What are the characteristic symptoms of bipolar disorder, including manic, hypomanic, depressive, and mixed episodes?

Symptoms of Bipolar Disorder

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

Manic Episode Symptoms

A manic episode lasts at least 7 days (unless hospitalization is required) and includes: 1

• Marked euphoria, grandiosity, and irritability that are not reactions to situations but represent fundamental changes in mental and emotional state 1
• Reduced need for sleep as a hallmark sign—patients feel rested after minimal sleep 1
• Mood lability with rapid and extreme mood shifts 1
• Psychomotor activation with increased goal-directed activity and energy 1
• Racing thoughts and pressure to keep talking 1, 2
• Psychotic features including paranoia, confusion, and florid psychosis, particularly in younger patients 1, 3
• Impairment across multiple settings—not isolated to one environment—with associated psychomotor, sleep, and cognitive changes 1

The key distinction: true mania shows pervasive impairment across different realms of life, not situational reactions. 1

Hypomanic Episode Symptoms

Hypomania is a milder elevation lasting at least 4 consecutive days with: 1

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

Episodes lasting less than 4 days do not meet hypomania criteria and should be classified as Bipolar Disorder Not Otherwise Specified. 1

Depressive Episode Symptoms

Depressive episodes in bipolar disorder are characterized by: 1

• Psychomotor retardation with slowed thinking, difficulty concentrating, and indecisiveness 1
• Hypersomnia rather than insomnia 1
• Pervasive sadness, feelings of emptiness, and anhedonia lacking the driven or expansive quality of mania 1
• Suicidality with significant suicide attempts—a critical feature requiring immediate assessment 1
• Psychotic features often present during severe episodes 1

Most patients with Bipolar I disorder experience major or minor depressive episodes during their lifespan, making depression a fundamental component of the illness. 1, 4

Mixed Features

Mixed states combine depressive and manic symptoms simultaneously and represent a more severe form of bipolar disorder with worse outcomes. 5, 6

A mixed episode requires: 1

• Simultaneous presence of both manic and depressive symptoms meeting full criteria for at least 7 days 1
• Concurrent symptoms, not sequential episodes separated by wellness 1

Common mixed features include: 5, 2

• Irritable mood (present in 32.6% of mixed presentations) 2
• Emotional/mood lability (29.8%) 2
• Distractibility (24.4%) 2
• Psychomotor agitation combined with depressive cognitions 6, 2
• Racing thoughts with negative thought content 2
• Anxiety correlating with opposite-pole symptoms 6

Notably, euphoria (4.6%), grandiosity (3.7%), and hypersexuality (2.6%) are less common in mixed states. 2 Research suggests that depressive episodes with three or more manic symptoms should be considered mixed states, occurring in approximately 29% of patients with major depressive episodes. 2

Rapid Cycling Patterns

Cycling frequency varies: 1

• 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

Age-Specific Presentations

In children and adolescents, bipolar disorder differs markedly from adult presentations: 1

• Irritability, belligerence, and mixed features are more common than euphoria 1
• Markedly labile and erratic changes in mood, energy, and behavior 1
• Psychotic symptoms are frequently associated 1
• More chronic and refractory to treatment than adult-onset cases 1
• High comorbidity with disruptive behavior disorders and ADHD 1

In adults, episodes show: 1

• Cyclical nature with distinct episodes and clearer boundaries 1
• Significant departure from baseline functioning that is more classic in presentation 1

Critical Diagnostic Pitfalls

When evaluating suspected bipolar disorder, avoid these common errors:

• Do not confuse chronic irritability with episodic mania—disruptive behavior disorders show baseline irritability, not episodic departures 1
• Assess for euphoria or grandiosity first when evaluating irritability and agitation, as their presence strongly suggests bipolar disorder 1
• Use life charting to document exact duration, functional impact across settings, and cycling patterns over time 1
• Distinguish normative childhood behaviors (boastful play, imaginative scenarios, typical overactivity) from true hypomanic features 1
• Recognize antidepressant-induced mania as unmasking of underlying bipolar disorder, not negating the diagnosis 3

Warning Signs and Risk Factors

Approximately 20% of youths with major depression develop manic episodes by adulthood. 1 Risk factors include: 1

• Depressive episodes with rapid onset, psychomotor retardation, and psychotic features 1
• Family history of affective disorders, particularly bipolar disorder 1
• History of mania or hypomania after antidepressant treatment 1
• Premorbid anxiety and dysphoria 1

When the clinical picture remains ambiguous, especially with psychotic symptoms, refer to a psychiatry specialist for comprehensive neuropsychological assessment. 1