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Bipolar mania, hypomania, and depression are symptoms of bipolar disorder. The dramatic mood episodes of bipolar disorder do not follow a set pattern — depression does not always follow mania. A person may experience the same mood state several times — for weeks, months, even years at a time — before suddenly having the opposite mood. Also, the severity of mood phases can differ from person to person.

Hypomania is a less severe form of mania. Hypomania is a mood that many don’t perceive as a problem. It actually may feel pretty good. You have a greater sense of well-being and productivity. However, for someone with bipolar disorder, hypomania can evolve into mania — or can switch into serious depression.

The experience of these manic stages has been described this way:

Hypomania: At first when I’m high, it’s tremendous … ideas are fast … like shooting stars you follow until brighter ones appear… All shyness disappears, the right words and gestures are suddenly there … uninteresting people, things, become intensely interesting. Sensuality is pervasive, the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria … you can do anything … but somewhere this changes.
Mania: The fast ideas start coming too fast and there are far too many … overwhelming confusion replaces clarity … you stop keeping up with it … memory goes. Infectious humor ceases to amuse. Your friends become frightened … everything is now against the grain … you are irritable, angry, frightened, uncontrollable, and trapped.

If you have periods of unusually high energy and high mood along with three or more of the following mania symptoms most of the day — nearly every day — for one week or longer, you may be having a manic episode of bipolar disorder:

Needing less sleep in order to feel rested
Talking very rapidly or excessively
Distractibility
Fast thoughts
Tendency to show poor judgment, such as impulsively deciding to quit a job
Inflated self-esteem or grandiosity — unrealistic beliefs in one’s ability, intelligence, and powers; may be delusional
Reckless behaviors (such as lavish spending sprees, impulsive sexual indiscretions, abuse of alcohol or drugs, or ill-advised business decisions)
Some people with bipolar disorder become psychotic when manic or depressed, hearing things that aren’t there. They may hold onto false beliefs, and cannot be swayed from them. In some instances, they see themselves as having superhuman skills and powers — even considering themselves to be god-like.

What Is Bipolar I Disorder?
Bipolar I disorder (pronounced “bipolar one” and also known as manic-depressive disorder or manic depression) is a form of mental illness. A person affected by bipolar I disorder has had at least one manic episode in his or her life. A manic episode is a period of abnormally elevated mood and high energy, accompanied by abnormal behavior that disrupts life.

Most people with bipolar I disorder also suffer from episodes of depression. Often, there is a pattern of cycling between mania and depression. This is where the term “manic depression” comes from. In between episodes of mania and depression, many people with bipolar I disorder can live normal lives.

Understanding Bipolar Disorder
Understanding Bipolar Disorder
Who Is at Risk for Bipolar I Disorder?
Virtually anyone can develop bipolar I disorder. About 2.5% of the U.S. population suffers from bipolar disorder — almost 6 million people.

Most people are in their teens or early 20s when symptoms of bipolar disorder first appear. Nearly everyone with bipolar I disorder develops it before age 50. People with an immediate family member who has bipolar are at higher risk.

What Are the Symptoms of Bipolar I Disorder?
During a manic episode in someone with bipolar disorder, elevated mood can manifest itself as either euphoria (feeling “high”) or as irritability.

Abnormal behavior during manic episodes includes:

Flying suddenly from one idea to the next
Rapid, “pressured” (uninterruptable), and loud speech
Increased energy, with hyperactivity and a decreased need for sleep
Inflated self-image
Excessive spending
Hypersexuality
Substance abuse
People in manic episodes may spend money far beyond their means, have sex with people they wouldn’t otherwise, or pursue grandiose, unrealistic plans. In severe manic episodes, a person loses touch with reality. They may become delusional and behave bizarrely.

Untreated, an episode of mania can last anywhere from a few days to several months. Most commonly, symptoms continue for a few weeks to a few months. Depression may follow shortly after, or not appear for weeks or months.

Many people with bipolar I disorder experience long periods without symptoms in between episodes. A minority has rapid-cycling symptoms of mania and depression, in which they may have distinct periods of mania or depression four or more times within a year. People can also have mood episodes with “mixed features,” in which manic and depressive symptoms occur simultaneously, or may alternate from one pole to the other within the same day.

Depressive episodes in bipolar disorder are similar to “regular” clinical depression, with depressed mood, loss of pleasure, low energy and activity, feelings of guilt or worthlessness, and thoughts of suicide. Depressive symptoms of bipolar disorder can last weeks or months, but rarely longer than one year.

