What are the clinical signs and symptoms of bipolar disorder in individuals of all ages?

Clinical Signs of Bipolar Disorder

Bipolar disorder is characterized by distinct episodes of mania (or hypomania) and depression, with manic episodes showing marked euphoria, grandiosity, irritability, and reduced need for sleep as hallmark features, while depressive episodes present with psychomotor retardation, hypersomnia, and significant suicidality. 1

Core Manic Episode Features

The defining characteristics of mania include:

• Marked euphoria, grandiosity, and irritability that represent a significant departure from baseline functioning 1
• Reduced need for sleep as a hallmark sign, not just insomnia but truly decreased sleep requirement 1
• Mood lability with rapid and extreme mood shifts occurring within episodes 1
• Psychotic features including paranoia, confusion, and florid psychosis may be present 1
• Racing thoughts and increased psychomotor activity that are evident across multiple settings 2

Critical diagnostic point: True manic grandiosity and irritability present as marked changes in mental and emotional state rather than reactions to situations, with impairment evident across different realms of life, not isolated to one setting. 1

Core Depressive Episode Features

Bipolar depression differs from unipolar depression with these characteristics:

• Psychomotor retardation is prominent 1
• Hypersomnia rather than insomnia 1
• Significant suicidality with serious suicide attempts 1
• Psychotic features are often present 1

Episode Duration Criteria

The temporal requirements distinguish disorder subtypes:

• Manic episode: Lasts at least 7 days unless hospitalization is required 1
• Hypomanic episode: Milder elevation lasting at least 4 days 1
• Mixed episode: Period lasting 7+ days with symptoms of both manic and depressive episodes simultaneously 1

Age-Specific Presentations

Adults

• Episodes represent a significant departure from baseline functioning with cyclical nature and distinct episodes 1
• More classic presentation with clearer episode boundaries 1

Adolescents

• Frequently associated with psychotic symptoms 1
• Markedly labile moods with mixed manic and depressive features 1
• More chronic and refractory to treatment than adult-onset cases 1
• Acute psychosis may be the first presentation of mania 2

Children

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

Major caveat: The diagnostic validity of bipolar disorder in preschool children has not been established, and caution must be taken before applying this diagnosis in very young children. 3

Cycling Patterns

Different cycling patterns indicate severity:

• Rapid cycling: Four or more mood episodes in one year 1
• Ultrarapid cycling: 5-364 cycles per year (hours to days per episode) 3, 1
• Ultradian cycling: More than 365 cycles per year (minutes to hours per cycle) 3, 1

Associated Features and Comorbidities

Look for these accompanying problems:

• High rates of suicidality with completed suicide risk 3
• Substance abuse is common, particularly in adolescents 3
• Premorbid anxiety and dysphoria often precede diagnosis 1
• Approximately 20% of youths with major depression develop manic episodes by adulthood 1, 4

Critical Diagnostic Pitfalls to Avoid

When evaluating irritability and agitation, first assess for euphoria or grandiosity—the presence of either strongly suggests bipolar disorder rather than other conditions. 1

• Do not confuse irritable mania with commonplace anger problems, especially given high comorbidity with disruptive behavior disorders 1, 2
• Do not mistake manic symptoms for ADHD, which can appear similar but represents a distinct condition 2
• Examine for environmental triggers and patterns, but recognize that true mania shows impairment across multiple settings, not just in response to specific situations 1
• Associated psychomotor, sleep, and cognitive changes must accompany the mood disturbance in true manic episodes 1

High-Risk Features Predicting Bipolar Disorder

In patients presenting with depression, these features increase likelihood of eventual mania:

• Rapid onset of depressive episode 1, 4
• Psychomotor retardation 1, 4
• Psychotic features 1, 4
• Family history of affective disorders, especially bipolar disorder 1, 4
• History of mania or hypomania after antidepressant treatment 1, 4

Family history represents the single most powerful predictor of bipolar disorder risk, with first-degree relatives having a four- to sixfold increased risk. 4