Bipolar Disorder

Overview

Bipolar disorder is marked by extreme mood changes from periods of feeling very “up,” energized, or elated (called manic episodes) to periods of feeling very “down,” sad, or hopeless (called depressive episodes). These shifts are more severe than the normal ups and downs that everyone experiences, and they cause significant impairments in functioning. The disorder can be chronic, meaning persistent or constantly recurring. Or it can be episodic, meaning it occurs occasionally and at irregular intervals.

Symptoms of bipolar disorder usually start during late adolescence or early adulthood. Although symptoms may come and go, bipolar disorder often requires lifelong treatment and does not go away on its own. Proper treatment can lead to better functioning and improved quality of life.

Related Terms: While “bipolar disorder” is the official diagnosis and commonly preferred term, this mental illness is still often referred to as manic-depressive illness, manic-depressive disorder, or manic depression.

Signs and Symptoms

Symptoms of bipolar disorder can vary in timing and severity. A person with bipolar disorder may have manic episodes, depressive episodes, or “mixed” episodes, which have both manic and depressive symptoms.

These mood episodes cause symptoms that last a week or two, or sometimes longer. Feelings are intense and occur with changes in behavior, energy levels, and/or activity levels that are severe and noticeable to others. In between episodes, mood usually returns to a more typical baseline. Without adequate treatment, episodes can occur more frequently as time goes on.

During a manic episode, a person may experience:

• Feeling very up, high, elated, extremely irritable, or touchy
• Feeling jumpy or wired or being more active than usual
• Having racing thoughts
• Decreased need for sleep
• Talking fast about a lot of different things (“flight of ideas”)
• Excessive appetite for food, drinking, sex, or other pleasurable activities
• Feeling able to do many things at once without getting tired
• Feeling unusually important, talented, or powerful
• Doing reckless things that show poor judgment

During a depressive episode, a person may experience:

• Feeling very down, sad, or anxious
• Feeling slowed down or restless
• Trouble concentrating or making decisions
• Trouble falling asleep, waking up too early, or sleeping too much
• Talking very slowly, feeling unable to find anything to say, or forgetting a lot
• Lack of interest in almost all activities
• Inability to do even simple things
• Feeling hopeless or worthless, or thinking about death or suicide

Both the depressive and manic phases of bipolar disorder can interfere with usual functioning, such as maintaining work responsibilities, social activities, and relationships.

Some people with bipolar disorder have milder symptoms than others. For example, some people have “hypomanic episodes,” which are like manic episodes but are less severe, and they don’t interfere as much with daily life. However, family and friends may notice mood swings and changes in activity levels as unusual behavior. While a person in a hypomanic state may be more productive at work and socially active, this tends not to last very long.

There are three basic types of bipolar disorder:

Bipolar I disorder is defined by manic episodes that last at least 7 days (most of the day, nearly every day) or when manic symptoms are so severe that hospital care is needed. Usually, separate depressive episodes occur as well, typically lasting at least 2 weeks. Episodes of mood disturbance with mixed features are also possible. The experience of four or more episodes of mania or depression within a year is termed “rapid cycling.”

Bipolar II disorder is defined by a pattern of depressive and hypomanic episodes, but the hypomanic episodes are less severe than the manic episodes in bipolar I disorder. Many people with bipolar II disorder spend extended periods in a persistent, low-grade depressive state.

Cyclothymic disorder (also called cyclothymia) is defined by recurrent hypomanic and depressive symptoms that are not intense enough or do not last long enough to qualify as hypomanic or depressive episodes.

There is also a category of bipolar disorder called “other specified and unspecified bipolar and related disorders.” This refers to bipolar disorder symptoms that do not match the three major types of bipolar disorder outlined above.

Signs and Symptoms in Children and Teens

Although most people are diagnosed with bipolar disorder in adolescence or adulthood, the symptoms can appear in childhood. Bipolar disorder is not the same as the typical ups and downs every child goes through. The mood changes in bipolar disorder are more extreme, often unprovoked, and accompanied by changes in sleep, energy level, and the ability to think clearly.

