Together at the Poles

Symptoms of Bipolar Disorder

By Daniel Bader, Ph.D.


Because bipolar disorder is such a wide spectrum disorder and because that disorder includes multiple phases and episodes, the symptoms are quite complex. In this article, I will discuss the various symptoms of bipolar disorder, as well as what to look for in behavior that might indicate a manic, hypomanic or major depressive episode.

Definitions

First, let’s start with some definitions:

According to the Diagnostic and Statistical Manual of Mental Disorders IV (the “DSM IV”), someone has Bipolar 1 Disorder when he or she has had one or more manic or mixed episodes (assuming that the episode is not triggered by drugs or explained by another mental illness). People with Bipolar 1 Disorder have usually had at least one major depressive episode, though this is not necessarily the case.

According to the DSM IV, someone has Bipolar 2 Disorder when he or she has had one or more hypomanic episodes, coupled with one or more major depressive episodes, but has not had a manic or mixed episode.

Okay, so we have the definitions of the disorders out of the way. What exactly, then, are manic episodes, hypomanic episodes and mixed episodes?

Manic Episodes

Sad and Happy Fingers

Source: katerha - CC BY 2.0

According to the DSM IV, which is the source of all the definitions below, in order to qualify as a manic episode, one must have mood that is elevated, expansive or irritable for at least one week (though the one-week period is lifted in cases of hospitalization). In addition, the episode must either significantly impair functioning, create danger or harm to self or others, require hospitalization or include psychotic symptoms.

  • An elevated mood is a mood described as feeling “high” or “on top of the world”.
  • An expansive mood is a mood where someone shows little restraint in expressing one’s emotions, has an exaggerated sense of one’s own abilities and is easily agitated.
  • An irritable mood is unfortunately poorly defined in the DSM IV (see for instance this article). It is a folk concept referring to easy provocation to anger and aggression.

In addition to these one of these three types of moods, one must also have at least three of the following symptoms (or four if the mood is irritable):

Inflated self-esteem or grandiosity

When one has an inflated sense of self-esteem or grandiosity, it means that one has a sense that one is far more important than one actually is. This can become delusional, in which people will actually believe that they are very important people (such as the Messiah or a reincarnation of a historical figure) or that they have some very special mission (such as having been sent by God).

Decreased Need for Sleep

People in manic episodes will often stop sleeping, sometimes nearly entirely. They simply never get tired and are unable to rest. In addition, when they do rest, they feel rested almost immediately, and may feel that they are completely rested after only sleeping for a few hours. Note that this lack of need is only an apparent lack of need. People in manic states are actually becoming increasingly sleep-deprived and physically exhausted.

Talkativeness and Pressured Speech

People with bipolar disorder may become extremely talkative, and it will often be difficult to have conversations with them, as they may interject constantly. In addition, speech tends to be both very rapid and also what is called “pressured“. In pressured speech, the person’s speech can’t keep up with his or her thoughts, leading to a sense that the person is trying to push out words as quickly as possible.

Racing Thoughts

In manic episodes, people’s thoughts start to race incredibly quickly and will often reach the point that they become incoherent. The person will fly from one idea to another, and will have the subjective experience that his or her own thoughts are simply moving along quickly without any conscious control.

Distractibility

Going along with the racing thoughts is often distractibility. The person focuses easily on small details without seeing the “big picture”, as it were. Little things that would not normally be noticed can immediately sway the person’s attention.

Increased Pursuit of Goals

People in manic episodes will tend to work toward specific goals, often ones which are unattainable. For instance, they might pursue the writing of a novel or a sexual conquest. In one sense, all action is goal-oriented, but the person in a manic episode is especially “driven”.

or Psychomotor Agitation

Someone in a manic state will often need to pace, will constantly fidget, will scratch incessantly, will rock and so forth. The person finds it difficult to sit still, and will actually find it uncomfortable to do so. The “or” here means that even if one has both increased pursuit of goals and psychomotor agitation, it only counts as a single symptom for the sake of diagnosing a manic episode.

