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Ask the Doctor: Dr. Ellen Frank on The Role of Circadian and Sleep-wake Factors in Bipolar Disorder
Sept. 23, 2011

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Ask the Doctor: Dr. Ellen Liebenluft on Bipolar Disorder in Adolescents
April 15, 2011

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Symptoms, Causes and Diagnosis


The occurrence of at least one episode of abnormal mood elevation such as mania or hypomania is the key feature that distinguishes bipolar disorder from other disorders such as depression. People living with bipolar disorder typically find more difficulty during depressive episodes, which tend to be more frequent and last longer than manic or hypomanic episodes.

With bipolar disorder there is a spectrum of symptoms, including:

  • Elevated mood, depressed mood (mania and depression)
  • Anxiety
  • Irritability
  • Intense imagination
  • Silliness
  • Oppositional behavior
  • High activity
  • Hypersensitivity
  • Difficulities with sleep

The states of mania and depression can occur in distinct episodes or can switch rapidly, even multiple times in one week. A person who is experiencing a severe bipolar episode of mania or depression may also have psychotic symptoms such as hallucinations or delusions. In individuals living with bipolar disorder, psychotic symptoms tend to be consistent with the direction of the person’s extreme mood. For example, a person in a manic state might believe he or she is famous or has special powers. An individual in a depressed state, however, might believe he or she is extremely poor or unable to perform normal tasks.

The occurrence of psychotic symptoms may lead to individuals with bipolar disorder being wrongly diagnosed as having schizophrenia, another severe mental illness that is often accompanied by hallucinations and delusions. Fortunately, these symptoms can be managed with the right treatment and support.

Mania Explained

Abnormal mood elevation such as mania or hypomania constitutes the essential feature required for diagnosis of bipolar disorder. The appearance and severity of mood elevation varies among individuals living with bipolar disorder. While some individuals will experience episodes of mania or hypomania many times, others may experience it only rarely. It is not the number of occurrences of mania that define which type of bipolar disorder is present, but the degree of impairment associated with the most severe episode of elevated mood during a person’s lifetime that determines what subtype of bipolar disorder a person might have.

When a period of lower-intensity mania without significant impairment in social or occupational ability occurs, it is called hypomania. A diagnosable manic episode has to include noticeable impairment. Although the experience of elevated mood may be very appealing, especially if it occurs after depression, the “high” often does not stop at a comfortable or controllable level.

A person’s mood state may rapidly become more irritable, his or her behavior more unpredictable and his or her judgment more impaired. During periods of mania, people frequently behave impulsively, make reckless decisions and take unusual risks. More often than not, during an episode the person discounts or is unaware of any negative consequences of their actions.

Symptoms of mania can include:

  • Feeling overly happy for an extended period of time.
  • An abnormally increased level of irritability.
  • Overconfidence or an extremely inflated self-esteem.
  • Increased talkativness.
  • Decreased amount of sleep.
  • Engaging in lots of risky behavior, such as spending sprees and impulsive sex.
  • Racing of thoughts, jumping quickly from one idea to another.
  • Easily distractable.
  • Feeling agitated or “jumpy.”

Depression Explained

Depression is more than just a sad mood that a person may experience after a bad day. Major depression is a medical illness that produces a combination of physical and emotional symptoms that inhibit one’s ability to function nearly every day for a period of at least two weeks.

Symptoms of depression can include:

  • Diminished capacity for pleasure or loss of interest in activities once enjoyed.
  • A long period of feeling hopeless, helpless or low self-esteem.
  • Decreased amount of energy; feeling constantly tired.
  • Inability to concentrate and make simple decisions.
  • Change in eating, sleeping or other daily habits.
  • Being agitated or slowed down in movement, speech or thought.
  • Thoughts of death or suicide attempts.

Not everyone will experience all of these symptoms. For example, someone may have problems sleeping and feel low in energy but find that their appetite is unaffected. The level of depression can range from severe to moderate to mild low mood. Mild low mood is called dysthymia when it is chronic or long term.

The lows of depression are often so debilitating that people in this phase of the illness may even be unable to get out of bed. Typically, depressed individuals have difficulty falling asleep and awaken throughout the night. However, about 20 percent of depressed individuals sleep more than usual.

When experiencing depression, even minor decisions such as what to have for dinner can be overwhelming; self-esteem plummets and the mind often becomes obsessed with losses and personal failures, and feelings of guilt and helplessness abound.

Negative thinking can lead to thoughts of suicide and actual ideation of suicide. In bipolar disorder, suicide is an ever-present danger on both sides of mood swings, as some individuals can become suicidal in manic or mixed (high and low) states.