Children and teens having a manic episode may:

• Show intense happiness or silliness for long periods of time
• Have a very short temper or seem extremely irritable
• Talk fast about a lot of different things
• Have trouble sleeping but not feel tired
• Have trouble staying focused and experience racing thoughts
• Seem overly interested in pleasurable but risky activities
• Do risky or reckless things that show poor judgment
• Have an inflated sense of ability, knowledge, and power

Children and teens having a depressive episode may:

• Feel frequent and unprovoked sadness
• Show increased irritability, anger, or hostility
• Complain a lot about physical pain, such as stomachaches and headaches
• Start sleeping a lot more
• Have difficulty concentrating
• Feel hopeless and worthless
• Have difficulty communicating or maintaining relationships
• Eat too much or too little
• Have low energy and no interest in activities they usually enjoy
• Think about death or have thoughts of suicide

Related Health Effects

The symptoms of bipolar disorder can lead to serious challenges to a person’s mental and physical health. Bipolar disorder can be an important factor contributing to job loss, family discord, and even suicide.

Many people with bipolar disorder also have other mental disorders or conditions, such as:

• Anxiety disorders
• Attention-deficit/hyperactivity disorder (ADHD)
• Misuse of drugs or alcohol
• Eating disorders

Sometimes people who have severe manic or depressive episodes also have symptoms of psychosis, such as hallucinations (hearing voices or seeing things that are not there) or delusions (false beliefs that are strongly held and resistant to evidence). The psychotic symptoms tend to match the person’s extreme mood. For example, someone having psychotic symptoms during a depressive episode may falsely believe they are financially ruined, while someone having psychotic symptoms during a manic episode may falsely believe they are famous or have special powers.

Causes and Risk Factors

Although the cause of bipolar disorder is unknown, research suggests that a combination of factors may contribute to the illness.

Genetics

Bipolar disorder often runs in families, which suggests that certain genes play a role. Research to date indicates that many genes are involved, and no single gene can cause the disorder.

Genes, however, are not the only factor. Studies of identical twins have shown that one twin can develop bipolar disorder while the other does not. Although people with a parent or sibling with bipolar disorder are more likely to develop the condition, not everyone with a family history of bipolar disorder will develop it.

Research also suggests that people with a genetic risk of having bipolar disorder may be more likely to develop it after experiencing trauma or other stressful life events.

Brain Structure and Function

Research shows that the brain structure and function of people with bipolar disorder may differ from those of people who do not have bipolar disorder or other mental disorders. Learning about the nature of these brain changes helps researchers better understand bipolar disorder and, in the future, may help predict which types of treatment will work best for a person with bipolar disorder.

Diagnosis

To diagnose bipolar disorder, a healthcare provider may assess family history, complete a physical exam, order medical testing to rule out other illnesses, and refer the person for an evaluation by a mental health professional.

Some people have bipolar disorder for years before it is diagnosed. People with bipolar II disorder may seek help only for depressive episodes; as a result, hypomanic and manic episodes may go unnoticed. When clinicians identify bipolar disorder in a person’s family history, they will often be more aware of evidence for past manic or hypomanic episodes.

Misdiagnosis

Misdiagnosis may occur because some symptoms of bipolar disorder are like those of other illnesses. For example, people with bipolar disorder who also have psychotic symptoms may be misdiagnosed with schizophrenia.

Some health conditions, such as thyroid disease, can cause symptoms like those of bipolar disorder. The effects of some prescribed, recreational, or illicit drugs can sometimes mimic or worsen mood symptoms.

If subtle signs of bipolar disorder are missed and an initial depressive episode is treated with antidepressant medicine alone — without a mood stabilizer — a manic episode or rapid cycling may be triggered.

Diagnosing Children and Teens

A healthcare provider will ask questions about a child’s mood, sleeping patterns, energy levels, and behavior. There are no blood tests or brain scans that can diagnose bipolar disorder. However, a healthcare provider may use tests to determine if something other than bipolar disorder is causing the child’s symptoms.