Excessive Involvement in Potentially Harmful Pleasurable Activities

This is the symptom that gets people with bipolar disorder in the most trouble. They will often engage in a number of activities without regard for the consequences. They will not just be any activities, but will generally have two components. First, the activity will be pleasurable, such as shopping, gambling or sex. Second, the person will significantly underestimate or ignore the consequences, likely because of their grandiosity.

Hypomanic Episodes

Hypomanic episodes are essentially less serious versions of manic episodes. In general, the symptoms are the same or similar, but either less severe or last for a lesser period of time.

First, a hypomanic episode requires a period of elevated, expansive or irritable mood that lasts four days (as opposed to seven).

Second, a hypomanic episode requires three of the same seven conditions as a manic episode: inflated self-esteem or grandiosity, decreased need for speech, talkativeness or pressured speech, racing thoughts, distractability, increased pursuit of goals or psychomotor agitation, and excessive involvement in potentially harmful pleasurable activities. Note that, unlike with manic episodes, only three conditions are needed in the case of irritability.

Hypomanic episodes must be accompanied by a change in functioning, they must be observed by someone else, they must impair social or occupational function, and they must include no psychotic symptoms, nor require hosiptalization, and they must be not be the result of drugs or pharmaceuticals.

In sum, hypomanic episodes are shorter than manic episodes, and cannot include any psychotic symptoms or hospitalization.

Major Depressive Episodes

All people with Bipolar 2 have had at least one major depressive episode, as have most people with bipolar 1. Note that people without bipolar disorder, especially people with major depressive disorder, also have major depressive episodes. This leads to the possibility of misdiagnosis in some cases.

A major depressive episode must last at least two weeks, and provide some kind of significant impairment in functioning. The depressive episode must not be the result of another medical condition nor be the result of hallucinations or delusions. The depressed person must also have at least five of the following symptoms, including at least one of depressed mood or loss of interest or pleasure.

In addition, in order to qualify as a major depressive episode, the symptoms below must result in significant distress or impairment in functioning. They must also not be the result of drugs or pharmaceuticals. In addition, they must not be the result of bereavement within two months of the loss of a significant person.

Depressed Mood

The person must have a depressed mood most of the day, nearly every day of the two-week or more period. No definition of depressed mood is given by the DSM IV, but whether or not someone should be considered depressed can be based simply on self-reporting. In other words, if you ask someone if they have been depressed, and they say “yes”, they are, for the purposes of this condition. In addition, a depressed mode can be seen by someone else, who notices some symptom like crying or refusal to get out of bed, for example. In children and adolescents, depressed mood can take the form of irritability.

Loss of Interest

Most of the day for nearly every day, the person loses almost all pleasure (or all pleasure) in activities of any kind. Because the person will not experience pleasure, it will usually also lead to the person losing interest in any activities that are normally pleasurable. As with depressed mood, this can either be self-reported or observed by someone else, who might, for example, witness the person stop doing activities that are normally pleasurable.

Weight Loss or Gain

People who are depressed have their weight respond differently. Some people will start eating excessive amounts and report an increase in appetite during the day. Others will be less hungry and start eating less. If someone’s weight increases or decreases by 5% during the month, that is considered sufficient, as is any self-reported gain or loss of appetite. For children, depression may lead to loss of expected weight gains, rather than weight loss.

Sleeping Too Much or Too Little

Many people who have major depressive episodes are either consistently unable to sleep or find themselves unable to stay awake. This is more than just a sleepless night or two, but must be consistent insomnia or hypersomnia that lasts through the entire duration of the episode, almost every day (or night).

