What are the symptoms of bipolar disorder?

Symptoms of Bipolar Disorder

Bipolar disorder presents with distinct manic (or hypomanic) and depressive episodes, each with characteristic symptom clusters that represent a significant departure from baseline functioning.

Manic Episode Symptoms

A manic episode lasting ≥7 days (or requiring hospitalization) includes the following core features:

• Marked euphoria, grandiosity, and irritability that represent a clear change from the person's usual state 1
• Reduced need for sleep (a hallmark sign) without feeling tired 1
• Increased energy and hyperactivity with excessive involvement in risky activities 2
• Rapid, pressured speech and racing thoughts 2
• Mood lability with rapid and extreme mood shifts 1
• Psychotic features such as paranoia, confusion, grandiose delusions, or florid psychosis may be present 1, 2
• Psychomotor, sleep, and cognitive changes accompany the mood disturbance 1
• Impairment across multiple settings (not isolated to one environment), distinguishing true mania from situational reactions 1

Hypomanic Episode Symptoms

Hypomania is a milder elevation lasting ≥4 days with similar but less severe features:

• Elevated, expansive, or irritable mood plus at least three additional symptoms (four if mood is solely irritable) 1, 3
• No marked impairment or need for hospitalization (this is the key distinction from full mania) 1, 3
• Spontaneous mood change not merely reactive to situational stressors 1
• Sleep disturbances and psychomotor activation accompanying the mood shift 1

Depressive Episode Symptoms

Depressive episodes in bipolar disorder are characterized by:

• Psychomotor retardation with slowed thinking, difficulty concentrating, and indecisiveness 1, 3
• Hypersomnia (excessive sleep) rather than insomnia 1, 3
• Pervasive sadness, feelings of emptiness, and anhedonia (inability to experience pleasure) 1
• Suicidality with significant suicide attempts 1, 3
• Psychotic features are often present 1, 3
• Feelings of worthlessness and guilt 2

Mixed Episode Symptoms

Mixed episodes (≥7 days) involve simultaneous presence of both manic and depressive symptoms:

• Full criteria for both manic and depressive episodes met concurrently 1, 2
• Prominent depressive symptoms (worthlessness, guilt, anhedonia) occurring during a manic episode 2
• Concurrent symptoms, not sequential episodes separated by wellness 1

Episode Patterns and Cycling

The temporal pattern of episodes helps characterize bipolar disorder:

• Rapid cycling: Four or more mood episodes in one year 1
• Ultrarapid cycling: 5-364 cycles per year 1
• Ultradian cycling: More than 365 cycles per year 1
• Episodes represent a cyclical nature with distinct episode boundaries in adults 1

Age-Specific Presentation Differences

Children and adolescents present differently than adults:

• In children: Markedly labile and erratic mood, energy, and behavior changes; irritability and belligerence more common than euphoria; high rates of comorbid disruptive disorders 1
• In adolescents: Frequently associated with psychotic symptoms, markedly labile moods, mixed manic-depressive features; more chronic and refractory to treatment than adult-onset cases 1, 3
• In adults: Episodes represent clearer departure from baseline with more classic presentation and distinct episode boundaries 1

Warning Signs and Risk Factors

Certain features increase suspicion for bipolar disorder:

• Premorbid anxiety and dysphoria are common 1
• Approximately 20% of youths with major depression develop manic episodes by adulthood 1
• Risk factors in depressed patients: Rapid onset, psychomotor retardation, psychotic features, family history of affective disorders, history of mania/hypomania after antidepressant treatment 1
• Strong family history of bipolar disorder increases likelihood of true bipolar disorder 1

Critical Diagnostic Distinctions

When evaluating irritability and agitation, assess for:

• Euphoria or grandiosity first—their presence strongly suggests bipolar disorder rather than other conditions 1
• Marked changes in mental/emotional state rather than reactions to situations 1
• Impairment across different realms of life, not isolated to one setting 1
• Episode duration: Mood episodes lasting <4 days do not meet hypomania criteria and should be classified as Bipolar Disorder NOS 1