What are the symptoms and treatment options for bipolar disorder?

Symptoms of Bipolar Disorder

Bipolar disorder is characterized by distinct episodes of mania (or hypomania) and depression, with manic episodes marked by abnormally elevated or irritable mood, decreased need for sleep, racing thoughts, increased psychomotor activity, grandiosity, and poor judgment, while depressive episodes mirror major depression with low mood, decreased energy, and potential suicidal ideation. 1, 2

Core Manic Episode Symptoms

The hallmark features that define a manic episode include:

• Abnormally elevated, expansive, or euphoric mood that represents a clear departure from baseline functioning 1, 3
• Marked irritability, often more prominent than euphoria, especially in younger patients 1
• Decreased need for sleep (not just insomnia)—patients feel rested despite minimal sleep, which is a critical distinguishing feature 1, 2
• Racing thoughts and flight of ideas with rapid, pressured speech 1, 2
• Grandiosity or inflated self-esteem that is markedly different from the person's usual self-perception 1, 2
• Increased psychomotor activity with excessive energy and goal-directed behavior 1, 2
• Poor judgment leading to reckless behavior, including impulsive spending, sexual indiscretions, or risky activities 1, 2
• Distractibility with attention easily drawn to irrelevant stimuli 1
• Mood lability with rapid shifts in emotional state 1

Depressive Episode Symptoms

Bipolar depressive episodes dominate the longitudinal course of illness and account for approximately 75% of symptomatic time 4, 5:

• Persistent low mood and dysphoria 6, 4
• Decreased energy and psychomotor retardation 7
• Loss of interest in activities (anhedonia) 8
• Changes in appetite and weight 8
• Difficulty concentrating and making decisions 8
• Feelings of worthlessness or excessive guilt 8
• Suicidal thoughts or behaviors—the annual suicide rate is approximately 0.9% in bipolar disorder versus 0.014% in the general population 4

Age-Specific Presentations

In adults, bipolar disorder presents as a cyclical illness with distinct episodes representing clear departures from baseline functioning 1. Episodes are typically well-demarcated with periods of relative normalcy between episodes 1.

In adolescents (ages 13-17), mania frequently presents with psychotic symptoms, markedly labile moods, and mixed manic-depressive features 1. Irritability and belligerence are more common than euphoria 1.

In younger children, the presentation often deviates from classic adult descriptions, with markedly labile and erratic mood changes rather than sustained elevated mood 1. However, diagnostic validity in very young children (under age 6) has not been established, requiring extreme caution 7, 3.

Critical Diagnostic Pitfalls

Manic symptoms must represent marked changes in mental and emotional state, not merely reactions to situations or temperamental traits 1, 3. Key differentiating factors include:

• Episodic versus chronic presentation: True bipolar disorder manifests as distinct episodes with clear onset and offset, not chronic irritability 3
• Spontaneous mood elevation: Manic symptoms occur spontaneously, not solely in response to environmental triggers 3
• Duration criteria: Symptoms must persist for at least 4 days for hypomania or 7 days for mania (or require hospitalization) 3
• Functional impairment: Symptoms must be evident and impairing across different realms of the person's life 3

Associated Features and Comorbidities

Bipolar disorder frequently presents with:

• High rates of comorbid conditions including anxiety disorders, substance use disorders, and ADHD 7, 3
• Psychotic symptoms during severe manic or depressive episodes 1
• Mixed episodes with simultaneous manic and depressive features 7, 1
• Rapid cycling (four or more mood episodes per year) in some patients 7

Treatment Overview

For acute mania, pharmacotherapy is the primary treatment, with lithium, valproate, and atypical antipsychotics (aripiprazole, olanzapine, risperidone, quetiapine) as first-line agents 7. Lithium remains the gold standard mood stabilizer with antimanic, antidepressant, and anti-suicide effects 5.

For bipolar depression, treatment options include lamotrigine, quetiapine, lurasidone, cariprazine, or the combination of olanzapine plus fluoxetine 7, 8, 4. Antidepressants should never be used as monotherapy due to risk of mood destabilization and manic switching 7, 5.

For maintenance treatment, lithium, lamotrigine, and certain atypical antipsychotics (olanzapine, aripiprazole, quetiapine) are FDA-approved to prevent recurrent episodes 7, 2, 4.

Common Pitfalls in Management

• Antidepressant monotherapy can destabilize mood and precipitate manic episodes; always combine with a mood stabilizer if used at all 7
• Substance-induced mania from antidepressants or stimulants must be distinguished from primary bipolar disorder 7
• Medication non-adherence affects more than 50% of patients and is a major cause of relapse 4
• Undertreatment of medical comorbidities: Metabolic syndrome (37%), obesity (21%), smoking (45%), and diabetes (14%) are highly prevalent and contribute to the 12-14 year reduction in life expectancy 4