Psychomotor Agitation or Retardation

As with manic episodes, psychomotor agitation can be a symptom of major depressive episodes. This is the need to constantly pace, move limbs and so forth. Unlike with manic episodes, however, this agitation needs to be observable by others, not simply self-reported. Often this is established by the psychiatrist asking if others have commented on the agitation (or the psychiatrist seeing it himself or herself).

On the other hand, psychomotor retardation or slowing down can also be a symptom of being depressed. This means that the person will find it hard to do simple tasks like chores, going up stairs, or doing basic arithmetic. Externally, people will often notice that the person wills stop showing, grooming or changing clothes.

Fatigue or Loss of Energy

Someone who has a major depressive episode may have nearly constant fatigue over the course of the entire episode. Fatigue means that the person is excessively tired, and always feels like he or she want to take a nap (even if he or she has just taken one). Loss of energy means that the person doesn’t feel “up to things”. The concept is poorly defined and can easily be confused with psychomotor retardation.

Worthlessness or Guilt

People in major depressive episodes may feel either worthless or guilty. Worthlessness means that they seriously underestimate themselves and their abilities, and tend to think of themselves in harsh and even insulting terms. Sometimes, this can take the form of guilt, in which people feel terribly guilty for things that do not warrant such guilt. Such guilt can even be delusional. Note that only inappropriate guilt is included here. Feeling guilty for something extremely serious is not a symptom of a major depressive episode.

Trouble Concentrating or Making Decisions

People in a major depressive episode can have trouble concentrating on basic tasks, on reading (some people find it difficult to read while depressed) or on conversations. Any activity that requires focus becomes far more difficult than usual.

People in a major depressive episode may also have trouble making even basic decisions. This can include insignificant decisions such as what to purchase for lunch, which clothes to wear, which door to exit from and so forth.

Thoughts of Death or Suicidal Thoughts or Actions

People in major depressive episodes may find themselves obsessed with death, either their own or just death in general (they may be what is popularly called “morbid”). This can include their own deaths, deaths of individuals, constant worry about what happens after death and so forth.

In some cases, they may have suicidal ideation (thinking that they may wish to kill themselves), suicidal planning (developing a specific plan to commit suicide) and even suicide attempts. The ideation and planning may be recurring throughout the entire episode.

Mixed Episodes

Mixed episodes combine the symptoms of a manic episode with those of a major depressive episode. In order for an episode to qualify as a mixed episode, it must meet all of the qualifications of both types of episode for its duration (except that it needs to only be one week long, not two). Like those episodes, it must include significant impairment to functioning, hospitalization or psychotic symptoms.

Conclusion

As you can see, the symptoms of manic depression are complex. The above is just an introduction to each of the symptoms that people with manic depression encounter. Although the above is derived from the diagnostic conditions for bipolar disorder, please do not use it for self-diagnosis. If the above symptoms seem familiar to you, please seek out professional help for yourself or for your loved one.

Further Reading

Bipolar 1 Vs. Bipolar 2: Recognizing the Differences
Two Lesser Known Forms of Bipolar Disorder: Cyclothymia and Bipolar Disorder, Not Otherwise Specified

More Information:

13 Responses to Symptoms of Bipolar Disorder

  • In presenting symptoms of Bipolar Disorder it has become increasingly evident that Cognitive Dysfunction in BP is a fundamental feature of the condition which has/is overlooked by the DMS-IV and clinicians. Too often people with BP are portrayed as the ‘creative’ ones, and the significant portion of those with significant cognitive impairment are left out of the discussion. Cognitive dysfunction is at the core of the poor results in social, educational and occupational outcomes for individuals with BP. More attention needs to be focused on this aspect of the condition.

  • I was told i was possibly bi polar and having read your symptoms i can put almost everyone at places in my life. ive learned to manage things in my own way but im 35 and have agraphobia and panic dissorder. Im confident in my self and have accepted what i am but cannot beat the panic symptoms having tried oc therapy, exposure and cognitive work. I feel so sad that after all the turmiol lifes passing me by…. can anyone help me x

    • Hi Victoria. I’m very sorry to hear what you have been going through. I noticed that you didn’t mention medications among the things that have been used to treat your anxiety. For bipolar people, anxiety is often tied to our mood episodes. Have you considered talking to a psychiatrist about some medicinal options?

