Bipolar disorder is a chronic mental health condition characterized by extreme mood swings that include emotional highs (mania or hypomania) and lows (depression).

To understand this, it is helpful to use an analogy. Think of the brain’s mood regulation system as a sophisticated thermostat that works to keep your emotional temperature stable and comfortable. In most people, this thermostat functions well, with minor, appropriate fluctuations in response to daily events. In bipolar disorder, this thermostat is broken. It can get stuck on “high heat,” leading to a period of intense, elevated, and often chaotic energy known as mania. At other times, the thermostat can shut off completely, plunging the person into a cold, dark, and debilitating state of depression. The illness is defined by this faulty regulation, and the episodes are far more extreme than typical mood swings.

There are several types of bipolar disorder, each defined by the pattern and severity of the mood episodes:

• Bipolar I Disorder: This is defined by the presence of at least one full manic episode. Manic episodes are periods of abnormally elevated, expansive, or irritable mood and high energy that cause significant impairment in daily functioning and may require hospitalization. People with Bipolar I disorder also typically experience major depressive episodes, though they are not required for the diagnosis.
• Bipolar II Disorder: This is defined by a pattern of at least one hypomanic episode and at least one major depressive episode. Hypomania is a less severe form of mania. While it involves an elevated mood and increased energy, it is not severe enough to cause major functional impairment or require hospitalization, and it does not include psychotic features. Because hypomania can feel productive or good, it often goes unrecognized as a problem, and individuals with Bipolar II often only seek help during their depressive episodes.
• Cyclothymic Disorder: This is a milder form where an individual experiences numerous periods of hypomanic symptoms and depressive symptoms for at least two years. However, the symptoms are not severe or long-lasting enough to be classified as full hypomanic or major depressive episodes.

In my experience, many patients struggle for years before getting the correct diagnosis, often misdiagnosed as depression or anxiety alone. Recognizing the pattern of highs and lows is key.

Bipolar disorder is believed to be caused by a complex interaction of genetic, biological, and environmental factors. While the exact cause isn’t known, researchers have identified several key contributors.

Brain Structure and Function

Studies have shown that there are subtle differences in the average size and activation of certain brain structures in people with bipolar disorder compared to those without. There are also differences in the function of key brain chemicals called neurotransmitters. These chemicals, including serotonin, dopamine, and norepinephrine, are responsible for communication between brain cells and play a crucial role in regulating mood, energy, sleep, and thinking. In bipolar disorder, the regulation of these neurotransmitter systems is believed to be dysfunctional.

Genetics

This is the most important factor. Bipolar disorder has a very strong hereditary component and runs in families. An individual with a first-degree relative (a parent or sibling) with bipolar disorder has a substantially higher risk of developing the illness compared to the general population (National Institute of Mental Health [NIMH], 2023).

Patients often feel confused and ashamed, but I reassure them: bipolar disorder is a medical condition, not a personal failing.

You do not “get” bipolar disorder from one single cause, it develops over time due to a mix of genetic vulnerability and environmental stressors. You can’t catch it like an infection, and it’s not caused by weakness or personality flaws.

• A Strong Genetic Link: As mentioned, family history is the greatest risk factor. However, genetics are not simple. There is no single “bipolar gene.” Instead, scientists have identified many different genes that each contribute a small amount to the overall risk.
• Environmental Triggers: It is believed that in a person who is already genetically vulnerable, the first mood episode can be “switched on” or triggered by an external event. Common triggers include:
  • Periods of high stress or a major life change.
  • A history of childhood trauma, abuse, or neglect.
  • Significant disruptions to sleep patterns.
  • Substance use or abuse.

The typical age of onset for bipolar disorder is in the late teens or early twenties, a time of significant brain development and often high stress.

Clinically, I’ve found that many first episodes are triggered by intense life events, especially in someone with a family history of mood disorders.

The hallmark of bipolar disorder is the presence of mood episodes, periods of mania/hypomania and depression. The intensity and duration of these episodes vary.

Symptoms of a Manic Episode (Required for Bipolar I)

A manic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood and increased energy, lasting at least one week and present most of the day, nearly every day. The symptoms are severe enough to cause marked impairment in social or occupational functioning. The symptoms include:

• Inflated self-esteem or grandiosity (feeling all-powerful or uniquely talented).
• A dramatically decreased need for sleep (e.g., feeling rested after only 3 hours).
• Being much more talkative than usual or feeling pressure to keep talking.
• Flight of ideas or the subjective experience that thoughts are racing.
• Extreme distractibility.
• A significant increase in goal-directed activity (at work, school, or sexually) or purposeless physical agitation.
• Excessive involvement in activities that have a high potential for painful consequences, such as unrestrained buying sprees, foolish business investments, or sexual indiscretions.
• In severe cases, mania can include psychosis, such as delusions (false beliefs) or hallucinations (seeing or hearing things that aren’t there).