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In this article
What Is Bipolar I Disorder?
Who Is at Risk for Bipolar I Disorder?
What Are the Symptoms of Bipolar I Disorder?
What Are the Treatments for Bipolar I Disorder?
Can Bipolar I Disorder Be Prevented?
How Is Bipolar I Different From Other Types of Bipolar Disorder?
What Are the Treatments for Bipolar I Disorder?
Manic episodes in bipolar I disorder require treatment with drugs, such as mood stabilizers and antipsychotics, and sometimes sedative-hypnotics which include benzodiazepines such as clonazepam (Klonopin) or lorazepam (Ativan).

Mood Stabilizers

Lithium: This simple metal in pill form is especially effective at controlling mania that involves classical euphoria rather than mixtures of mania and depression simultaneously. Lithium has been used for more than 60 years to treat bipolar disorder. Lithium can take weeks to work fully, making it better for maintenance treatment than for sudden manic episodes. Blood levels of lithium as well as tests to measure kidney and thyroid functioning must be monitored to avoid side effects.

Valporate (Depakote): This antiseizure medication also works to level out moods. It has a more rapid onset of action, often making it more effective for an acute episode of mania than lithium. It is also often used “off label” for prevention of new episodes. As a mood stabilizer that can be used by a “loading dose” method — beginning at a very high dose — valporate allows the possibility of significant improvement in mood as early as four to five days.
Some other antiseizure drugs, notably carbamazepine (Tegretol) and lamotrigine (Lamictal), can have value in treating or preventing manias or depressions. Other antiseizure medicines that are less well-established but still sometimes used experimentally for the treatment of bipolar disorder, include gabapentin (Neurontin), oxcarbazapine (Trileptal), and topiramate (Topamax).

Antipsychotics

For severe manic episodes, traditional antipsychotics (such as Haldol, Loxapine, or Thorazine) as well as newer antipsychotic drugs — also called atypical antipsychotics — may be necessary. Cariprazine (Vraylar) is a newly approved antipsychotic to treat manic or mixed episodes. Aripiprazole (Abilify), asenapine (Saphris), clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon) are often used, and many other drugs are available. The antipsychotic lurasidone (Latuda) is approved for use — either alone or with lithium or valproate (Depakote) — in cases of bipolar I depression. Antipsychotic medicines are also sometimes used for preventive treatment.

Benzodiazepines

This class of drugs includes alprazolam (Xanax), diazepam (Valium), and lorazepam (Ativan) and is commonly referred to as minor tranquilizers. They are sometimes used for short-term control of acute symptoms associated with mania such as agitation or insomnia, but they do not treat core mood symptoms such as euphoria or depression.

Common antidepressants such as fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) have not been shown to be as effective for treating depression in bipolar disorder as in unipolar depression. In a small percentage of people, they can also set off or worsen a manic episode in a person with bipolar disorder. For these reasons, the first-line treatments for depression in bipolar disorder involve medicines that have been shown to have antidepressant properties but also no known risk for causing or worsening mania. The three FDA-approved treatments for bipolar depression are lurasidone (Latuda), olanzapine-fluoxetine (Symbyax) combination, quetiapine (Seroquel) or quetiapine fumarate (Seroquel XR). Other mood-stabilizing treatments that are sometimes recommended for treating acute bipolar depression include lithium, Depakote, and Lamictal (although none of these later three medicines is FDA-approved specifically for bipolar depression). If these fail, after a few weeks a traditional antidepressant or other medicine may sometimes be added. Psychotherapy, such as cognitive-behavioral therapy, may also help.

People with bipolar I disorder (mania or depression) have a high risk for recurrences and usually are advised to take medicines on a continuous basis for prevention.

Electroconvulsive Therapy (ECT)
Despite its scary reputation, electroconvulsive therapy (ECT) is an effective treatment for both manic and depressive symptoms. ECT is seldom used to treat bipolar I disorder, but can be helpful if medicines fail or can’t be used.

Can Bipolar I Disorder Be Prevented?
The causes of bipolar disorder are not well understood. It’s not known if bipolar I disorder can be prevented entirely.

It is possible to lower the risk of episodes of mania or depression once bipolar disorder has developed. Regular therapy sessions with a psychologist or social worker can help people to identify factors that can destabilize mood (such as poor medication adherence, sleep deprivation, drug or alcohol abuse, and poor stress management), leading to fewer hospitalizations and feeling better overall. Taking medicine on a regular basis can help to prevent future manic or depressive episodes.

