What are the signs and symptoms of bipolar disorder?

Signs and Symptoms of Bipolar Disorder

Bipolar disorder presents with distinct episodes of mania (or hypomania) and depression, characterized by marked changes in mood, energy, and behavior that represent a clear departure from baseline functioning. 1

Manic Episode Symptoms

The hallmark features of mania include:

• Marked euphoria, grandiosity, and irritability with reduced need for sleep being a cardinal sign 1
• Mood lability with rapid and extreme mood shifts that can occur within minutes to hours 1
• Flight of ideas and racing thoughts that present as rapid, pressured speech and jumping between topics 2
• Increased psychomotor activity with excessive goal-directed behavior or agitation 1
• Psychotic features including paranoia, confusion, and florid psychosis may be present, particularly in adolescents 1

A true manic episode must last at least 7 days (unless hospitalization is required), while hypomania represents a milder elevation lasting at least 4 days. 1

Depressive Episode Symptoms

Bipolar depression differs from unipolar depression in several key ways:

• Psychomotor retardation (slowed movements and thinking) is more prominent 1
• Hypersomnia (excessive sleeping) rather than insomnia 1
• High suicidality with significant suicide attempts—10-20% of individuals with bipolar disorder die by suicide 3
• Psychotic features are frequently present during depressive episodes 1
• Early age of onset (typically late teens), frequent episodes, and family history of serious mental illness suggest bipolarity rather than unipolar depression 4

Mixed Episodes and Rapid Cycling

• Mixed episodes last 7+ days with simultaneous symptoms of both mania and depression 1
• Rapid cycling involves four or more mood episodes per year and is more common in women 3
• Ultrarapid cycling (5-364 cycles/year) and ultradian cycling (>365 cycles/year) describe even more frequent mood shifts, though these terms are not part of standard diagnostic criteria 5, 1

Age-Specific Presentations

In Adults:

• Episodes represent a significant departure from baseline functioning with clear episode boundaries 1
• More classic presentation with distinct manic and depressive phases 1

In Adolescents:

• Psychotic symptoms are frequent and may be the first presentation 6
• Markedly labile moods with mixed manic-depressive features 1
• More chronic and refractory to treatment than adult-onset cases 1

In Children:

• Irritability, belligerence, and behavioral dyscontrol are more common than euphoria 1
• Changes in mood, energy, and behavior are markedly labile and erratic 1
• High rates of comorbid ADHD and disruptive behavior disorders complicate diagnosis 5

Critical diagnostic pitfall: Distinguishing childhood bipolar disorder from ADHD is challenging, as approximately 10-20% of adults with bipolar disorder had childhood hyperactivity, but most children with ADHD do not develop bipolar disorder. 5

Warning Signs and Prodromal Features

Approximately 20% of youths with major depression will develop mania by adulthood. Risk factors include: 5, 1

• Depressive episodes with rapid onset, psychomotor retardation, and psychotic features
• Strong family history of bipolar disorder or affective disorders (4-6 fold increased risk in first-degree relatives) 5
• Antidepressant-induced hypomania or mania
• Premorbid mood lability, anxiety, attention difficulties, and behavioral dyscontrol 5

Comorbidities

Nearly all patients with bipolar disorder have comorbid psychiatric conditions: 7

• Anxiety disorders (most common) 7
• Substance use disorders (high rates, particularly in adolescents) 5
• ADHD, personality disorders 4
• Medical conditions including cardiovascular disease, hypertension, and obesity 4

The most common presentation in primary care is depression—more than 1 in 5 patients presenting with depression actually have bipolar disorder, making careful screening essential. 7