Understanding Bipolar Disorder
Bipolar disorder is a serious condition that affects 1% to 3% of people worldwide. It involves alternating episodes of manic (“high”) moods and depressed (“low”) moods, with periods of stability in between. The distinctive mood cycles of bipolar disorder have been recognized in cultures around the world, for thousands of years.
Of course, the clinical term “bipolar disorder” is relatively recent. So is the concept of bipolar as a brain-based condition, treatable with medication. Lithium, the first prescription drug for bipolar, was not approved by the Food and Drug Administration until 1970.
Despite its prevalence, bipolar disorder is still widely misunderstood. In everyday speech, the word “bipolar” is often used to mean any mood swings.
For example, a person might be called “bipolar” if they:
get aggressive when they drink
have conflict-filled relationships
have sudden, unpredictable mood shifts
are elderly and having personality changes
In reality, none of these traits are symptoms of bipolar disorder!
Let’s talk about what bipolar disorder really is, from a clinical standpoint.
Bipolar disorder is categorized as a mood disorder. It’s in the same diagnostic category as major depressive disorder, but it includes different symptoms. Specifically, bipolar disorder involves swinging between two opposing mood states: “low” mood (depression) and “high” mood (hypomania or mania). Each mood state lasts at least several days.
Most people with bipolar disorder also have “neutral” periods between episodes, during which they don’t experience symptoms and can function well.
Bipolar I vs Bipolar II
The two most common types of bipolar disorder are Bipolar I (episodes of mania, possibly alternating with depression) and Bipolar II (episodes of hypomania, a milder form of mania, alternating with depression).
Some people with Bipolar I or II also experience “mixed” episodes, in which symptoms of depression and hypomania/mania occur at the same time.
The symptoms of a depressive episode include deep sadness or inability to feel pleasure; sleep and appetite changes; fatigue; feelings of guilt and worthlessness; and possible suicidal thoughts.
The symptoms of a hypomanic/manic episode include grandiose beliefs about oneself; euphoria or irritability; reckless and impulsive behavior; a reduced need for sleep; racing thoughts; and rapid speech.
Hypomania is a milder form of mania. With hypomania, someone may feel unusually creative, goal-oriented, and productive. They sleep less than usual. They may be more reactive or impulsive than usual. These changes can feel good at first, and others might not pick up on them right away.
What is Mania?
With Bipolar I disorder, hypomania is usually a precursor to mania. The symptoms of mania are hard to miss. Someone who is manic may believe that they are incredibly famous, talented, or powerful. They may talk nonstop, and sleep only 1-2 hours a night.
Someone who is manic may also act recklessly, such as going on spending sprees; having sex with multiple strangers; driving dangerously; or making life-altering decisions on a whim. To diagnose this behavior as mania, it must be considered extreme or out-of-character for the person.
Sometimes, manic episodes also include delusions (beliefs that seem paranoid or bizarre to others) and/or hallucinations (seeing or hearing things that aren’t there). These symptoms are known as psychosis. They can also occur during depressive and mixed episodes. The presence of psychosis indicates a severe bipolar mood episode.
Someone who is experiencing psychosis, an inability to sleep or function, very risky behavior, or suicidal thoughts needs immediate psychiatric care (such as in an emergency room).
The course of Bipolar episodes
Bipolar mood episodes follow a distinctive course. They tend to build up gradually, over several days or longer. Once an episode is in full force, it lasts several days, weeks or even months.
You may have heard the term “rapid cycling,” which is a subtype of bipolar disorder. This term is often misunderstood. Rapid cycling refers to having 4 or more bipolar mood episodes per year. It does not refer to sudden, unpredictable mood swings that occur throughout the day. When mood swings occur this often, they may not be caused by bipolar disorder.
With treatment, people with bipolar disorder can lead satisfying lives. Without treatment, bipolar mood episodes often become more frequent and disabling.
Medications for Bipolar Disorder
Medications are the cornerstone of treatment for most people with bipolar disorder. Meds must be taken consistently, even between mood episodes. This helps prevent future episodes.
Medications for bipolar disorder do not block all human emotions; rather, they keep someone’s emotions within the expected “ups and downs” of life.
There are three broad categories of medication used to treat bipolar disorder: antidepressants, mood stabilizers, and antipsychotics. There are dozens of medications within each category.
No single medication is considered “best for bipolar.” Everyone with bipolar disorder is different. Medications can be trial and error at first.
Incidentally, many of the meds used to treat bipolar disorder are also used for other conditions such as anxiety, depression, impulse control problems, insomnia, delirium, and seizure disorders. For this reason, it’s impossible to tell who has bipolar disorder based on their medications alone!