Although some ground has been made in discovering the factors associated with the risk of developing bipolar disorder, scientists have not discovered a single precise cause. Based on the best available date, many scientists suggest that bipolar disorder can be caused by more than one factor (e.g., genes, environmental stress, nutrition, inflammatory factors or other stress in the brain).


Bipolar disorder often runs in families and studies suggest a genetic component to the illness. Genes help control how the body works and grows. The chances of manifesting bipolar disorder are increased if a child’s parents or siblings have the disorder. However, this does not necessarily mean that a child from a family with a history of bipolar disorder will develop the disorder.

Furthermore, studies of identical twins have found that even if one twin develops bipolar disorder it does not mean the second twin will develop it as well. This is worth noting because identical twins share all the same genes. Because one twin may develop bipolar disorder and the other may not means that there are other factors in play.


Often a stressful event such as an unexpected loss, general medical illness, difficult relationship or financial problems—or any major change in life—can trigger the first bipolar episode. Therefore, an individual’s coping skills or style of handling stress may also play a role in the development of the illness. In some cases, drug abuse can trigger the disorder. For some people triggers are not identifiable or become harder to identify as an individual experiences more episodes.

Brain Structure

Brain scans cannot diagnose bipolar disorder in an individual. However, researchers using techniques such as functional magnetic resonance imaging (FMRI) and positron emission tomography (PET) have shown subtle differences in the average size or pattern activation of some brain structures in the people with bipolar disorder compared to the brains of people without a mental illness as well as people with other mental disorders. While brain structure alone may not cause bipolar disorder, some conditions which damage brain tissue can predispose a person to the mental illness.


As with all types of illness, a doctor must be seen to provide a proper diagnosis. The doctor may perform a physical examination, an interview and lab tests. Unfortunately, bipolar disorder cannot be identified through a simple blood test or body scan. But these tests can help rule out other potential causes such as a hyperthyroidism. If it is determined that the symptoms are not caused by any other illness, the doctor may recommend the individual sees a mental health professional such as a psychiatrist.

Doctors usually diagnose bipolar disorder by using the Diagnostic and Statistical Manual of Mental Disorders, or DSM. It is currently in its fourth edition, with a new revision slated to come out in 2013. The DSM-IV defines four basic subtypes of bipolar disorder:

Bipolar I Disorder is defined as an illness in which people have experienced one or more episodes of mania. Though an episode of depression is not necessary for a diagnosis, most people will have episodes of both mania and depression. In order to be diagnosed, manic or mixed episodes must last at least seven days, or be so severe that they require hospitalization.
Bipolar II Disorder is a subset of bipolar disorder in which people largely experience depressive episodes shifting back and forth with hypomanic episodes, but never a full manic episode.
Cyclothymic Disorder, or Cyclothymia, refers to a more chronic unstable mood state. This diagnosis is given when an individual experiences hypomania and mild depression for at least two years. A person with cyclothymia may have periods of normal mood, but these periods are brief and last less than eight weeks.
Bipolar Disorder Not Otherwise Specified (BP-NOS) is diagnosed when a person does not meet the criteria for bipolar I, II or cyclothymia but has had periods of clinically significant abnormal mood elevation. The symptoms may either not last long enough or did not meet the full criteria for episodes required to diagnose bipolar I or II. For instance, a person with one or more episodes of hypomania but never depression or mania would be diagnosed BP-NOS, as would a person with periods of fluctuating mood as described above for cyclothymia but lasting less than one year.

African Americans and Latinos are more prone to misdiagnosis, likely due to differing cultural or religious beliefs or language barriers. For anyone who has received a diagnosis of bipolar disorder, it is important to look for a health care professional who understands a person’s cultural background and shares the same expectations for treatment.

Co-occuring Disorders

A person living with bipolar disorder often meets the criteria for one or more additional disorders. Anxiety disorders, including posttraumatic stress disorder (PTSD) and attention-deficit hyperactivity disorder (ADHD) routinely co-occur with bipolar disorder.

Substance abuse is also common among people with bipolar disorder. Many people use alcohol or drugs to try to control their mood states or help treat symptoms. However, using drugs will ultimately result in a worsening of the illness not an improvement. The use of drugs can lead to more frequent relapse and an increase in suicide attempts.

Successful treatment of bipolar disorder almost always improves these other conditions. Similarly, successful treatment of these conditions usually improves the symptoms of bipolar disorder. These other illnesses, however, can make it hard to diagnose and treat bipolar disorder. Some medicines used to treat obsessive-compulsive disorder (antidepressants) and ADHD (stimulants) may worsen symptoms of bipolar disorder and may even trigger a manic episode, so care should be taken when beginning medication.