Other mental and behavioral disorders — such as ADHD, disruptive mood dysregulation disorder, oppositional defiant disorder, conduct disorder, and anxiety disorders — have symptoms like those of bipolar disorder. A healthcare provider who specializes in working with children and teens can carefully evaluate a child’s symptoms to provide an accurate diagnosis.

Treatment and Management

Treatment helps many people, even those with the most severe forms of bipolar disorder. Mental health professionals treat bipolar disorder with medicines, often combined with some form of psychotherapy.

Medicines

Certain medicines can help control the symptoms of bipolar disorder. Some people may need to try several different medicines before finding what works best. The most common types of prescribed medicines include mood stabilizers and atypical antipsychotics.

Mood stabilizers such as lithium or valproate can help prevent mood episodes or reduce their severity. Lithium also can decrease the risk of suicide.

Bipolar depression is often treated with a mood stabilizer or an atypical antipsychotic. For some people experiencing a depressive episode, antidepressants may be added to these medicines. However, antidepressants are not used alone because they can trigger a manic episode or rapid cycling in a person with bipolar disorder. Medicines that target sleep or anxiety are sometimes added to mood stabilizers as part of a treatment plan.

Talk with your healthcare provider to understand the risks and benefits of each medicine. Report any concerns about side effects to your healthcare provider right away. If you are thinking about reducing or stopping your medicine, talk to your healthcare provider first.

Psychotherapy

Psychotherapy, also known as talk therapy, is a term for various treatment techniques that aim to help a person identify and change troubling emotions, thoughts, and behaviors. Psychotherapy can provide support, education, skills, and strategies to people with bipolar disorder and their families, such as keeping a daily life chart or mood chart to track one’s own moods, behaviors, and sleep patterns.

Some types of psychotherapy, when used along with medicine, can effectively treat bipolar disorder, including:

• Interpersonal and social rhythm therapy, which aims to understand and work with a person’s biological and social rhythms
• Family-focused therapy, which has been shown to help adolescents and adults when introduced with mood-stabilizing medicine following an episode of bipolar depression or mania
• Cognitive behavioral therapy (CBT), an important treatment for depression; CBT adapted for the treatment of insomnia can be especially helpful as a component of the treatment of bipolar depression

Other Treatments

Some people may find other treatments helpful in managing their bipolar disorder symptoms.

Electroconvulsive therapy (ECT) is a brain stimulation procedure that can help relieve severe symptoms of bipolar disorder. ECT is usually only considered if a person’s illness has not improved after other treatments such as medicine or psychotherapy, or in cases that require rapid response, such as with suicide risk or catatonia (a state of unresponsiveness).

Transcranial magnetic stimulation (TMS) is a type of brain stimulation that uses magnetic waves to relieve depression over a series of treatment sessions. Although not as powerful as ECT, TMS does not require general anesthesia and presents little risk of memory or adverse cognitive effects.

Light therapy is the best evidence-based treatment for seasonal affective disorder (SAD), and many people with bipolar disorder experience seasonal worsening of depression in the winter, in some cases to the point of SAD. Light therapy could also be considered for lesser forms of seasonal worsening of bipolar depression.

Treatment for Children and Teens

Several types of medicine can help treat symptoms of bipolar disorder in children. Children respond to medicines in different ways and may need to try different types to find the one that works best. Healthcare providers usually try to prescribe the fewest number of medicines and the smallest doses possible to help treat a child’s symptoms.

Different kinds of psychosocial therapy can also help children and their families manage the symptoms of bipolar disorder. Therapies based on scientific research — including cognitive behavioral approaches and family-focused therapy — can provide support, education, and guidance to youth and their families. These therapies teach skills that can help people manage bipolar disorder, including skills for maintaining routines, enhancing emotion regulation, and improving social interactions.

Your child’s healthcare provider may recommend keeping a daily life chart or mood chart to track your child’s moods, behaviors, and sleep patterns. This may make it easier to track the illness and see whether treatment is working.

