What is Bipolar Disorder?

Bipolar Disorder is the name now used for what was formerly called Manic Depression.  For all practical purposes, they are the same. In an effort to standardize psychiatric language, the scientific community shifted to the new term.

Regardless of the name, however, the defining characteristics remain fundamentally unchanged. It is defined by episodes of mania or hypomania (a less severe form of mania) and, almost always, episodes of depression.

 

Over time, people with bipolar disorder typically move unpredictably through periods of depression, mania or hypomania, and intervals of their baseline mood. 

 

A Brief Historical Perspective

Long before modern psychiatry or diagnostic manuals existed, physicians recognized that episodes of elevated mood and energy and episodes of profound depression were often linked. In the first century CE, Aretaeus of Cappadocia described mania and melancholia as different expressions of the same underlying illness — a condition marked by shifts in mood, energy, thinking, and behavior over time.

 

Today terminology and classification systems have evolved.  However, as noted above, bipolar disorder has changed little over time.

 

The Modern Diagnostic Framework

From a technical standpoint, bipolar disorder is defined by criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

 

Bipolar disorder is identified by the presence of manic or hypomanic episodes. Although depressive episodes are common in practice, they are not required for the diagnosis.

 

Manic and hypomanic episodes involve a distinct period of abnormally elevated, expansive, or irritable mood during which a minimum number (3 or 4) of characteristic symptoms must be present:

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• Inflated self-esteem or grandiosity

• Decreased need for sleep

• Increased talkativeness or pressure to keep talking

• Racing thoughts or flight of ideas

• Distractibility

• Increased goal-directed activity or psychomotor agitation

• Excessive involvement in activities with a high potential for negative consequences

 

In terms of definition, mania and hypomania are separated by duration and degree of impairment, rather than by different symptoms.

 

As a practical matter, most people with bipolar disorder experience both, and subjectively the boundary between them is often imperceptible. A patient in the midst of either state is rarely able to distinguish which it is.  

 

How Bipolar Disorder Is Experienced

Although the DSM is particularly helpful for classification and standardization, it is not designed to describe the lived experience for those with the illness. That is understandable and largely due to the fact it cannot capture the breadth of its presentation from individual to individual.  Therefore, the following sections attempt to capture what patients describe when experiencing the defining changes of bipolar disorder.    

 

The Experience of Mania

Changes in Mood

For most people, the mood of a manic or hypomanic episode is experienced as profoundly elevated — sometimes described as a natural high or feeling on top of the world. Patients asked to rate their mood one to ten may say "eleven!" At its most intense, the elevated mood may become frank euphoria — a state of transcendence and spirituality in which the boundaries of reality may begin to loosen.

 

Alongside this elevation, irritability and impatience are almost always present. When everything feels vivid, fast and important, others who are not "on board" can seem genuinely frustrating. The person may accuse others of holding them back and become resentful or angry. Furthermore, in some individuals, the mood is not elevated at all — it is predominantly irritable from the outset. This may be harder to recognize because it may be dismissed as personality and circumstances (which may well be true).

 

Not all mood episodes follow a clean trajectory in one direction, and the boundaries between mood states are not always distinct. Mixed states occur when symptoms of mania and depression are present simultaneously. The individual feels restless, driven, and unable to sleep while also experiencing despair, hopelessness, or intense self-criticism. Despite feeling depressed, they remain energized — a combination that can promote self-destructive behavior. Suicidal thoughts and impulses are more prominent during mixed states than at any other phase of the illness. It is also in mixed states that rage is most likely to emerge, and on rare occasions this can escalate to violence — a recognized but uncommon presentation.

 

Increased Confidence and Grandiosity

Confidence tends to rise sharply during manic and hypomanic episodes. People often feel demonstrably smarter, more capable, more attractive, and more physically powerful than usual. They may feel they understand things their boss, colleagues, or friends do not. They may feel it urgent to express their opinion unsolicited, which may lead to confrontations — sometimes with strangers.

At higher intensities, this confidence becomes something closer to invincibility. People may feel bulletproof, even entitled to stretch rules or laws. The sense of being untouchable can drive behavior that carries serious legal, financial, or personal consequences, none of which may feel significant or relevant while the episode is unfolding.

 

Changes in Thinking and Speech

Manic and hypomanic episodes often develop in a recognizable progression. While the exact pattern varies from person to person, it is common for one of the earliest changes to involve a shift in the pace of thinking.