Therapy for Bipolar Disorder
Along with medications, therapy can be very helpful for people with bipolar disorder. Some people struggle to understand and manage their bipolar symptoms. Others may want to learn better ways to handle stress, or to understand how they were affected by family members with bipolar disorder.
Bipolar Episodes: Genetics + Stress
Bipolar disorder has a strong genetic component. A family history of bipolar is present in 80-90% of people with the diagnosis. Bipolar mood episodes are often set in motion by stress, which interacts with someone’s genetic predisposition for bipolar.
Common triggers for bipolar mood episodes include high-pressure situations, like final exams or a new job; traumatic events, like a car accident or losing a loved one; prolonged sleep deprivation; and heavy substance use.
The average age of onset for bipolar disorder is 25. Some people have their first bipolar episode in their teens; others may not have one until their 40s. However, a first bipolar episode past age 65 is rare. New mood swings, aggression, and behavior changes in older people require a medical workup. Such symptoms often have an underlying medical or neurological cause.
For a deeper dive into the symptoms and types of bipolar disorder, please visit https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders.
Having reviewed what bipolar disorder is, let’s shift the conversation to what it isn’t. There are many possible explanations for mood swings. Not all mood swings are bipolar!
Natural variations in temperament
We are each born with a certain temperament—a collection of inborn traits that determine how we experience and react to the world.
Some people have more reactive, impulsive, sensitive temperaments. Others have more placid, consistent, go-with-the-flow temperaments.
Someone with a sensitive temperament might be perceived as moody, flighty, or unpredictable. They might even be called “bipolar,” but temperament (unlike bipolar) is constant, not episodic. It is usually noticeable from infancy onward.
Of course, sensitive temperaments also come with many strengths, such as creativity, enthusiasm, and empathy! Variations in temperament are just part of human diversity. No diagnosis needed here.
Acute stress reactions
Most people don’t feel like themselves after a serious trauma or loss. For up to 1 month after the event, they may have trouble sleeping, irritability, nightmares, flashbacks, and emotional ups and downs. These symptoms, taken alone, do not mean someone has suddenly developed bipolar disorder.
The best “treatment” in such cases is often emotional support and practical help, such as with meals and childcare. Many people also find therapy helpful in times of acute stress.
Post-traumatic stress disorder (PTSD)
If acute stress symptoms go on longer than 1 month, or are severe and disabling, then PTSD may be a concern. Someone with PTSD experiences disrupted sleep, nightmares, flashbacks, irritability, hypervigilance, sensory triggers (certain smells, sounds, etc) and efforts to suppress memories of the trauma.
The anxiety and reactivity of PTSD can seem “bipolar.” However, PTSD symptoms usually relate directly to the trauma (flashbacks, nightmares, etc) and do not include grandiosity or recklessness.
Trauma therapy is the main form of treatment for PTSD. Therapy for PTSD focuses on emotional support, reducing trauma-related distress and avoidance, and defusing trauma-related bodily sensations.
Complex PTSD (cPTSD)
cPTSD is widely recognized among mental-health clinicians, though it’s not yet an official diagnosis. cPTSD is a form of PTSD resulting from prolonged or repeated (“complex”) trauma, often in childhood.
Examples of complex trauma include childhood abuse or neglect; repeated sexual trauma; domestic abuse; religious trauma; food and housing insecurity; multiple deaths of family members; and the effects of racism, ableism, sexism, fatphobia, homophobia, and/or transphobia.
People with cPTSD may have frequent mood swings. They become easily “flooded” by anger, fear, or shame. These mood swings can caused by sensory overload; reminders of a trauma; interpersonal conflict; or a fear of abandonment.
People with cPTSD usually have trouble trusting others and themselves. They may have an unstable sense of identity. They may not know how to maintain boundaries in relationships.
Under stress, someone with cPTSD may lash out, escape, or become “frozen” and unable to act. cPTSD can also involve chronic suicidal thoughts, dissociation, and feelings of emptiness.
These features of cPTSD can look “bipolar” on the surface, but they are not. Unlike bipolar disorder, cPTSD isn’t a mood disorder. It is a long-term, nervous-system response to deprivation, invalidation, or abuse. cPTSD “makes sense” given what someone has been through. Mood swings in cPTSD are brief and sudden, and do not look like bipolar mood episodes.
cPTSD is primarily treated with psychotherapy. There is a range of therapy modalities that work with the core symptoms of cPTSD, including somatic therapies, Internal Family Systems, Dialectical Behavior Therapy, EMDR, and relational models of therapy. Support groups, such as for adult survivors of child abuse, can also be very helpful.
Side effects from antidepressants
For someone with undiagnosed bipolar disorder, starting on an antidepressant can trigger their first manic episode.
However, even someone without bipolar disorder may experience so-called “activating” side effects on a new antidepressant. These can include increased anxiety, restlessness, low appetite, and poor sleep.
