Bipolar Disorder: Signs of Mania, Hypomania, and Depression, and How It Is Treated

What Bipolar Disorder Is

Bipolar affective disorder (F31 in ICD-10; bipolar type I and type II disorder in ICD-11 and DSM-5) belongs to the mood disorders. Its essence is recurrent episodes in which mood and activity levels change significantly: sometimes they rise (mania or hypomania), and sometimes they fall (depression). Sometimes there are mixed states, when signs of elevation and depression are present at the same time.

This disorder used to be called manic-depressive psychosis, but the term is outdated: most people with bipolar disorder have no psychotic symptoms, and with proper treatment they work, study, and raise families. Bipolar disorder usually begins in adolescence or young adulthood. Heredity plays a significant role, and episodes can be triggered by stress, disrupted sleep, crossing time zones, and the use of alcohol and stimulants.

Bipolar I and Bipolar II

In bipolar I disorder, there has been at least one episode of full-blown mania that seriously disrupts life and often requires hospitalization. In bipolar II disorder, there are episodes of hypomania and depression, but there has never been full mania. Type II should not be considered mild: its depressive periods are often long and severe.

Cyclothymia

Cyclothymia is a milder but long-lasting condition in which, for at least two years in adults, periods of mild elevation and mild low mood alternate without reaching the level of full episodes. It can also interfere with life and needs monitoring, since it sometimes develops into bipolar disorder.

Signs of Mania and Hypomania

Mania is not just a good mood. The person feels an unusual surge of energy and confidence, may sleep 2–4 hours a night without feeling tired, talks fast and a lot, jumps from topic to topic, and makes grandiose plans. Impulsiveness rises sharply: large purchases, loans, risky investments, hasty new relationships, dangerous driving. Often irritability and a tendency toward conflict prevail instead of euphoria. According to the criteria, the symptoms last for at least a week, most of the day, or for any length of time if hospitalization was needed.

Hypomania is a less pronounced form: the elevation is noticeable to others and lasts at least four days (according to DSM-5), but it does not wreck the person’s life and is not accompanied by psychotic symptoms. The person often experiences hypomania as a productive period and does not see it as a problem. That is why, when seeing a doctor about depression, it is important to remember and mention such periods: the correct diagnosis depends on it.

• An unusually elevated, euphoric, or irritable mood
• A reduced need for sleep: 2–4 hours is enough, with no tiredness
• Rapid speech that is hard to interrupt, and racing thoughts
• Inflated self-esteem and a sense of special abilities or a mission
• Lots of new projects and plans, none of which are finished
• Risky spending, loans, investments, and hasty decisions
• Increased sex drive and rash new relationships and actions
• In severe mania: grandiose delusions and a loss of insight

What Bipolar Depression Looks Like

Depressive episodes in bipolar disorder resemble ordinary depression: low mood, loss of interest, lack of energy, disturbed sleep and appetite, guilt, difficulty concentrating, and thoughts of death. However, there are features that may alert a doctor: early onset, episodes that start and end abruptly, excessive sleepiness and increased appetite, marked slowing down, depression after childbirth, and cases of bipolar disorder among relatives.

Many people with bipolar disorder receive treatment only for depression for years, because that is what they see a doctor about. This is dangerous: antidepressants without mood stabilizers can cause a switch into mania or more frequent episodes. That is why, with any depression, a psychiatrist always asks about periods of elevated mood and about family history. The risk of suicide is higher in bipolar depression and mixed states, and this requires close monitoring.

How Bipolar Disorder Differs From Mood Swings

Mood fluctuations over the course of a day or in response to events are a normal part of life. Bipolar disorder is suspected when not only mood but also energy, sleep, activity, and thinking change, and the episodes last for days and weeks and differ noticeably from the person’s usual self. Family members often say “he became a different person,” and this is one of the most valuable observations for a doctor.

Rapid emotional shifts over a matter of hours, especially in response to relationships and feelings of rejection, are more typical of borderline personality disorder than of bipolar disorder. Mood swings also occur with the use of alcohol and stimulants and with thyroid disease. That is why the diagnosis is not based on a single symptom but on the whole picture and the history of episodes, sometimes after observing the person over time.

A Mood Diary

A simple and useful tool is to record every day your mood on a scale, hours of sleep, energy level, alcohol use, and important events. Within a few weeks it becomes clear whether there are episodes and what triggers them. Such a diary helps the doctor with diagnosis and, later, with preventing relapses.

How Bipolar Disorder Is Treated

Treatment of bipolar disorder aims to bring the person out of the current episode and to prevent new ones. It is based on medications that stabilize mood: mood stabilizers and certain second-generation antipsychotics; antidepressants are used with caution and only alongside stabilizers. The psychiatrist selects the treatment plan taking into account the type of disorder, the current episode, co-existing illnesses, and plans for pregnancy. Many of these medications require regular lab monitoring.

Maintenance treatment is usually long-term, often for many years. Stopping medication on your own when you feel well is one of the main causes of relapse. Psychotherapy (psychoeducation and cognitive behavioral, family, and interpersonal therapy with a focus on daily rhythms) helps people recognize the early signs of an episode, build a routine, and reduce the risk of recurrence. Severe mania or depression with a risk to life requires inpatient treatment.

• Taking prescribed medications regularly, even when you feel well
• A stable sleep schedule: going to bed and getting up at the same time
• Avoiding alcohol, stimulants, and energy drinks
• Keeping a mood diary and knowing your own early signs of an episode
• A plan for a relapse drawn up in advance with your doctor and family
• Regular visits to a psychiatrist and lab monitoring

Bipolar Disorder and Addiction: Why They Must Be Treated Together

Misuse of alcohol and other substances is much more common among people with bipolar disorder than in the general population. During mania, a person tends toward risky behavior and experimentation; during depression, they try to drown out their misery. Substance use makes episodes more frequent, increases impulsiveness, raises the risk of suicide, and reduces the effectiveness of treatment, and alcohol interacts dangerously with many psychiatric medications.

When bipolar disorder and addiction occur together, treatment must be coordinated. At Narcology 24, the psychiatrist and the addiction specialist work together: during a home visit or an inpatient stay, they assess both the mood state and substance use, carry out detoxification if needed, and select therapy that takes both problems into account. This reduces the risk of conflicting prescriptions, relapses, and repeat hospitalizations.

When to see a doctor

• There have been periods of unusual elation or irritability when you hardly felt like sleeping
• Depression keeps coming back, starts and ends abruptly, and antidepressants have made you agitated
• Your family notices sharp changes in behavior, large purchases, or risky actions
• Relatives have been diagnosed with bipolar disorder, and you have marked swings in your state
• You are already being treated for bipolar disorder but notice early signs of a new episode
• Mood swings are combined with the use of alcohol or stimulants

Questions and answers

Medically reviewed by

Arman Magzhanov, MDPsychiatrist · experience 24 years

Schizophrenia, bipolar disorder and acute psychosis, including substance-induced psychosis; psychiatrist home visits.