  • I was diagnosed with Bipolar 1 Rapid Cycling 2 yrs ago. This was after a major manic episode that had lasted for some time and ended up costing me my marriage of 27 yrs. It can be a horrific thing to go through. Thankfully I am on medications, seeing a psychiatrist once a month and a therapy every week (which really seems to help).
    After being divorced for 4 yrs now, my ex is talking to me and we are trying to work things out. Bipolar can literally destroy lives. I hope the very best for everyone that has bipolar. It can be such a horrible thing to deal with….

    • I’m sorry to hear that you’ve had such a terrible experience, Johna. I’m happy to hear you and your ex-husband are trying to work things out. I find bipolar disorder is usually horrible as well, and I’ve found medications and therapy very helpful as well.

  • I use Mindfullness and Behavior Chain Analysis to cope with the episodes, google them, they help so much! Great job on the article!

    • Thank you, Brenda :). I’ve been looking into mindfulness, but I hadn’t heard of behavior chain analysis. It’s definitely worth looking into. Thanks!

  • Hello Dr. Bader
    This was well put together. I would like to add something if I may. I remember wanting to die when I was 7, also remember being called a crybaby because if you looked at me wrong, I would cry. This also made me a target for child abuse, mental, physical and sexual. Then my teen’s hit and they are a blurr, I did so many drugs and was very sexually active, but I also cried a lot. I’ve tried suicide 6 times now, 15, 20, 25, 40, 43 and 47. I guess God isnt ready for me yet. Oh yea, was hospilized for being Homocidal, I was really gonna do it. Rage is my demon. I was in my late thirty’s when I was told I was Bipolar. They gave me a list to check off. I checked off all of them and thought to myself, how could this piece of paper know me so well?

    It has been my experience over the years, I am now 47. Bipolar hits everyone differently. Seems everyone is on something different (Chemical Cocktail) There was a something you listed that doesnt effect me, like the Messiah or a reincarnation of a historical figure but I will say I am addicted to the euphoric feeling of mania but dread the crash of depression that always follows.

    Something that has me alittle puzzled, I started writing poetry 2 yrs ago, and I am good, I didnt know I could do that, I flunked language in school?? hmmm anyways It is usually about depression or Mania.

    Thanks for the artical, I am glad I found you. Have a blessed day

    • You’re welcome, Cindy, and thank you for the comment :) I discovered recently that bipolar people are 19 times more likely to be poets than the general population! I’ve written about this here, if you are interested. It’s definitely something that we often something have a lot of talent for.

  • Hi Daniel,

    in my specific case all manic phases seem to entail a strong sex-related drive (cheating on my partner, dating several women at the same time, compulsive sex …). I mentioned this both to my doctor and therapist but they havent been able to come up with any clear explanation or suggestion. Is excessive sexual drive a known symptom of BP disorder?
    Thank you for your help
    Cheers from Belgium

    • Hi Perry,

      Yes, it definitely is, and it’s called “hypersexuality”. It’s something that many and probably most people with bipolar disorder encounter during hypomania or mania.

  • Hi there,

    I am looking for Daniel’s mood chart referred to in Michael Ligtenberg’s guest post can someone point me to the right page?

    Thanks
    Terri

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Psychotherapy from Daniel

Daniel Bader, Ph.D., RP (Qualifying), CCC

Daniel Bader, Ph.D., is a Registered Psychotherapist (Qualifying) and Canadian Certified Counsellor specializing in bipolar disorder, offering in-person psychotherapy in Kitchener, Ontario, and online and telephone psychotherapy within Canada.

To book an appointment with Daniel, please visit his Psychology Today profile.