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/Hypomanic Episode Symptoms

Manic episodes (lasting at least 7 days or requiring hospitalization) or hypomanic episodes (lasting at least 4 days) include:

• Core feature: Increased energy/activity 1
• Mood changes:
  • Marked euphoria
  • Grandiosity
  • Irritability (more common than euphoria) 1
  • Mood lability
• Sleep disturbances:
  • Marked decrease in need for sleep without feeling tired
• Cognitive symptoms:
  • Racing thoughts
  • Flight of ideas
  • Distractibility
• Behavioral symptoms:
  • Pressured speech/talkativeness
  • Increased goal-directed activity
  • Psychomotor agitation
  • Risky behavior 1

Depressive Episode Symptoms

Depressive episodes in bipolar disorder often present with:

• Psychomotor retardation
• Hypersomnia
• Significant suicide risk
• Psychotic symptoms (more common than in unipolar depression) 1
• Mixed features (depression with concurrent subsyndromal hypomanic symptoms) 2

Key Diagnostic Considerations

• Duration criteria: Mania requires symptoms lasting at least 7 days or requiring hospitalization; hypomania requires at least 4 days 1
• Impairment level: Mania causes marked impairment in functioning or requires hospitalization; hypomania represents a change in functioning but is not severe enough to cause marked impairment 2
• Episodic pattern: Symptoms occur in distinct episodes that represent a change from baseline 1
• Age of onset: Typically between 15-25 years, with depression often being the initial presentation 3
• Course of illness: Approximately 75% of symptomatic time consists of depressive episodes or symptoms 3

Special Presentations

• Mixed episodes: Simultaneous presence of both manic and depressive symptoms 1
• Rapid cycling: Four or more mood episodes within a 12-month period 2
• Childhood/adolescent presentation:
  • More likely to show irritability and belligerence than euphoria
  • Symptoms often markedly labile and erratic rather than persistent
  • High rates of comorbid disruptive disorders 1
  • Early-onset cases (before age 13) are predominantly male 4

Risk Factors and Associations

• Genetic component: Strong heritability (approximately 70%), with a four to sixfold increased risk in first-degree relatives 1, 5
• Premorbid conditions: Common in early-onset bipolar disorder:
  • Disruptive behavior disorders
  • Irritability
  • Behavioral dyscontrol
  • Anxiety and dysphoria 4
• Temperament: Dysthymic, cyclothymic, or hyperthymic (irritable, driven) temperaments may precede eventual bipolar disorder 4

Diagnostic Challenges

• Early diagnosis is challenging and misdiagnoses are frequent 6
• Diagnosis is often delayed by approximately 9 years following an initial depressive episode 3
• Bipolar II disorder is frequently underdiagnosed in clinical practice 2
• No valid biomarkers currently exist; clinical assessment remains key 7

Health Outcomes

• Life expectancy is reduced by 12-14 years in individuals with bipolar disorder 1, 3
• 1.6-2 fold increased risk of cardiovascular mortality 1, 3
• Annual suicide rate is approximately 0.9% (compared to 0.014% in general population) 3
• Approximately 15-20% of people with bipolar disorder die by suicide 3

Understanding these signs and symptoms is crucial for early identification and appropriate treatment of bipolar disorder, which can significantly improve prognosis and quality of life for affected individuals.