 

During emerging hypomania or mania, individuals may experience a subjective sense of mental acceleration. Internally, some people describe this experience as their mind "going a hundred miles an hour," or feeling "wide open." As the episode progresses, the pace of thought can become increasingly difficult to slow down. Although productivity may increase early on, organization often deteriorates over time, and many projects may be started simultaneously without being completed.

 

Speech may become unusually rapid or difficult to interrupt. Some individuals notice that they speak so quickly that they struggle to keep up with their own thoughts. Additionally, people experiencing mania or hypomania may have difficulty disengaging from conversations, may talk over others, or may struggle to modulate volume, intensity, or pacing when speaking verbally. These changes in speech and behavior will sometimes lead others to wonder whether the individual is "on drugs."

 

Increased Energy, Activity, and Drive

Alongside changes in thinking and speech, there is often a noteworthy increase in energy and activity. People may feel driven, restless, or unusually productive, describing a sense of having an "engine inside." They may be able to stay up all night and need only a cat nap to get started again. This increase in activity can initially feel creative or energizing, but over time it often becomes diffuse, unfocused, and exhausting.

 

Expanded Appetites

Interest in pleasurable activities often intensifies. As confidence and mood increase, inhibition falls, and these activities may be pursued with remarkable enthusiasm. Spending commonly increases, sometimes in multiple small purchases — filling online shopping carts or buying unnecessary items during routine errands. Larger purchases may also occur, including impulsive travel, major household items, or automobiles. There may also be excessive generosity: picking up large restaurant or bar tabs, purchasing expensive gifts, or giving away property of significant value, the importance of which is underestimated at the time.

 

Sexual thoughts and behaviors often intensify as well. There may be increased preoccupation with sexual ideas, heightened flirtation, or engagement in behavior that is uncharacteristic for the individual and later experienced with regret or shame. Sometimes relationships will come to an end — particularly if the partner is not aware of the diagnosis.

 

Other pleasurable pursuits expand as well. People may take up extreme sports or physically dangerous activities — skydiving, motorcycle racing, cliff jumping — often with little or no prior experience. Substance use tends to increase as well; alcohol, cocaine, and stimulants are particularly common, and may feel like they match or amplify the internal state rather than impair it.

 

How These Changes May Be Misunderstood

For both the individual and those close to them, these changes can be confusing and distressing, especially when the behavior feels out of character or difficult to reconcile with the person they know. Over time, repeated episodes can strain relationships and undermine trust. These outcomes are often misinterpreted as a lack of effort or flawed character, when in fact they more accurately reflect the effects of an underlying illness that has not yet been recognized or understood.

 

Bipolar Depression

Depressive episodes commonly occur with bipolar illness. When this occurs, it is called "bipolar depression." The name can be confusing because it may suggest the depression of bipolar disorder is fundamentally different. That is not really the case. Depression in bipolar disorder is still depression — the same experience described in the

Major Depressive Disorder section of this site. It is just as painful, disabling, and damaging. It also carries a comparable risk of suicide.

   

This section does not attempt to describe the full experience of depression, as it is addressed more completely in the site's Major Depressive Disorder section. The purpose here is narrower: to explain why depression occurring in the context of bipolar disorder is even distinguished.

 

What bipolar depression signals, correctly, is that the depression occurs within a unique psychiatric condition.  The distinction is relevant in that bipolar depression responds differently to medications used for other illnesses causing depression, including Major Depressive Disorder. 

 

In fact, the use of antidepressants for bipolar depression can cause two significant problems.  In the first instance, they can precipitate mania, hypomania, or mixed states. In addition, they may lead to broader mood destabilization, including a paradoxical increase in depression frequency.  

 

Therefore, correctly recognizing bipolar illness is crucial to effective treatment of all phases, including depression. The risk of mistaking the diagnosis is not just that the disease goes undertreated, but that it may be made worse.

 

Psychosis in Bipolar Disorder

Psychotic symptoms can occur during severe mood episodes, including mania, depression, and mixed states. In this context, psychosis refers to experiences in which a person loses contact with shared reality — perceiving things that are not there (hallucinations) or holding beliefs that are demonstrably false or impossible yet cannot be shaken (delusions).

