Bipolar Disorder Signs, Symptoms, Statistics, Tests

By The Fix staff 01/21/15

Bipolar Disorder, Symptoms and Treatments

Bipolar Disorder

Bipolar Disorder (BPD), formerly termed manic-depressive disorder, is an affective (mood) disorder in which people experience extreme fluctuations in mood, from the lows of depression to the highs of mania. Both depression and mania can have different degrees of severity. Not everyone with BPD experiences the same pattern of moods. Therefore, BPD is divided into several types:

  • Type I is considered the classic form of BPD, in which people experience shifts from major depression to full-blown mania or mixed-manic episodes.
  • Type II BPD consists of major depression but a less severe form of mania, known as hypomania.
  • In cyclothymic disorder, people may experience a depression of less severity, known as dysthymia, and hypomania.
  • A person may have BPD NOS (not otherwise specified) if they do not fit into one of the other three subtypes of BPD. For example, some people may experience states of mixed-mania that alternate with dysthymia.

Mood states are only one component in BPD, whereas mood cycling is another. Some people experience rapid cycling BPD, where they frequently experience mood changes. Rapid cycling occurs when the person experiences four or more shifts in mood per year.

Signs and Symptoms

BPD can be difficult to diagnose and is easily misdiagnosed as unipolar depression. Most people with BPD start by showing signs of depression or only report their depressive symptoms, which adds to the difficulties in finding an accurate diagnosis. Hallucinations and delusions that can occur with full-blown manic episodes can cause a misdiagnosis of schizophrenia. Those with bipolar depression may experience the classic depression symptoms, such as:

  • Sadness
  • Loss of appetite
  • Hopelessness
  • Fatigue
  • Suicidal thoughts or lack of desire to live
  • Irritability
  • Poor motivation and concentration

However, atypical depression is often more common in people with BPD. Atypical depression has similar symptoms as typical depression, but people are more likely to experience:

  • Increased appetite and weight gain (often emotional eating)
  • Hypersomnia

Full-blown mania is often associated with reckless or erratic behavior, such as:

  • High energy
  • Little or no sleep for days, without feeling tired
  • Engaging in drugs and alcohol use
  • Risky sexual behavior
  • Pressured speech
  • Flight of ideas and delusions of grandeur
  • Hallucinations and/or psychosis
  • Spending sprees (including gambling)
  • Elation

The hypomanic phase of BPD can be difficult to identify, especially if the behavior is not destructive. A person experiencing hypomania may seem to feel better, since they recently experienced a depressive episode. Hypomanic episodes are less extreme than mania. Although the person may sleep less, their behavior is typically less reckless than in a manic episode. When the person experiences hypomania, it is easy for the behavior to be mistaken for changes in motivation or productivity, because the person may stay up for several nights and do their work or have a sudden bought of creativity.

Mixed-mania is a mood state that features signs of both depression and hypomania at the same time and may be called “agitated depression.” The person may experience low-grade depression and irritability. Since these features are similar to depression with a comorbid anxiety disorder, it can be difficult to identify the mood as a mixed-manic state.

Treatment Options

Treatment requires a combination of therapy and medication management. The initial misdiagnosis of BPD as depression often results in initial treatment with an antidepressant alone, which can cause a shift into a manic state or increase the likelihood of suicide attempts. Treatment with only an antidepressant can also trigger rapid cycling.

Once the appropriate diagnosis of BPD is made, finding the right combination of medications is usually the next step and can take several attempts. People who have been diagnosed with BPD for decades may need their medications adjusted regularly to achieve the maximum benefits. The types of medications used to manage BPD include:

Mood Stabilizers

Many people with BPD are initially placed on a mood stabilizer, the most common being lithium or valproic acid. Both mood stabilizers require consistent blood tests to avoid serious side effects. When taking lithium, there is a fine line between therapeutic levels and toxic levels, which can cause some psychiatrists to be less inclined to start BPD patients with lithium. Other mood stabilizers include:

  • Carbamazepine
  • Lamotrigine
  • Topiramate

Although lithium is often the first-line choice of mood stabilizers in the treatment of BPD, psychiatrists might make their choice based on symptom presentation. In general, lithium tends to be more effective in people who experience Type I BPD, for the stabilization of manic and mixed manic episodes and for maintenance therapy in Type I BPD.


