Bipolar disorder, also known as manic depressive illness, is common but also frequently misdiagnosed, even by professionals. At times, the diagnosis can be clear as a crystalline sky on a brilliant winter’s day, but just as commonly, no amount of careful history-taking or watching someone over stretches of time can clear the fog. Let’s do a deeper dive and see what we can see.

Here are some of the basics. Despite its name, bipolar illness actually has three states: mania, depression, and baseline. By “baseline” we mean how a person is when they are as well as they get. A more technical term for this is “euthymia,” Greek for “feeling well.” Now we are already getting into the weeds, because all of us have personalities and past experiences, and some of us have been deeply scarred by difficult or traumatic lives, and so not everyone’s baseline is as serene as one would wish for. We will be discussing this more deeply later.

Depression, as we have seen previously, is not mere sadness or a bad couple of days. It is a persistent state that goes on for at least a couple of weeks in a row, more often months or years. This minimum time is very important diagnostically and is used specifically to distinguish it from moodiness. Also important are the “neurovegetative signs” which must accompany it: changes in sleep and appetite (can be less or more), decreased motivation, diminished interest in pleasurable activities, lower physical energy, decreased socialization, loss of ability to enjoy oneself (called “anhedonia”), feelings of guilt, poor memory, concentration difficulties, loss of sex drive (libido), and suicidal thoughts. One doesn’t have to have all of these to be diagnosed, but most have to be present. 

So, both unipolar and bipolar depression look quite similar so far. Therefore, it is the presence of manic episodes that must distinguish unipolar from bipolar disorders. Mania also has a lower time limit: one week. Again, this distinguishes mania from getting “hyped up” about something. Manic people are also hyped up, but they stay that way for extended periods of time. But if they are not always that way, they probably have something else going on. 

Mania, like depression, also has physical symptoms associated with it. Rapid speech, racing thoughts, heightened physical activity, elevated mood (euphoria), decreased appetite, being overly friendly or overly sexual, and impulsiveness are common. Although many manic people seem to be having a grand old time, they can also become very irritable, especially as the episode drags on. They may spend unusual amounts of money, running up their credit cards as if the bill will never come. They can make terrible choices, believing the whole time that their judgment is brilliant. They often have an unusually high opinion of themselves (grandiosity). But the symptom I like to focus on most is sleep. Manic people almost always sleep less than they usually do, and for days and weeks in a row. Despite this, they seem to have more energy than usual. Importantly, when we see that combination of persistently decreased sleep and increased energy, the diagnosis is clear.

Sometimes mania (and less often, depression) comes along with what we call psychotic symptoms. These include hearing voices, paranoia, delusions, belief in mind reading or thought control, and “ideas of reference.” This last is the belief that things that have nothing to do with you, do pertain to you. For example, strangers are talking about you, or music lyrics contain a special message for you. 

We see almost every pattern imaginable, from people who almost always are depressed or manic, to people who have episodes separated by decades. The most common pattern is one or two episodes a year separated by months of being asymptomatic. Most people spend the most time euthymic, less time depressed, and the least manic. 

There is a variant called bipolar type II, where the lows are just as low as in bipolar type I, but the highs are less high. We call those “hypomanic” episodes.

I can’t stress this point enough: the symptoms I’ve described for mania or depression have to come in discrete episodes. These episodes have to be a deviation from the way the person normally is. They have to have a beginning and an end. There have to be several symptoms occurring together, at the same time. If a person spends too much money all the time, this is not evidence of bipolar disorder. If they spent a lot once but had no other symptoms, then it’s not evidence. But if they went through a 6-week spell where they slept less than usual and had more energy than usual and talked faster than usual and spent more money than usual, and then they stopped being like that, then it may well have been a manic episode.

I told you it was complicated, but it gets murkier. There are lots of things that overlap with the symptoms of bipolar disorder and that can deceive even the most careful clinician.

Probably the most common is depressed people with a bad temper. Folks can be depressed all the time or periodically, then get angry suddenly. And anger is a manic symptom, right? Well, not so fast! Almost everyone who gets angry, gets angry quickly, so it can look like an episode. But remember that one symptom alone doesn’t make the diagnosis. And most of these people, even if they aren’t always angry, do have a longstanding propensity towards irritability. But, if they aren’t usually irritable, and for several weeks they are, and they’re not sleeping much, and they just bought a boat they can’t afford…you get the picture!

Then there are people who are very emotionally reactive. They may get depressed, then anxious, then angry, then happy. Their anxiety or irritability can get them pretty amped up, and therefore they may look like they are manic. But the time scale here is mostly hours to a few days, and they don’t have all the other symptoms described above. “Rapid cycling bipolar” is defined as four or more episodes in a year. However, the duration criteria remain the same, and this is how we try to distinguish these reactive people from those with bipolar disorder. These people have often had a difficult upbringing or a traumatic past. Some are diagnosed with borderline personality disorder. These are probably the folks who stump the experts most often. Over the course of their lives, some clinicians will label them as bipolar, some as borderline. One of our clinicians has coined the term “borderpolar” for those where we really just can’t tell.

While some depressed people are always depressed, probably no one is always manic. If a person seems to be always hyper, we should be thinking about something else, like ADHD-hyperactive type. Also, some people are always anxious and activated by this. Other people seem to talk and move fast because from birth they have fast-moving brains. These people have no mental health diagnosis; we probably all know people who are faster or slower than most but seem just fine otherwise.

Recreational drugs or drugs of abuse can also alter one’s moods and complicate the diagnosis. Unfortunately, the most common drug of all, alcohol, is the one most likely to make people depressed but also irritable. Stimulants clearly make people manic, and when they wear off, people can “crash,” so it can look a lot like mood cycles.

Therapeutic drugs, especially antidepressants, can occasionally trigger a manic episode in depressed people who have never been manic before. Plus, in people who are already known to suffer from bipolar disorder, antidepressants can take them right out of depression and straight into mania.

Bipolar disorder tends to run strongly in families and so is thought to be largely biological in nature. Events may trigger an episode, but the presence of the illness overall seems to be determined by genes. We just wish we knew which ones, because a blood test or scan would really help with the murkiness.

If you find all this somewhat confusing, you are in good company. This is my take on bipolar disorder, and I have tried hard to stick to the official diagnostic criteria in the DSM V. But many excellent clinicians would take issue with some of the things I’ve said, often tending toward a more liberal interpretation of the criteria. Some speak of a “bipolar spectrum.” Some, for example, will give patients the bipolar diagnosis if their mood swings last a day or two.

Sometimes we try to try to tease out whether multiple symptoms are occurring together in discrete episodes, but patients can’t recall, or be clear, or even grasp this concept. Sometimes talking to a close friend or relative makes it clearer, but often not. Sometimes mental health is just murky, as I warned you at the beginning.

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