 

When this happens, it does not mean the diagnosis is wrong, that the person has developed a different illness, or that the overall course of bipolar disorder has necessarily worsened. Psychosis is a recognized part of how bipolar disorder can present. Indeed, studies suggest that psychotic symptoms occur in a substantial proportion of people with bipolar disorder, especially bipolar I disorder. One systematic review found that psychotic symptoms had occurred at some point in the lives of 63% of individuals with bipolar I disorder and 22% of individuals with bipolar II disorder. Psychotic symptoms were especially common during manic episodes.

 

In bipolar disorder, psychotic symptoms tend to be mood congruent — meaning their content reflects the emotional state of the episode in which they occur. During mania, delusions are often grandiose or religious in nature: believing one has a special relationship with a higher power, possesses extraordinary abilities, or has unique insight into universal truths. Hallucinations, when they occur, often carry a similar quality — voices that affirm, instruct, or confirm the person's sense of special purpose or power.

 

During depression, the content shifts accordingly. Delusions may center on guilt, worthlessness, or punishment — a belief that one has committed an unforgivable act, that one is physically ill or dying, or that one is responsible for harm to others. Hallucinations during depressive episodes may take the form of voices that condemn, accuse, or confirm the person's worst beliefs about themselves.

 

When psychotic symptoms emerge, individuals or those around them may wonder whether the correct diagnosis is, in fact, schizophrenia. That question is understandable. However, in bipolar disorder, psychosis occurs only in the context of mood episodes and typically resolves as the underlying mood state improves. In contrast, schizophrenia is characterized by psychosis as the primary and defining feature of the illness, and episodes of mania or depression may never occur.

 

This distinction is important clinically. Accurately identifying whether psychosis is mood-related or primary helps guide more timely and effective treatment decisions for either condition. Medications that help for one may not be effective for the other.

 

Course and Outcome

Unfortunately, bipolar disorder is among the most frequently misdiagnosed conditions in psychiatry. It is commonly mistaken for Major Depressive Disorder. This is partly because people often seek help for depression, but rarely for hypomania or mania. Unless the episode is severe, patients may not recognize them as times when anything was wrong. Instead past manic or hypomanic episodes may be misinterpreted as times when life was going particularly well before depression struck. 

 

The timing of manic and depressive episodes can also obscure the diagnosis. An episode of mania or hypomania may occur years before a later depression and, because of that distance, feel unrelated to the current illness. But if the earlier episode was truly mania or hypomania, it still changes the diagnostic meaning of the depression that follows. 

 

Studies commonly find delays of 5 to 10 years between the onset of bipolar illness and its diagnosis, and these delays can carry real consequences. Repeated mood episodes take a toll across most life domains. The mercurial, sometimes volatile, fluctuations of mood and behavior may be increasingly misattributed to flaws of character. Individuals may be labeled irresponsible, selfish, or morally deficient instead of struggling with a chronic condition. Although the two are not mutually exclusive, it is important that the first not be mistaken for the latter.

 

The individual is usually more aware of the problem than anyone. Without effective and timely recognition, the disease can erode a person's core belief about themselves. Mistakes, criticisms, and disappointments may become fused to identity, as though they reflect who the person is rather than the disease itself. Over time, the illness becomes more corrosive, and repair can become even more difficult.

 

Even when the correct diagnosis becomes clear, significant barriers to beginning treatment can remain. Sometimes patients see the diagnosis as a label that subtly invalidates their self and life. They may feel that taking medicine reinforces a disease-based identity and minimizes their identity as a person facing real difficulties. Finally, there may be a fear treatment will take away who they really are.

 

Sometimes treatment is also undermined by the perceived positives of mania itself. In contrast to the destructiveness of depression, hypomania or mania may be remembered as desirable, productive, even essential.

Understanding that stability does not require sacrificing the richness of life can take time. It can also be a leap of faith. One cannot know this until there has been stability for a meaningful period of time.

 

The path is not always straightforward. Finding the right treatment regimen often involves medication starts and stops, lab tests, and dose adjustments. Furthermore, many of those changes occur because medications can have intolerable side effects. At times it can look like the changes and adjustments are the destination, not the journey.

 

Appropriate treatment does not require flattening one's life or eliminating the qualities that make a person who they are. Successful treatment does exist. With it comes a remarkable stability that allows individuals to free themselves from the stress of recurrent money troubles, employment changes, legal setbacks, and relationship volatility. It permits one to live the life they were meant to, free from the interference of an illness they did not choose.