Symptoms of a Hypomanic Episode (Required for Bipolar II)

A hypomanic episode has the same symptoms as a manic episode, but it is less severe. It must last at least four consecutive days. The change in mood and functioning is noticeable to others, but it is not severe enough to cause major functional impairment or to require hospitalization, and it never includes psychotic features. To the individual experiencing it, hypomania can sometimes feel good and productive, so it is often not reported as a problem.

Symptoms of a Major Depressive Episode

This is the “low” pole of the illness and is characterized by a depressed mood or a loss of interest or pleasure that lasts for at least two weeks. The symptoms are debilitating and include:

• Depressed mood most of the day, nearly every day.
• Markedly diminished interest or pleasure in all, or almost all, activities (anhedonia).
• Significant weight loss when not dieting or weight gain.
• Insomnia (inability to sleep) or hypersomnia (sleeping too much).
• Fatigue or profound energy loss.
• Feelings of worthlessness or excessive and inappropriate guilt.
• Diminished ability to think, concentrate, or make decisions.
• Recurrent thoughts of death, suicidal ideation, or a suicide attempt. If you or someone you know is having suicidal thoughts, it is critical to seek help immediately.

I’ve often seen patients describe depressive episodes clearly, but only realize their highs were problematic after loved ones mention risky behaviors or personality changes.

Diagnosing bipolar disorder is based on clinical interviews rather than blood tests or imaging. The key to a correct diagnosis is identifying the patient’s history of mood episodes over time. This can be challenging, as bipolar disorder is one of the most commonly misdiagnosed mental illnesses. It is frequently mistaken for major depressive disorder because people are far more likely to seek help when they are depressed and may not recognize their hypomanic episodes as part of an illness.

The diagnostic process includes:

• A comprehensive psychiatric evaluation where the doctor will ask detailed questions about mood symptoms, sleep patterns, thought processes, and behavior over the person’s lifetime.
• Gathering collateral information from close family members can be invaluable, as they may have observed mood episodes that the patient did not recognize.
• A physical exam and lab tests to rule out other medical conditions that can cause mood symptoms, such as thyroid problems or neurological disorders.
• A comparison of the patient’s symptoms to the criteria laid out in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

In practice, careful tracking of mood patterns over time, through journals or caregiver input, can be critical to an accurate diagnosis.

Bipolar disorder is a lifelong condition, but with the right treatment plan, most people can manage symptoms and lead fulfilling lives.

The gold standard of care is a combination of medication and psychotherapy.

1. Medications

Medication is the cornerstone of bipolar disorder treatment.

• Mood Stabilizers: These are the primary medications used to control mood swings. They are taken daily on a long-term basis to prevent future episodes. Common mood stabilizers include lithium, valproic acid, lamotrigine, and carbamazepine.
• Atypical Antipsychotics: These medications can be used to treat the acute symptoms of a manic episode and can also be used as long-term mood stabilizers. Examples include olanzapine, risperidone, quetiapine, and aripiprazole.
• Antidepressants: Antidepressants must be used with extreme caution in bipolar disorder. If prescribed alone, they can trigger a switch into mania or hypomania.

2. Psychotherapy

Therapy is a crucial partner to medication. It helps individuals and their families learn to cope with the illness.

• Psychoeducation: Learning everything you can about the disorder, its triggers, and early warning signs of an episode.
• Cognitive-Behavioral Therapy (CBT): Helps patients identify and change the negative thought patterns and behaviors associated with depressive episodes and learn strategies to manage the impulsivity of mania.
• Family-Focused Therapy: Helps educate family members, improves communication, and builds a strong support system.

3. Lifestyle Management

A stable and healthy lifestyle is vital for managing bipolar disorder. This includes maintaining a regular sleep schedule, managing stress, engaging in regular exercise, and avoiding alcohol and illicit drugs. I’ve found that medication combined with therapy is most effective, especially when patients actively engage in tracking their mood and maintaining structure in daily life.

Bipolar disorder is a serious biological brain disorder that poses immense challenges for those who live with it. The extreme shifts in mood from the euphoric, chaotic energy of mania to the debilitating despair of depression can disrupt every facet of a person’s life. It is essential to combat the stigma and misunderstanding that surrounds this illness and to recognize it as a treatable medical condition. While the journey is lifelong, a commitment to consistent treatment with mood-stabilizing medications and supportive psychotherapy provides a clear path to stability. Patients often tell me that having a name for what they’re going through, and a plan to manage it, makes all the difference. Hope begins with understanding.

National Institute of Mental Health (NIMH). (2023). Bipolar disorder. Retrieved from https://www.nimh.nih.gov/health/topics/bipolar-disorder

Mayo Clinic. (2024). Bipolar disorder. Retrieved from https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc-20355955

American Psychiatric Association. (n.d.). What is bipolar disorder? Retrieved from https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders