The younger the age of onset, the more likely the first few episodes are to be depressive.[1] Because a bipolar diagnosis requires a manic or hypomanic episode, many patients are initially diagnosed and treated as having major depression.[2]
Manic episodes
Mania is the defining feature of bipolar disorder. Mania is a distinct period of elevated or irritable mood, which can take the form of euphoria, and lasts for at least a week (less if hospitalization is required).[3] People with mania commonly experience an increase in energy and a decreased need for sleep, with many often getting as little as three or four hours of sleep per night. Some can go days without sleeping.[4] A manic person may exhibit pressured speech, with thoughts experienced as racing.[5] Attention span is low, and a person in a manic state may be easily distracted. Judgment may be impaired, and sufferers may go on spending sprees or engage in risky behavior that is not normal for them. They may indulge in substance abuse, particularly alcohol or other depressants, cocaine or other stimulants, or sleeping pills. Their behavior may become aggressive, intolerant, or intrusive. They may feel out of control or unstoppable, or as if they have been "chosen" and are "on a special mission", or have other grandiose or delusional ideas. Sexual drive may increase. At more extreme levels, a person in a manic state can experience psychosis, or a break with reality, where thinking is affected along with mood.[6] This can occasionally lead to violent behaviors. [7] Some people in a manic state experience severe anxiety and are irritable (to the point of rage), while others are euphoric and grandiose. The severity of manic symptoms can be measured by rating scales such as the Altman Self-Rating Mania Scale[8] and clinician-based Young Mania Rating Scale.[9][10]The onset of a manic episode is often foreshadowed by sleep disturbances. Mood changes, psychomotor and appetite changes, and an increase in anxiety can also occur up to three weeks before a manic episode develops.[11]
Hypomanic episodes
Hypomania is a mild to moderate level of elevated mood, characterized by optimism, pressure of speech and activity, and decreased need for sleep. Generally, hypomania does not inhibit functioning as mania does.[12] Many people with hypomania are actually more productive than usual, while manic individuals have difficulty completing tasks due to a shortened attention span. Some hypomanic people show increased creativity, although others demonstrate poor judgment and irritability. Many experience hypersexuality. Hypomanic people generally have increased energy and increased activity levels. They do not, however, have delusions or hallucinations.Hypomania may feel good to the person who experiences it. Thus, even when family and friends recognize mood swings, the individual often will deny that anything is wrong.[13] What might be called a "hypomanic event", if not accompanied by depressive episodes, is often not deemed as problematic, unless the mood changes are uncontrollable, volatile or mercurial. If left untreated, an episode of hypomania can last anywhere from a few days to several years. Most commonly, symptoms continue for a few weeks to a few months.[14]
Depressive episodes
Signs and symptoms of the depressive phase of bipolar disorder include persistent feelings of sadness, anxiety, guilt, anger, isolation, or hopelessness; disturbances in sleep and appetite; fatigue and loss of interest in usually enjoyable activities; problems concentrating; loneliness, self-loathing, apathy or indifference; depersonalization; loss of interest in sexual activity; shyness or social anxiety; irritability, chronic pain (with or without a known cause); lack of motivation; and morbid suicidal thoughts. In severe cases, the individual may become psychotic, a condition also known as severe bipolar depression with psychotic features. These symptoms include delusions or, less commonly, hallucinations, usually unpleasant. A major depressive episode persists for at least two weeks, and may continue for over six months if left untreated.[15]Mixed affective episodes
In the context of bipolar disorder, a mixed state is a condition during which symptoms of mania and depression occur simultaneously. Typical examples include weeping during a manic episode or racing thoughts during a depressive episode. Individuals may also feel very frustrated in this state, for example thinking grandiose thoughts while at the same time feeling like a failure. Mixed states are often the most dangerous period of mood disorders, during which the risks of substance abuse, panic disorder, suicide attempts, and other complications increase greatly.[16]Associated features
Main article: Associated features of bipolar disorder
Associated features are clinical phenomena that often accompany the disorder but are not part of the diagnostic criteria. In adults with the condition, bipolar disorder is often accompanied by changes in cognitive processes and abilities. These include reduced attentional and executive capabilities and impaired memory. How the individual processes the world also depends on the phase of the disorder, with differential characteristics between the manic, hypomanic and depressive states.[11] Some studies have found a significant association between bipolar disorder and creativity.[17] Some patients may have difficulty in maintaining relationships.[18]There are several common childhood precursors seen in children who later receive a diagnosis of bipolar disorder. These include mood abnormalities, full major depressive episodes, and ADHD.[19]
