divalproex) and antipsychotics such as Risperdal (risperidone), Seroquel (quetiapine), and Zyprexa (olanzapine) are also possible front line options. The antipsychotics can be combined with Depakote or lithium if the symptoms are resistant to the initial medication choice. Any antidepressant medications the patient is taking should be put on hold during the manic episode and can make symptoms worse if they are not stopped temporarily.
These are particularly difficult to treat, and the Food and Drug Administration has only approved two medications for them. These are Seroquel (quetiapine) and a combination of Zyprexa (olanzapine) and Prozac (fluoxetine).
Lithium and Depakote are the first choice medications for preventing new episodes of mania and depression and reducing the risk of suicide. Lamictal (lamotrigine) is a good choice for people who are especially prone to depression. For people who responded well to antipsychotic medications during new-onset mood episodes, those may simply be continued as maintenance medications. The Food and Drug Administration has also approved Risperdal Consta, which is a long-acting, injection version of risperidone that patients receive once every two weeks. Stopping any maintenance medication should be done gradually, as ending one suddenly can instigate relapse.
Psychoeducation is the most important form of psychotherapy for Bipolar Disorder I or II, and every patient with Bipolar Disorder I or II should receive at least some form of it. This type of therapy focuses on teaching people how best to detect the symptoms of an oncoming episode of mania, hypomania, or major depression. This gives people more lead time to schedule an appointment with a doctor or therapist to address the upcoming issues. People who receive this type of therapy as part of their treatment enjoy longer periods of time free from mood episodes.
Three other therapy types are can be useful in treating new major depressive episodes or in preventing relapse: family-focused therapy, Cognitive Behavioral Therapy (CBT), and interpersonal and social rhythm therapy.
Family-focused therapy involves educating family members about Bipolar Disorder and stresses communication and training to manage mood episodes. This therapy combined with medication can reduce future manic, hypomanic, and depressive episodes by a third. Cognitive Behavioral Therapy seems to only be useful in treating depressive episodes in patients who have had fewer than 12 mood episodes total and is not useful in preventing mood episodes. In interpersonal and social rhythm therapy, patients learn how important regular daily routines and a reliable sleep schedule are for maintaining a stable mood. Using this treatment during mood episodes extends times of stable mood and improves functioning during those times.
Managing Bipolar Disorder I and II
Family support skills
Communication between members of the immediate family is one of the most important factors in noticing and managing mood episodes. Any family members who live with the a person with Bipolar Disorder should learn the signs of upcoming mood changes. Reduced need for sleep is a very common early sign of mania and hypomania, while low mood and decreased energy signal upcoming depression. These families should practice approaching these situations as early as possible rather than letting them fester.
People sometimes try to use alcohol and other drugs to bring down the highs of mania or fight the lows of depression. However, these are not effective solutions in any long term sense and repeated drug use in these situations will only make symptoms ultimately worse. Replace drinking and drugs with regular exercise and proper sleep. Mania, hypomania, and depression all affect sleep, and the best response is to commit to spending 8 hours a night in bed. Get into bed during a mania or hypomania even if you don’t feel tired, and try to get out of bed as much as possible during a depressive episode.
A good exercise schedule can help burn off some of the extra energy from manias and hypomanias and can make it easier to get to sleep at night. During a depression, a work-out routine will help get you out of the home and socializing, especially if you engage in a group activity.
Be your own look-out
Once you have been diagnosed with Bipolar I or II and found a medication that works for you, the work to prevent relapse begins. It is helpful to know what warning symptoms are unique to you when episodes of mania, hypomania, and depression are looming on the horizon. Write them down and put the list in a place you will see often. Have a set of resources that you have tested and know work for you when you feel a mood episode coming on. These could be scheduling a therapy appointment, attending a support group, or having a conversation about it with your partner. Have an emergency contact and plan for managing a bad episode so you know what to do when things take a turn for the worse.