Living With Bipolar Disorder

There is not yet a cure for bipolar disorder, but long-term, ongoing treatment can help manage symptoms and enable you to live a full and healthy life. Here are some things you can do:

• Keep medical and therapy appointments.
• Take medicine and treatment as directed.
• Structure activities. Keep a routine for eating, sleeping, and exercising.
• Try exercise like jogging, swimming, or bicycling, which can help with depression and anxiety, promote better sleep, and support heart and brain health.
• Avoid using drugs and alcohol.
• Keep a life chart or mood journal to help recognize your mood swings.
• Ask for help when trying to stick with your treatment.
• Be patient. Improvement takes time. Social support helps.

How to Help a Loved One

If your friend or family member has bipolar disorder, here are a few ways you can help them:

• Offer emotional support, understanding, patience, and encouragement.
• Listen and be open to their experiences.
• Understand triggers and be alert to any major mood changes.
• Include them in fun activities.
• Offer hope by reminding them that getting better is possible with the right treatment.
• Offer practical help, such as driving your loved one to healthcare appointments or picking up their prescriptions.
• Take care of yourself, too.

How to Help a Child or Teen

If your child has bipolar disorder, here are some basic things you can do:

• Be patient.
• Encourage your child to talk and listen carefully.
• Pay attention to your child’s moods. Be alert to any major changes.
• Understand triggers and learn strategies for managing intense emotions and irritability.
• Help your child have fun.
• Remember that treatment takes time. Sticking with the treatment plan can help your child get better and stay better.
• Help your child understand that treatment can make life better.

Caring for a child or teenager with bipolar disorder can be stressful. As a caregiver, it is critically important that you take care of yourself, too. Finding support and strategies for managing your own stress can help both you and your child.

Find Clinical Trials

Clinical trials uncover better ways to prevent, diagnose, treat, and understand diseases and conditions. To ensure results apply to everyone, volunteers of all ages, sexes, and backgrounds, including both healthy individuals and those with specific medical conditions, are needed. Find clinical trials on bipolar disorder.

Find Treatment

If you have concerns about your mental health, talk to a primary care provider. They can refer you to a qualified mental health professional, such as a psychologist, psychiatrist, or clinical social worker, who can help you figure out the next steps.

If you are unsure of where to get help for a child, your doctor, pediatrician, or other family healthcare provider is a good place to start. A healthcare provider can refer you to a qualified mental health professional, such as a psychiatrist or psychologist, who has experience treating bipolar disorder and can evaluate your child’s symptoms.

Community Support

The following organizations provide information and support for people with bipolar disorder and their families:

• The National Alliance on Mental Illness (NAMI) offers support groups and family education programs for people with bipolar disorder and their loved ones. The NAMI HelpLine can connect you with the NAMI office in your state and help you find programs close to home.
• The Substance Abuse and Mental Health Services Administration (SAMHSA) provides resources for finding support and locating mental health services in your area.

Note: This resource list is for informational purposes only. It is not comprehensive, and an organization’s inclusion does not constitute an endorsement by NIH.  

Research Information

The National Institutes of Health (NIH) is the largest public funder of biomedical research in the world. NIH invests most of its budget in medical research seeking to enhance life and to reduce illness and disability. NIH-funded research has led to breakthroughs and new treatments helping people live longer, healthier lives, and building the research foundation that drives discovery.  

NIH supports research to understand the biological, genetic, and environmental factors that contribute to bipolar disorder. This research includes studies examining how different factors influence when bipolar disorder symptoms appear and how they change over time. Other research focuses on identifying patterns in brain activity that could help predict and track symptom progression.

NIH also supports research to improve treatments for people with bipolar disorder. This includes research to better understand the relationship between bipolar disorder and co-occurring conditions, like anxiety disorders and substance use disorders. Understanding the relationship between these conditions could lead to more effective treatment approaches.

Find NIH-funded research projects using NIH RePORTER, a searchable database of current and past research projects supported by NIH and other federal agencies.  

Multimedia

Mental Health Minute: Bipolar Disorder in Adults