The Symptoms of Bipolar Disorder, Phase by Phase

The manic phase

Mania is the defining feature of bipolar I and the most severe of the elevated states. It is a distinct period, lasting at least a week or requiring hospital care, of abnormally elevated, expansive, or irritable mood combined with a marked and sustained increase in energy and activity. Contrary to the cheerful stereotype, mania is often experienced as agitation and irritability rather than happiness, and it can be frightening rather than fun.

• A greatly reduced need for sleep, feeling rested after only two or three hours or going without sleep for days
• Racing thoughts and rapid, pressured speech that is hard to interrupt
• Inflated self-esteem or grandiosity, sometimes reaching unrealistic beliefs about one's abilities or importance
• Distractibility, jumping between ideas and tasks without finishing them
• A surge in goal-directed activity or restless agitation
• Impulsive, high-risk behaviour: overspending, reckless driving, impulsive sexual or business decisions
• In severe cases, a loss of contact with reality, including delusions or hallucinations (psychosis)

Because judgement is impaired, a person in the grip of mania often does not recognise that anything is wrong, and may resist help precisely when they most need it. This lack of insight is a symptom of the state, not stubbornness.

The hypomanic phase

Hypomania is the elevated state of bipolar II and cyclothymia. It shares the same ingredients as mania, elevated or irritable mood, extra energy, less sleep, faster thoughts, more confidence, but at a lower intensity and for a shorter minimum duration, and without the severe impairment, psychosis, or need for hospital care. The catch is that hypomania can feel good. Many people describe it as their most creative, sociable, and productive self.

That is exactly what makes it dangerous to overlook. Because it can be pleasant and productive, hypomania is rarely what brings someone to a clinic, and it may not be reported at all unless specifically asked about. Yet it is still a clear departure from the person's baseline, still disrupts sleep and routine, and often tips into either a crash into depression or an escalation toward mania. A hypomanic episode that goes unrecognised is a common reason bipolar disorder is misdiagnosed as depression alone.

The depressive phase

Bipolar depression is, for most people, the heavier burden. It resembles major depression in any other context and is what people spend the most time experiencing. The symptoms are not the opposite of mania in a tidy mirror image; they are their own distinct and disabling state.

• Persistent low, empty, or hopeless mood most of the day, most days
• Loss of interest or pleasure in activities that normally matter
• Marked fatigue and loss of energy; even small tasks feel enormous
• Changes in sleep and appetite, in either direction
• Difficulty concentrating, remembering, and making decisions
• Physical and mental slowing, or restless agitation
• Feelings of worthlessness or excessive guilt
• Recurrent thoughts of death or suicide

Because the depressive phase looks identical to unipolar depression from the outside, the history of past elevated episodes is what distinguishes bipolar depression, and it changes how the depression should be managed. This is one reason accurate diagnosis matters so much.

Mixed features

Mood does not always fall neatly on one side. In an episode with mixed features, elevated and depressive symptoms occur at the same time: a person may feel the hopelessness and despair of depression while also carrying the racing thoughts, agitation, and sleeplessness of mania. This combination of low mood with high energy is particularly distressing and is considered a higher-risk state, because the despair of depression is paired with the drive and impulsivity of the elevated pole.

The three states side by side

Laying the elevated and depressed phases next to each other makes the pattern easier to hold in mind. Note how several dimensions, energy, sleep, thinking, and self-view, move in opposite directions between the poles.

Warning signs that need urgent help

Most of the time, symptoms are managed steadily over the long term. But two situations call for immediate action rather than watchful waiting, one at each pole.

Where to go next

To understand why these episodes happen, read causes. For how the phases are stabilised and prevented, see treatment, and for day-to-day self-management, the coping strategies.