Bipolar disorder (formerly known as Manic Depression) is a chronic mental health condition associated with large fluctuations in mood, energy, and activity levels. These mood shifts go beyond typical ups and downs; they can be intense, disruptive, and sometimes dangerous if left untreated. They can last anywhere from a few days to a few months, meaning these changes can significantly impact an individual’s ability to function on a social or occupational level.
Bipolar disorder occurs across a spectrum, with variations in severity, usually falling into one of three different categories: Bipolar I, Bipolar II, or Cyclothymic Disorder.
DSM-5 Criteria and Symptoms
Bipolar I Disorder
According to the DSM-5, manic episodes are an important part of Bipolar I Disorder. They are characterized as a distinct period of abnormally and persistently elevated, expansive, or irritable mood, followed by a persistently increased level of goal-directed activity or energy.
In some cases, a manic episode can have psychotic features. They need to last at least one week and be present during most of the day, nearly every day. During this period, at least three of the following symptoms must be present—or at least four symptoms if the person’s mood is irritable rather than elevated or expansive:
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- Increased talkativeness or pressure to keep talking
- Flight of ideas or racing thoughts
- Easily distracted
- Increased goal-oriented activity or psychomotor agitation (ex. pacing, fidgeting, racing speech)
- Excessive involvement in risky activities (ex. spending sprees, foolish business investments, sexual indiscretions)
In Bipolar I, manic episodes may be followed by a hypomanic episode, a major depressive episode, or both.
A hypomanic episode is similar to a manic episode, but is less severe, doesn’t require hospitalization, and needs to last at least four consecutive days. Although hypomanic episodes are common in Bipolar I, they are not required for a diagnosis.
A major depressive episode is common in Bipolar I, but as with a hypomanic episode, is not required for diagnosis. Major depressive episodes are characterized by at least two weeks of depressed mood or loss of interest/pleasure, followed by four or more additional symptoms:
- Significant weight loss or weight gain
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness or excessive guilt
- Inability to concentrate or think
- Recurrent thoughts of death
Mixed episodes are usually described as the worst part of bipolar disorder by individuals who experience it. These episodes have symptoms of both a manic and a depressive episode. Individuals can experience negative thoughts and feelings, but still feel restless and have high energy levels.
In order to be diagnosed with Bipolar I, these symptoms must have a severe impact on social and occupational functioning, and can’t be attributed to the physiological effects of substance use or another medical condition.
Bipolar II
In order to be diagnosed with Bipolar II, according to DSM-5, an individual needs to experience at least one hypomanic episode and at least one major depressive episode, but have no history of manic episodes.
It is often misunderstood as a “milder” form of Bipolar I Disorder. However, this can be misleading, since major depressive episodes last longer than hypomanic ones, and can severely impair an individual’s ability to function.
Bipolar II Disorder carries a high risk of misdiagnosis or under-treatment, because symptoms of hypomania are often overlooked or misinterpreted as a “good” period. This can lead to worsening mood and an increased risk of suicide.
Patients may also face challenges in relationships, employment, and self-esteem as a result of unpredictable shifts between an elevated and depressed mood.
Cyclothymic Disorder (Cyclothymia)
Cyclothymia is a milder but chronic form of bipolar disorder. It involves at least two years of numerous periods of hypomanic symptoms and periods of depressive symptoms that don’t fully meet the criteria for either a hypomanic episode or a major depressive episode.
Individuals diagnosed with Cyclothymic Disorder often experience mood shifts spontaneously, in some cases even within the same day.
Treatment methods
Bipolar is a lifelong disorder, but with the right treatment, symptoms can be managed and individuals can lead a functional and fulfilling life. Treatment plans usually combine medication, psychotherapy, alternative treatments (ECT and TMS), and lifestyle changes tailored to the individual’s needs.
Medication is usually the foundation of treatment for bipolar disorder, as it helps stabilize mood shifts and reduce the severity and frequency of manic or depressive episodes. Some examples of medication include:
- Mood stabilizers (lithium, valproate, lamotrigine, etc.)—often the cornerstone of treatment, helping prevent mood shifts and reduce the risk of relapse.
- Atypical antipsychotics (quetiapine, olanzapine, lurasidone, etc.) can be effective for acute mania or depression, and for maintenance therapy (helping to prevent an episode in the future).
- Antidepressants are used cautiously, always in combination with mood stabilizers, as they can trigger mania or rapid shifts in some individuals.
- Anti-anxiety medication may be prescribed in the short term for severe agitation or insomnia, but in general, they are not a long-term solution.
Psychotherapy helps individuals recognize warning signs of their mood shifts, learn healthy coping mechanisms, and most importantly, understand their condition. Some evidence-based approaches include:
- Cognitive Behavioral Therapy (CBT) – a very structured, goal-oriented mode of therapy. CBT focuses on recognizing and changing negative thinking patterns and behaviors.
- Interpersonal and Social Rhythm Therapy (ISRT) – this specific approach was designed to help people who struggle with mood disorders. It focuses on an individual’s biological and social rhythms (ex. daily routines, sleep, and meal times) and teaches them how to manage stressful events in order to avoid disruptions in those rhythms.
- Family-focused therapy (FFT) – mainly focuses on psychoeducation of individuals and their loved ones on the topic of bipolar disorder. It helps them improve communication and problem-solving skills within the household.
Lifestyle strategies play an important role in the treatment process. It is recommended to be mindful of daily habits by keeping a consistent sleep schedule, engaging in regular exercise, avoiding alcohol or other substances that can trigger bipolar symptoms, and using mood tracking tools (ex. mood charts) to monitor progress in treatment.
In some cases, a professional might consider alternative treatment methods, such as:
- Electroconvulsive Therapy (ECT) – a medical treatment which is used in severe cases of bipolar disorder, especially where the risk of suicide is high. During ECT, a brief, controlled electrical stimulation is applied to the brain, rapidly improving mood symptoms. This procedure is considered safe and very effective in treating treatment-resistant cases.
- Transcranial Magnetic Stimulation (TMS) – a non-invasive brain stimulation technique used primarily in cases of treatment-resistant depression. The treatment is usually performed by placing an electromagnetic coil against the scalp, which generates magnetic pulses that stimulate nerve cells in regions of the brain that are responsible for mood regulation. Patients usually undergo a few sessions over several weeks.
Crisis and relapse planning
Bipolar disorder carries a high risk of relapse, especially during stressful life events, which is why having a written crisis plan can be crucial. This plan can include emergency contact numbers, steps to take when early warning signs appear, or agreements with loved ones on how to respond in a crisis.
Being part of a support group can also provide valuable understanding, encouragement, and assistance, particularly during times of crisis.