How Is Bipolar I Different From Other Types of Bipolar Disorder?
People with bipolar I disorder experience full episodes of mania — the often severe abnormally elevated mood and behavior described above. These manic symptoms can lead to serious disruptions in life (for example, spending the family fortune, or having an unintended pregnancy).

In bipolar II disorder, the symptoms of elevated mood never reach full-blown mania. They often pass for extreme cheerfulness, even making someone a lot of fun to be around — the “life of the party.” Not so bad, you might think — except bipolar II disorder usually involves extensive and disabling periods of significant depression, which can often be harder to treat than if episodes of hypomania had never occurred.

What Is Rapid in Cycling Bipolar Disorder?
Rapid cycling is a pattern of frequent, distinct episodes in bipolar disorder. In rapid cycling, a person with the disorder experiences four or more episodes of mania or depression in one year. It can occur at any point in the course of bipolar disorder, and can come and go over many years depending on how well the illness is treated; it is not necessarily a “permanent” or indefinite pattern of episodes.

Understanding Bipolar Disorder
Who Gets Rapid Cycling Bipolar Disorder?
Virtually anyone can develop bipolar disorder. About 2.5% of the U.S. population suffers from some form of bipolar disorder – nearly 6 million people. A rapid cycling pattern may occur in about 10% to 20% of people with the disorder. Women, and people with bipolar II disorder, are more likely to experience periods of rapid cycling.
Most people are in their late teens or early 20s when symptoms of bipolar disorder first start. Nearly everyone with bipolar disorder develops it before age 50. People with an immediate family member with bipolar disorder are at higher risk.

What Are the Features of Bipolar Disorder?
The major features of bipolar disorder include:

At least 1 episode of mania or hypomania in the patient’s lifetime
Episodes of depression (major depressive disorder), which are often recurrent
Mania is a period of abnormally elevated mood and high energy, usually accompanied by erratic behavior lasting at least seven days at a time. Hypomania is an elevated mood not reaching full-blown mania a minimum of four days.

A few people with rapid cycling bipolar disorder alternate between periods of hypomania and major depressive disorder. Far more commonly, though, repeated and distinct episodes of depression dominate the picture. Repeated periods of depression are punctuated by infrequent, shorter periods of elevated or normal mood.

How Is Rapid Cycling Bipolar Disorder Identified?
Bipolar disorder is diagnosed after someone experiences a hypomanic or manic episode along with multiple additional episodes of either mania, hypomania or depression. Rapid cycling in itself is not a diagnosis, but rather a “course specifier” or descriptor of the course of illness. In bipolar disorder rapid cycling is identified when four or more distinct episodes of depression, mania, or hypomania occur during a one year period. Rapid cycling can occur at any time in the course of bipolar disorder and may come and go at varying points over a lifetime

How Is Rapid Cycling Bipolar Disorder Identified? continued…
Rapid cycling bipolar disorder can be difficult to identify, because a single mood episode can sometimes simply wax and wane without resolving. As a result, they don’t necessarily represent multiple separate and distinct episodes. Rapid cycling may seem to make the changing mood states of bipolar disorder more obvious, but because most people with rapid cycling bipolar disorder spend far more time depressed than manic or hypomanic, they are often misdiagnosed with unipolar depression.

For example, in one study of people with bipolar II disorder, the amount of time spent depressed was more than 35 times the amount of time spent hypomanic. Also, people often don’t take note of their own hypomanic symptoms, mistaking them for a period of unusually good mood.

How Is Bipolar Disorder with Rapid Cycling Treated?
Because symptoms of depression dominate in most people with a rapid cycling course of bipolar disorder, treatment is usually aimed toward stabilizing mood, mainly by relieving depression while preventing the comings-and-goings of new episodes.
Antidepressants such as Prozac, Paxil, and Zoloft have not been shown to treat the depression symptoms of rapid cycling bipolar disorder, and may even increase the frequency of new episodes over time. Many experts therefore advise against the use of antidepressants (especially long term) in bipolar patients with rapid cycling.

Mood-stabilizing drugs — such as lithium, Depakote, Tegretol and Lamictal — are the core treatments of rapid cycling. Often, a single mood stabilizer is ineffective at controlling episode recurrences, resulting in a need for combinations of mood stabilizers. Several antipsychotic medicines such as Zyprexa or Seroquel also have been studied in rapid cycling and are used as part of a treatment regimen, regardless of the presence or absence of psychosis (delusions and hallucinations).

Treatment with mood stabilizers is usually continued (often indefinitely) even when a person is symptom-free. This helps prevent future episodes. Antidepressants, if and when used, are generally tapered as soon as depression is under control.

