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
With bipolar disorder there is a spectrum of symptoms,
- Elevated mood, depressed mood (mania and depression)
- Intense imagination
- Oppositional behavior
- High activity
- 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
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
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 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
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
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
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 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
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.
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
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