What are the signs and symptoms of bipolar disorder?

Signs and Symptoms of Bipolar Disorder

Bipolar disorder is characterized by distinct episodes of mania or hypomania alternating with depression, with marked changes in mood, energy, behavior, and sleep that represent a significant departure from an individual's baseline functioning. 1

Manic Episode Symptoms

Manic episodes include:

• Mood changes:

  • Marked euphoria
  • Grandiosity
  • Irritability
  • Mood lability (rapid mood shifts)

• Cognitive symptoms:

  • Racing thoughts
  • Flight of ideas
  • Distractibility

• Behavioral symptoms:

  • Increased psychomotor activity
  • Decreased need for sleep (hallmark sign)
  • Increased goal-directed activities
  • Excessive involvement in pleasurable activities with high potential for painful consequences

• Other features:

  • Paranoia
  • Confusion
  • Psychotic symptoms (in severe cases)
  • Mixed features (simultaneous manic and depressive symptoms)

Depressive Episode Symptoms

Depressive episodes in bipolar disorder often present with:

• Psychomotor retardation
• Hypersomnia (rather than insomnia)
• Significant suicide risk
• Psychotic symptoms (more common than in unipolar depression)
• In severe cases, progression to catatonia

Age-Related Presentation Differences

Adolescents

• Frequently experience psychotic symptoms
• Markedly labile moods
• Mixed manic and depressive features
• More chronic and treatment-resistant than adult-onset cases 1

Children

• More likely to show irritability and belligerence than euphoria
• Symptoms often markedly labile and erratic rather than persistent
• High rates of comorbid disruptive disorders
• Rapid cycling or ultradian cycling (multiple mood shifts within a day)
• Changes in mood, energy, and behavior often more erratic than in adults 1

Course of Illness

• Cyclical nature with episodes representing departure from baseline functioning
• Depressive episodes dominate the longitudinal course (approximately 75% of symptomatic time) 2
• Age of onset typically between 15-25 years 2
• Depression is the most frequent initial presentation 2
• Diagnosis often delayed by approximately 9 years after initial symptoms 2

Comorbidities and Risk Factors

• High rates of psychiatric comorbidities:

  • ADHD (especially in childhood-onset cases)
  • Anxiety disorders
  • Substance use disorders

• Medical comorbidities contributing to mortality:

  • Metabolic syndrome (37%)
  • Obesity (21%)
  • Type 2 diabetes (14%)
  • Cardiovascular disease 2

• Family history:

  • Strong genetic component (approximately 70% heritability) 3
  • Four to sixfold increased risk in first-degree relatives 1

Diagnostic Challenges

• Bipolar II disorder (hypomania + depression) is particularly difficult to diagnose due to similarity with recurrent unipolar depression 4
• No valid biomarkers currently exist, making clinical assessment crucial 5
• Detection of hypomanic periods and longitudinal assessment are essential for accurate diagnosis 5

Mortality Risks

• Life expectancy reduced by 12-14 years 6, 2
• 1.6-2 fold increased risk of cardiovascular mortality 6, 2
• Annual suicide rate approximately 0.9% (compared to 0.014% in general population) 2
• 15-20% of people with bipolar disorder die by suicide 2

Early recognition of these signs and symptoms is critical, as early diagnosis and treatment are associated with more favorable outcomes. Careful attention to mood patterns, sleep disturbances, and family history can help identify bipolar disorder and distinguish it from other conditions like unipolar depression or ADHD.