Antipsychotic medications are another class of medications that are used to treat BPD. Antidepressants and/or mood stabilizers may be combined with antipsychotics to achieve maximum benefits. Although antipsychotics are used in the treatment of schizophrenia, people with BPD do not need to experience hallucination or delusions for antipsychotics to be effective. Most antipsychotics are used for the management of manic or mixed-manic states in BPD, but some are helpful in the management of bipolar depression. Some people can manage both the manic and depressive phases of BPD by using a single antipsychotic medication.

Many second-generation antipsychotics have fewer long-term risks of movement disorders than first-generation antipsychotics, such as haloperidol, or older atypical antipsychotics, such as clozapine. However, many second-generation antipsychotics cause significant weight gain and somnolence and may be reserved for patients who have not had success with newer antipsychotics.


There are three major classes of antidepressants: tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs) and reuptake inhibitors. Tricyclic antidepressants are rarely used, due to the risk of overdose in potentially suicidal patients. MAOIs must be administered with careful dietary restrictions but can be more effective in people with BPD who exhibit atypical depression. MAOIs work by inhibiting the activity of monoamine oxidase, which facilitates the break down neurotransmitters before they can reach receptor sites.

Reuptake inhibitors are the most commonly prescribed antidepressants because they are relatively safe and do not pose the same risks as other classes of antidepressants. Reuptake inhibitors vary in the neurotransmitters they affect. The most common are selective serotonin reuptake inhibitors (SSRIs), which prevent the reuptake of serotonin, allowing more serotonin to be available and reach receptor sites.

Another commonly prescribed reuptake inhibitor is serotonin-norepinephrine reuptake inhibitors (SNRIs), which prevent the reuptake of both serotonin and norepinephrine, increasing the availability of both neurotransmitters. Other types of reuptake inhibitors can include:

  • Dopamine reuptake inhibitors (DRIs)
  • Norepinephrine-dopamine reuptake inhibitors (NDRIs)
  • Norepinephrine reuptake inhibitors (NRIs)
  • Serotonin-dopamine reuptake inhibitors (SDRIs)
  • Serotonin-norepinephrine-dopamine reuptake inhibitors (SNDRIs)

A person with BPD may be prescribed multiple reuptake inhibitors as long as they work on different neurotransmitters. Finding the appropriate antidepressant requires trying different ones, because even when two medications have similar mechanisms of action, they can have different levels of effectiveness.


There is no single cause of BPD. Although people who eventually develop BPD may have evidence of affective or psychotic disorders in their family, it is not a guarantee they will develop the BPD. As with most mental health conditions, the combination of genetics, biochemistry, brain structure and environment are all components in developing BPD. When a person develops BPD, it is not uncommon for them to have at least one relative in their immediate family with an affective disorder, whether or not a diagnosis was made. This suggests there is a genetic component to affective disorders.

The Diathesis-Stress Model is one such explanation that is applicable to all mental illnesses. According to the model, people are born with a predisposition to developing a mental illness, with each person having a stronger or weaker predisposition. People with a stronger predisposition to mental illness are more vulnerable to the impact of stressors or trauma and their ability to trigger mental illness.

Diagnosis and Tests

BPD is typically diagnosed based on a psychiatric evaluation and a thorough history of symptoms, which may require input from friends or family. A psychiatrist must rule out other causes of affective changes, which can be medical or substance-abuse related. A medical evaluation by a family physician can be helpful during the diagnostic phase because the doctor can order tests to check for hormonal imbalances, thyroid conditions or neurological diseases that can mimic BPD.

The diagnosis by a psychiatrist can be difficult when differentiating BPD from unipolar depression. Most people with BPD rarely report symptoms consistent with mania because they feel good during that time and typically focus on symptoms of depression. Friends or family may be the only people who report changes in behavior that are consistent with manic episodes.

The Beck Depression Inventory (BDI) is a psychological assessment that is administered to people who have signs of depression. The results of the inventory can identify the presence of depression. However, the diagnosis of manic, hypomanic or mixed-manic episodes is usually based on the Mood Disorders Questionnaire (MDQ) or self-reports of symptoms. Some clinicians may want a person to keep a symptom journal to aid in diagnosis.

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