If these side effects are uncomfortable or intolerable, it’s a good idea to contact the doctor or nurse who prescribed the antidepressant. If the side effects include suicidal thoughts, the safest plan is to call 988 or go to the nearest ER.
Major depressive disorder (without bipolar)
Major depression, by itself, can include symptoms that are mistaken for bipolar.
Some depressed people feel very “low” and sluggish. They sleep and eat more than usual, and struggle to complete basic tasks of self-care.
However, other depressed people feel very tense and on-edge. They have obsessive, racing negative thoughts. They can’t sleep, despite being tired. These symptoms don’t necessarily mean someone has bipolar disorder, but they are still concerning.
A depressed person is at higher risk for suicide if they haven’t slept in days, or if they are feeling increasingly frantic, hopeless, and trapped with no way out. Someone in this state of mind cannot be talked out of it. Even if they don’t mention suicide, the risk is present. The safest plan is to call 988 or go to the nearest ER.
Heavy substance use
Heavy drug or alcohol use can trigger mood swings, even in people without bipolar disorder. Here are some examples.
Some people who drink heavily become weepy, grandiose, or aggressive, but only when intoxicated. These are not true bipolar episodes, but they can be dangerous nonetheless.
Heavy drinking also puts someone at higher risk for suicide. Alcohol use can cause or worsen depression. It also increases impulsivity, making someone more likely to act on suicidal thoughts.
Prolonged use of concentrated THC products (such as strong edibles and vape pens) can cause manic episodes in some people, even without a family history of bipolar.
Someone who is high on cocaine, stimulants, or methamphetamine use can appear manic. The symptoms go away once the drug wears off.
Of course, some people with substance use problems also do have bipolar disorder. They may have started using to cope with their mood symptoms.
In such cases, it’s often best to address the substance use disorder first. Someone who is actively using substances is unlikely to take medications for bipolar. It may not even be safe for them to do so.
In addition, it’s easier to correctly diagnose (or rule out) bipolar disorder once someone has stopped using for a period of time.
Attention Deficit Hyperactivity Disorder (ADHD)
ADHD is a neurodevelopmental condition present from early childhood. In ADHD, the brain prioritizes tasks that feel stimulating and reinforcing, even when other tasks may be more important.
It is hard for someone with ADHD to prioritize tasks that are boring, difficult or highly detailed. Such tasks can feel like torture—to the point that they go undone, despite the painful consequences.
People with ADHD struggle with impulse control, emotional regulation, short-term memory, and organization. They are drawn toward risky or impulsive choices that they later regret. However, people with ADHD can also be extraordinarily driven, creative, and empathetic. Many people with ADHD are “jacks of all trades” and have a broad set of skills.
The symptoms of ADHD can be confused with bipolar disorder. Some people with ADHD have trouble handling frustration or criticism. They can have sudden mood shifts or seem “thin-skinned” in general.
In addition, many people with ADHD focus intensely on a single topic of interest, sometimes for weeks at a time. They may have disrupted sleep during these periods of hyperfocus, which may raise concern about mania or hypomania.
However, a period of ADHD hyperfocus doesn’t typically become severe or dangerous, and it passes on its own. Notably, many people with ADHD are “night owls” by nature, and struggle to maintain consistent sleep.
People with ADHD can benefit from therapy to strengthen their executive functioning, self-esteem, and emotional regulation. Stimulant medications can be essential for some people with ADHD. Living with ADHD often means modifying one’s environment—for example, using organizers and alarms, maintaining a sleep schedule, and choosing jobs that play to one’s strengths.
Can you have one of the above conditions *and* bipolar disorder?
Absolutely. Bipolar disorder can co-occur with many other mental-health conditions. In these cases, each condition is treated separately medication-wise, but therapy can help address the complex interplay of symptoms and help you feel better overall.
Final thoughts
Combating stigma and misinformation about bipolar disorder starts with understanding it. Bipolar disorder is a mood disorder with a strong genetic component and a distinctive set of symptoms. While mood swings in bipolar disorder are primarily treated with medications, this is not true for all types of mood swings.
Many personality variations, problems in living, trauma responses, and mental-health conditions can cause mood swings, but aren’t bipolar disorder. Generally, mood swings that are frequent, sudden, brief, or brought on by substance use are less likely to be bipolar disorder. However, clinical bipolar disorder is a complex condition that can look different in different people.
If you have concerns about your symptoms or diagnosis, please speak with a licensed mental-health provider, such as a psychologist or therapist, who can get to know you and your family history. We have many qualified therapists on our team who work with women, trans folks, and teen girls in Illinois. You can reach out to us at any time!
This article is for general information only. It is not intended to be used for self-diagnosis, nor for any other diagnostic or treatment purposes.
