Bipolar disorder

What it's like

The highs and the lows, from the inside — and the three kinds.

From the inside

• The high: Elated or irritable; racing thoughts, talking fast, barely needing sleep, feeling unusually important.
• Good, at first: Hypomania can feel good, and the person may not notice anything is wrong.
• Reward louder: Success hits harder, and confidence can surge past what's realistic.
• The low: Empty, slowed down, hopeless — and often the more disabling side.
• Both at once: Mixed episodes bring manic and depressive symptoms together.

Signs of a manic episode

• Feeling very up, elated — or very irritable.
• Racing thoughts, and talking fast.
• Needing much less sleep, without feeling tired.
• Huge energy, and a strong appetite for pleasurable or risky activities.
• Feeling unusually important, talented or powerful.
• Poor judgement that damages work or relationships.

Signs of a depressive episode

• Feeling very sad, empty or anxious.
• Feeling slowed down; trouble concentrating.
• Sleeping too much or too little.
• Losing interest in almost everything.
• Feeling hopeless or worthless; thinking about death or suicide.

The three types

• Bipolar I: Manic episodes lasting at least 7 days, or severe enough to need hospital care — usually with depressive episodes too.
• Bipolar II: Depressive episodes and hypomania — a milder high that may not disrupt life, and that the person may not notice.
• Cyclothymic disorder: Recurring highs and lows that aren't intense or long enough to be full episodes.

Easy to miss

Depression is often the more disabling side, and hypomania can feel good — the person may not notice anything is wrong. So it can be mistaken for depression alone, and thyroid problems or drugs can mimic it.

• Myth: Bipolar just means moody. In fact: Episodes last days to weeks — at least 7 days for mania in bipolar I — and change sleep, energy, thinking and judgement, not just mood.
• Myth: Mania is just being really happy. In fact: It can be irritable rather than happy, and it brings poor judgement that can wreck work, money and relationships.
• Myth: An antidepressant will fix the lows. In fact: On their own, antidepressants can trigger mania or rapid cycling; they're used, if at all, alongside a mood stabiliser.

What's happening in the brain

During mania: drive up, brakes down. The model lights each one as you read.

Drive up

Pharmacology and imaging converge on too much dopamine signalling in mania, with an overactive reward network. People with a history of mania react intensely to success and reward, and surges of confidence can push goals to excess.

Brakes down

In mania the inferior frontal cortex is underactive, while limbic areas including the amygdala are overactive during emotional tasks. Weaker links between the ventral prefrontal cortex and the amygdala leave emotion poorly regulated.

Questions people ask

The things people wonder about bipolar disorder, from both sides — answered.

Why it happens

Genes, mostly — and what tips an episode off.

• ~85% heritability: In twin studies, with no detectable effect of shared family environment.
• 2.4% lifetime spectrum: 0.6% bipolar I, 0.4% bipolar II, and more with milder forms.
• 77% had sleep warnings: Disturbed sleep came before mania in a median of 77% of people across studies.

Three-quarters of people on the bipolar spectrum have another condition as well, most often anxiety. Drugs can mimic its symptoms, and avoiding drugs and alcohol is part of staying well.

Getting a diagnosis

What a doctor looks at, and what helps them see it.

Bipolar disorder is diagnosed from the severity, length and frequency of symptoms across someone's life, plus family history; a doctor may also run tests to rule out other causes, such as thyroid disease.

What helps the doctor

• A mood chart: daily mood, sleep and energy over weeks.
• Any past highs — even ones that felt good — not just the lows.
• Family history of bipolar disorder, depression or suicide.
• What a family member has noticed: the person in a high often can't see it.

What helps

Medication to prevent episodes, therapy to keep life steady.

• Lithium (The longest-established mood stabiliser.): Mood stabilisers like lithium help prevent episodes or make them milder. Across 48 trials, lithium also greatly reduced suicides compared with placebo.
• Other mood stabilisers and antipsychotics (Valproate; atypical antipsychotics for acute episodes, including bipolar depression.): Used to prevent episodes and to treat them when they happen.
• Therapy (Interpersonal and social rhythm therapy, family-focused therapy, CBT including CBT for insomnia.): Used alongside medication to keep routines and relationships steady.
• Antidepressants alone (Without a mood stabiliser.): Not used on their own, because they can trigger mania or rapid cycling.

Day to day

• Keep a mood chart to spot swings early.
• Keep regular times for sleeping, eating and exercise.
• Protect sleep — losing it is the commonest early warning of mania.
• Stick with treatment, even when well.
• Avoid drugs and alcohol.

Supporting someone

Plan when they're well, act early when they're not.

• Instead of "You're being crazy again.", try "I've noticed you've barely slept this week. We agreed that's a sign to call the doctor — can we do that today?". Disturbed sleep is the most reliable early warning, and a plan made while well is easier to follow than an argument in the moment.
• Instead of "Can't you just calm down?", try "Let's slow down on the big decisions until you've seen the doctor.". Mania brings poor judgement that can damage work, money and relationships; pausing big decisions limits the damage.
• Instead of "You seemed so much happier when you were up.", try "I miss how energetic you were too. I also remember how that week ended.". Hypomania can feel good, and that's part of what makes it easy to miss — and to want back.

Make a plan while they're well

• Agree on their personal early warning signs — sleep first.
• Agree on what you'll do when you see them: who to call, which doctor.
• Agree on safeguards for the high: cards, car keys, big purchases.

When to get help

When to call the doctor, and when it's an emergency.

Call the doctor if…

• Sleep has dropped off and they don't feel tired.
• They're talking fast, starting huge projects, or spending wildly.
• A low has gone on for two weeks or more.
• They've stopped their medication.

When it's an emergency

Thoughts of death or suicide are part of bipolar depression. If someone talks about wanting to die, is acting in ways that put them in danger, or has lost touch with reality, get help now. Asking directly about suicide doesn't put the idea there.

Put it into practice

Four real situations. Choose what you'd do, and see why.

• Your sister, who has bipolar I, has slept three hours a night all week. She says she feels amazing and has never been more productive. What's the most important thing to do? Gently raise the sleep, and help her contact her doctor now. Needing much less sleep is a hallmark of mania, and sleep disturbance is the most robust early warning sign. Acting early is easier than acting late.
• A friend with bipolar II has been depressed for a month. His GP is considering an antidepressant on its own. What's worth raising? That antidepressants alone can trigger mania in bipolar disorder. Antidepressants aren't used alone in bipolar disorder because they can trigger mania or rapid cycling. The GP needs to know about the bipolar diagnosis.
• Your dad has taken lithium for years and is stable. He says he feels fine now and wants to stop. What should he know? Feeling fine is the lithium working — any change should go through his doctor. Mood stabilisers prevent episodes, lithium reduces suicide risk, and sticking with treatment matters even when well.
• Your 19-year-old daughter has had two serious depressions. Her aunt has bipolar disorder. Last summer, she had a week of barely sleeping and big plans that everyone thought was "just her being fun". What should you tell her doctor? About the summer week and her aunt's bipolar disorder, as well as the depressions. Diagnosis rests on the pattern of symptoms over a lifetime plus family history, bipolar disorder is highly heritable, and hypomania is easy to miss.