What Are the Risks of Rapid Cycling Bipolar Disorder?
The most serious risk of a rapid cycling course in bipolar disorder is suicide. People with bipolar disorder are 10 times to 20 times more likely to commit suicide than people without bipolar disorder. Tragically, 8% to 20% of people with bipolar disorder eventually lose their lives to suicide.

People with a rapid cycling course may be at even higher risk for suicide than those with nonrapid cycling bipolar disorder. They are hospitalized more often, and their symptoms are usually more difficult to control long term.

Treatment reduces the likelihood of serious depression and suicide. Lithium in particular, taken long term, has been shown to reduce the risk.

People with bipolar disorder are also at higher risk for substance abuse. Nearly 60% of people with bipolar disorder abuse drugs or alcohol. Substance abuse is associated with more severe or poorly controlled bipolar disorder.

There are other mental disorders besides bipolar disorder, which can produce mood swings. For example, mood swings can be caused by general medical conditions or other physical illnesses that affect the body’s regulatory systems. Suspect medical conditions include various brain chemical imbalances, hormone disorders (such as hyper- or hypothyroidism), bacterial or viral infections, and autoimmunity conditions (leading to body rhythm dysregulation). Such illnesses could cause people to experiencebipolar-like mood swings even though they don’t have actual bipolar disorder. See our section onContemporary Understandings of Bipolar Disorder for a more detailed discussion of medical conditions, which must be ruled out prior to bipolar diagnosis.

Equally confusing is the use of street drugs and/or alcohol, which can lead to altered mood states. Intoxication with central nervous system stimulant drugs (such as Cocaine, or Methamphetamine) can easily mimic a manic state. Similarly, intoxication with central nervous system depressant drugs (such as alcohol, or Valium) can mimic a depressive state. When it is not clear if a mood condition is due to a drug or to a disease process, doctors will tend to hold off making definitive bipolar diagnoses until enough time has passed so as to allow any drug effect that might be affecting mood to metabolize and clear out of the affected person’s system.

As previously mentioned, manic people tend to show poor judgment and to be pleasure-seeking in the extreme. For this reason, it is not at all uncommon for people in the midst of a manic disorder episode to take drugs and/or drink alcohol. Similarly, people experiencing a depressive episode tend to feel awful, and sometimes will “self-medicate” with street drugs and/or alcohol in an attempt to help themselves feel better. . Though some short-term relief may be gained by such self-medication attempts, substance abuse and addiction problems can result in the long-term, which compounds the existing mental disorder. Addicts, of course, are at the mercy of the availability of their drugs; they may develop manic depressive mood symptoms as a result of withdrawal symptoms, or efforts to ward off experiencing withdrawal symptoms. When either of these situations occur, you have a situation where a true bipolar condition and drug effects may exist simultaneously. Once again, this sort of situation can be ruled out by a diagnosing doctor by simply letting enough time pass for the effects of any drugs or alcohol to wear off.

There is perhaps a weak bi-directional causal relationship between substance abuse disorders and bipolar disorder. People who have bipolar affective disorder have an increased risk for developing substance abuse problems, and people who use substances may help to release whatever inborn potential or vulnerability they may have for developing bipolar disorder (see our section on the Diathesis-Stress Hypothesis for more detail). Whatever the true relationship is between bipolar conditions and substance abuse, it is not in question that the combination of the two conditions leaves people worse off than either alone.

Complicating bipolar diagnosis further is the possibility that an individual with mood swings is suffering from a mental illness other than bipolar disorder. A number of other mental disorders are associated with mood swings. Mental disorders which may be commonly confused with bipolar disorder include Borderline Personality Disorder , Schizoaffective Disorder, Unipolar Depression, and Premenstrual Dysphoric Disorder.

Recognizing the diversity of types and intensities of mood episodes, the DSM-IV-TR (the Diagnostic and Statistical Manual of Mental Disorders, the book that describes mental health diagnoses) has subdivided the diagnosis of bipolar disorder into four basic categories, each defined by a particular pattern of severity of spontaneous depressions, manias, hypomanias or mixed episodes. The term “Bipolar I Disorder” is applied to patients who demonstrate full-strength manic and depressive episodes. The term “Bipolar II Disorder” is applied to patients who demonstrate full-strength depression, but only hypomanic presentations rather than full-strength manias. The term “Cyclothymic Disorder” is used to describe patients who demonstrate repeated mood swings which are never quite severe enough to qualify as major depressive or manic episodes. Finally, the term “Bipolar Disorder, Not Otherwise Specified (NOS)” is used to describe all other patients with bipolar symptoms which cannot neatly be fitted into the above categories. We’ll have more to say about DSM bipolar diagnoses in our discussion below.

Periodicity of Swings

Besides the energy or intensity of mood episodes, the other important factor relating to bipolar mood swings has to do with their periodicity; how long each episode lasts, and how rapidly they fluctuate. Most of the time bipolar mood swings occur with relative slowness, over periods of weeks and months. Usually, less than four complete mood cycles occur within a given year, and each mood episode might last up to two months.

There is generally a period of relatively normal mood that occurs between mood episode extremes. However, some individuals bipolar disorder do not experience this normal inter-episode period and instead experience this interval as a point in time when their mood symptoms are milder than normal (rather than being absent). For example, a person who is clearly between episodes might still feel low on some days or slightly manic on others.

Though less common than the longer cycling forms of bipolar disorder, a rapid-cycling variation of bipolar disorder is recognized. Rapid cycling bipolar disorder occurs when complete mood cycle periods occur four or more times per year. Rapid cycling bipolar conditions are thought to occur in 20% or less of all bipolar patients.

Two additional cycling terms are now beginning to enter the literature. Ultra-rapid cycling is in use to describe cases where complete mood cycles occur in less than one month. Ultridian cycling is in use to indicate cases where complete mood cycles occur inside the space of one day (and thus might be confused with a mixed episode). It is important to note that ultra-rapid and ultridian forms of mood cycling are not yet formally recognized in the DSM and thus are not currently official terms.

Rapid cycling in any form of bipolar disorder tends to be associated with a poorer long-term prognosis, which is to say, rapid-cyclers don’t tend to hold their lives together as well as do bipolar patients who have longer cycles.

Just as the manic aspect of bipolar disorder is associated with manic episodes, the depressive aspect of bipolar disorder is likewise associated with depressive episodes. The severe form of depressive episode is known as a Major Depressive Episode.

Major depressive episodes are characterized by five or more of the following symptoms, all of which must be present in a more or less uninterrupted manner for at least a two week period:

• A pervasive depressed mood that colors and tones daily experience
• A diminished ability to take pleasure from activities that used to be pleasurable (such as sex, food, hobbies, social interaction)
• Appetite changes (either more hungry or less), which may be accompanied by weight loss or gain. (No conscious dieting is occurring)
• Sleep changes (either sleeping more or less than normal)
• Psychomotor (e.g., body) agitation or retardation; either can’t sit still, or can hardly move.
• Constant complaints of fatigue and low energy
• Thoughts of the affected person’s worthlessness, guilt or shame plague him or her
• Concentration becomes more difficult to achieve than before
• Thoughts of the desirability of death and suicide

People experiencing a major depressive episode may be lacking in energy and show slower, unmotivated movements, or they may appear irritable and agitated. They may have a hard time getting out of bed in the morning, or they may stay up all night with insomnia. Either way, they are likely to complain of constant tiredness and difficulty concentrating on tasks. They may eat very little or eat to excess so as to comfort themselves, possibly leading to rapid changes in weight. They may lose interest in doing things they previously enjoyed or spending time with other people. The low mood tone, inability to accomplish tasks, and general shut-down of the brain’s ability to think clearly and rationally can lead to exaggerated feelings of worthlessness, misery and despair. Such extreme negative feelings and self-judgments drive a substantial minority of bipolar-diagnosed people towards contemplating and (all too often) actually committing suicide.

There is no corollary to a hypomanic episode for depression; no short-term “hypodepressive” episode that can be diagnosed. There is a related condition known as Dysthymic Disorder or Dysthymia, which describes a long-lasting mild depression. Dysthymia cannot be diagnosed at the same time as bipolar disorder, however, because in order to qualify for a diagnosis of Dysthymia, you have to show evidence of consistently mild depressive symptoms occurring more days than not over a period of at least two years. The presence of manic or hypomanic episodes during the two year period would disqualify any dysthymic disorder diagnosis.

Mixed Episodes

While bipolar disorder most frequently manifests as a swing between manic and depressive episodes, in a minority of cases, a third type of Mixed mood episode occurs. In a mixed episode, the criteria for mania and the criteria for depression are both simultaneously met more often than not for at least a one week period duration. Just because criteria for both manic and depressive episodes are both met during a single day does not mean that both sets of symptoms are simultaneously present, however. Instead, what appears to be more the case is that there is a rapid alteration between manic and depressive states, occurring one or more times in a single day. Mixed episodes tend to be severe when they occur; psychotic symptoms such as hallucinations and delusions, and suicidal thinking are frequently present.