Bipolar disorder is characterized by symptoms that occur in distinct episodes with periods of normal mood in between. Many times, there is no clear pattern of when or how frequently manic episodes will occur, or when or how often they alternate with depressive episodes. Severe mood swings can happen over a period of hours, days, weeks, months and sometimes even years.
Signs and symptoms of mania (manic episode)
The core symptoms of the disease must be present for 1 week and/or require hospital admission:
- A distinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least 1 week (or any duration if hospitalisation is necessary)
- During the period of mood disturbance, 3 (or more) of the following symptoms should have persisted (4 if the mood is only irritable) and have been present to a significant degree:
- inflated self-esteem or grandiosity
- decreased need for sleep (e.g. feels rested after only 3 hours of sleep)
- more talkative than usual or pressure to keep talking
- flight of ideas or subjective experience that thoughts are racing
- distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli)
- increase in goal-directed activity (either socially at work or school, or sexually) or psychomotor agitation
- excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions or foolish business investments)
- The symptoms do not meet criteria for a ‘mixed episode'
- The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalisation to prevent harm to self or others, or there are psychotic features
- The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication, or other treatment) or a general medical condition (e.g. hyperthyroidism)
What are the symptoms of depression?
Five (or more) of the following symptoms have to be present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: do not include symptoms that are clearly due to a general medical condition or
mood-incongruent delusions or
hallucinations.
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad or empty) or observation made by others (e.g. appears tearful). Note: in children and adolescents can be irritable mood
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
- Significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. In children, consider failure to make expected weight gains
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day (observable by others not merely subjective feelings of restlessness or being slowed down)
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
- Diminished ability to think or concentrate, or indecisiveness nearly every day (either by subjective account or as observed by others)
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan or a suicide attempt or a specific plan for committing suicide
Can psychosis be a symptom of bipolar disorder?
Severe episodes of mania or depression can include the symptoms of
psychosis. People may have hallucinations: they hear or see or sense the presence of certain things that are not actually there. Another possible symptom is delusions: patients have false, but strong beliefs that cannot logically be explained.
The type of psychotic symptoms reflects the mood of the patients. During a manic episode, they may believe themself to be a person with special powers or wealth. During depressive episodes, they may believe themself to be worthless, or to be ruined or to be guilty of a crime.
It is important to note that people with bipolar disorder suffering from psychosis are often incorrectly diagnosed as suffering from schizophrenia, another severe mental illness.
Obviously, when patients suffer psychotic symptoms, urgent intervention by a doctor is required.
Severity of the symptoms
When a person is diagnosed with manic symptoms, he or she can experience these symptoms at various levels of severity from mild to moderate to severe. The same can be said for depressive symptoms.
The mood states of a bipolar patient can alternate between two opposite poles with severe mania at one end and severe depression at the other.
The severity of the depressive and manic episodes can vary from person to person, and in the same person at different times.
Hypomania is a mild to moderate form of mania with similar but less severe symptoms lasting at least 4 days. In contrast to mania, people are not psychotic and do not suffer from hallucinations or delusions. Because hypomania is potentially associated with good functioning, increased productivity and less impairment, people often don't feel that anything is wrong. However, without treatment hypomania may escalate into mania or switch into depression.
What is the frequency and duration of the symptoms?
The kind of episodes a person experiences can differ. Some people have equal numbers of manic and depressive episodes, others have mostly one type or the other. Some persons with bipolar disorder will have many periods of depression before becoming manic. Others will quickly switch between high and low moods and back again.
On occasion a person may have symptoms of mania and depression at the same time. This is known as a "mixed state". The symptoms often include agitation, trouble sleeping, significant change in appetite, psychosis and suicidal thinking.
People have bipolar I disorder if they have at least one manic or mixed mood episode with or without depression. This form typically presents as full blown mania, and may require hospitalisation. People have bipolar II disorder if they have at least one hypomanic and at least one depressive episode (no full manic episodes). Bipolar II disorder can go un-recognized because the hypomanic symptoms may not be identified. People often overlook hypomania and only seek treatment during depressive episodes. Unfortunately, when antidepressants are prescribed, there is a risk that the medication induces or 'triggers' a manic episode and that episodes become more frequent. Some people with initial hypomania (bipolar II) may later have a manic episode and develop bipolar I disorder, while others have only recurring hypomania.
What is the frequency and duration of episodes?
In most people the number of episodes experienced in a lifetime is approximately 8-10, but many patients have more and some have less. The average person with bipolar disorder has 4 episodes during the first 10 years of the illness. While in some patients a number of years pass between the first 2 or 3 episodes of mania or depression, without treatment people may have more frequent episodes. Sometimes the episodes follow a seasonal pattern (for example getting hypomanic in the summer and depressed in the winter). A small number of people cycle frequently or even continuously through the year. The duration of the episodes is not identical for everyone. On average, without treatment, manic or hypomanic episodes last a few months while depressive episodes may last well over 6 months. Some people recover entirely between episodes and are symptom free for many years while others continue to have low-grade but troubling depression or mild mood swings.
When at least 4 episodes occur within a 12-month period in any combination of manic, hypomanic, mixed or depressive episodes, people are said to have bipolar disorder with 'rapid cycling' . Fast mood swings (rapid cycling) are more common in women than in men, and they can be triggered by antidepressant treatment. In severe cases rapid cycling can occur even within a one-day period.
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Item code: NPR/08-0048
Date of Preparation: July 2009
