Test Your Knowledge

Symptoms of bipolar disorder generally remain constant from one episode of a given type (e.g., manic, depressive) to the next in the same patient, but they may improve or worsen during this time. For example, a patient who formerly had only hypomanic episodes may develop a manic episode, or vice versa. All patients with bipolar disorder suffer from some impairment in function. This may result from the episodes themselves or chronic unpredictable mood swings and unreliable ability to function.

Symptoms of manic episodes include:

• Euphoria and elevated, “high” feelings or irritability. The patient may be in a good mood that remains despite occurrences that would normally dampen the mood.
  
  
• Uncharacteristically elevated self-esteem, feelings of grandiosity or unrealistic confidence. Patients often feel very good about themselves or feel like they can take on the world.
  
  
• Decreased need for sleep. The patient may wake up feeling rested after only a few hours of sleep.
  
  
• Rapid talking, talking more than usual or feeling a need to keep talking. Patients may be excessively talkative. They may be loud or talk too fast.
  
  
• "Flight of ideas," feeling as though thoughts are racing, distraction or agitation. Patients may be easily distracted or restless. They may have rapidly shifting thoughts that may be revealed in conversation as the patient constantly changes the subject.
  
  
• Increased goal-directed activity. Productivity may be increased.
  
  
• Intrusive or aggressive behavior. The patient may seem nosy or aggressive, sometimes with destructive outbursts.
  
  
• Denial that a problem exists. Because patients feel good and are often more productive, they may deny that there is a problem.
  
  
• Seeking pleasure without regard to consequences, reckless behavior or poor judgment. Patient may engage in spending sprees, sexual promiscuity, substance abuse or other behaviors when they would normally exercise better judgment.

In children and adolescents, manic episodes are more likely to be characterized by irritability and destructive outbursts than by elation or euphoria.

Hypomanic episodes are similar to manic episodes, but are less severe or have a shorter duration. They may not cause actual impairment. In fact, hypomania often results in increased productivity.

Major depressive episodes are the most common episodes in bipolar disorder. Nearly all patients will have one at some point during their lifetime. However, if only major depressive episodes occur, without manic, mixed or hypomanic episodes, the diagnosis is major depression, not bipolar disorder. The symptoms of major depressive episodes include:

• Altered mood. The patient may experience sadness, anxiety, anger, irritability or apathy (lack of emotion). They may be pessimistic (feel that everything in life will turn out badly) or discouraged and may experience crying spells or excessive emotional sensitivity.
  
  
• Anhedonia. Reduction or loss of interest in activities the patient formerly found pleasurable, such as food, sex, work, friends, hobbies and entertainment.
  
  
• Significant change in appetite or weight. Reduced or increased appetite or significant weight loss or gain.
  
  
• Changes in sleep patterns. The patient may sleep too much (hypersomnia) or not enough (insomnia). Often, the patient wakes up early in the morning and cannot get back to sleep.
  
  
• Physical or verbal activity. The patient may be agitated and anxious. They may wring their hands, pace or not be able to sit still. Conversely, the patient may have sluggish movements or speech. There may be a pause before answering questions or starting actions. The patient may speak quietly or not be able to be heard. They may not speak except in response to a direct question or may become completely mute (not talking at all).
  
  
• Fatigue and loss of energy.
  
  
• Self-worth. The patient may have feelings of worthlessness, self-reproach or excessive or inappropriate guilt.
  
  
• Loss of concentration. There may be a diminished ability to think or concentrate.
  
  
• Death thoughts. The patient may have recurrent thoughts of death and death wishes. They may think about committing suicide (suicidal ideation) or have suicidal actions. The patient may even attempt or complete suicide.

Sometimes, symptoms of depression may occur during a manic episode, resulting in a mixed episode. These may be more frequent in early onset bipolar disorder and in patients over the age of 60 years.

Psychotic features (e.g., hallucinations, delusions) may be present in manic, mixed or depressive episodes and tend to relate to the mood. For example, during manic episodes, patients may believe they are invulnerable to physical harm and, during major depressive episodes, patients may believe they are guilty of a great crime or sin. Obsessions and compulsions may also occur.