Symptoms and Diagnosis of Bipolar Disorder

Bipolar disorder isn't just about having mood swings. It's a serious mental health condition that used to be referred to as manic depression.

According to the DSM-5, the guide used to diagnose mental illnesses, there are two main types of bipolar disorder that can be diagnosed based on the severity and nature of their symptoms:

  • Bipolar I – Individuals with bipolar I experience at least one manic episode in their lives. Although not required for the formal diagnosis, the vast majority will also experience major depressive episodes during the course of their lives.
  • Bipolar II – Individuals with bipolar II have at least one hypomanic episode (a less serious form of mania) and at least one major depressive episode.

Assessing Symptoms

Bipolar disorder symptoms
Illustration by Hugo Lin. © Verywell, 2018. 

Being a mental health condition, blood draws or imaging exams won't help with diagnosing bipolar disorder but may sometimes be ordered to help rule out medical conditions that may be contributing to the symptoms. To confirm a diagnosis, a person must meet the criteria outlined above (symptoms and frequency), which will be assessed through a psychiatric assessment.

Note that symptoms of bipolar disorder are the same in women and men, but societal and gender roles can affect how they manifest or how others perceive them.

Bipolar Mania Symptoms

Manic episodes last at least seven days. Hypomanic episodes involve the same symptoms, but the individual's functioning isn't markedly impaired and psychotic symptoms cannot be present.

Symptoms of a manic or hypomanic episode include:

  • Decreased need for sleep
  • Talking excessively
  • Racing thoughts
  • Being easily distracted
  • Physical agitation and relentless movement
  • Increased sexual desire
  • Impulsive risk behaviors (including gambling and lavish spending)
  • Grandiosity or inappropriate behavior
  • Irritability, hostility, or aggression
  • Delusions or hallucinations

Bipolar Depression Symptoms

During a depressive episode, an individual may experience the following symptoms: 

  • Crying for no reason or prolonged periods of sadness
  • Feelings of guilt or hopelessness
  • Loss of interest in activities that usually give you pleasure
  • Extreme fatigue, including the inability to get out of bed
  • Loss of interest in your health, nutrition, or physical appearance
  • Difficulty concentrating or remembering things
  • Sleeping excessively or difficulty sleeping
  • Suicidal thoughts or an impulse to self-harm

Problems with cognitive skills, such as short-term memory trouble, difficulty concentrating, and indecision, may be the first things noticed by others when someone has bipolar depression. It can interfere with an individual's performance and make it difficult to complete tasks.  

Physical Symptoms Associated With Depressive Episodes

During depressive episodes, individuals may experience a variety of physical symptoms, including unexplained aches and pains. 

Changes in weight are also common. While some people struggle to eat when they're feeling down, others turn to food for comfort. Thus, both weight loss and weight gain can be symptoms of a depressive episode.

Psychomotor agitation, an increase in activity caused by mental rather than physical tension or psychomotor retardation, slowing of both thought and physical activities, may also occur.

Differential Diagnosis

There are distinct diagnostic criteria that have been proposed for bipolar disorder, but even with these criteria, the diagnosis is far from easy. Psychiatric conditions that can manifest symptoms similar to bipolar disorder include:

Attention Deficit Hyperactivity Disorder (ADHD)

Hyperactivity and distractibility are two of the hallmark symptoms of attention deficit hyperactivity disorder (ADHD). However, they are also quite predominant in bipolar disorder, especially as it relates to children. To further complicate things, these conditions can often co-occur.

Alcohol/Substance Abuse

It is very common for those with bipolar disorder to struggle with alcohol and substance abuse issues. This is often an attempt, even on an unconscious level, to self-medicate. Additionally, the effects of certain subtance use (which may cause hallucinations or the inability to sleep) can be confused with the symptoms of bipolar disorder. In addition to these concerns, alcohol may interact with the medications used to treat bipolar disorder.

Borderline Personality Disorder 

The diagnostic criteria for borderline personality disorder include impulsivity, suicidal behavior, reactivity of mood, inappropriate anger, and transient paranoia. All of these are also associated with bipolar disorder. It is possible for an individual to be diagnosed with both of these disorders as well. (Learn more about the similarities and differences between bipolar disorder and borderline personality disorder.)

Delusional Disorder

The hallmark of delusional disorder is non-bizarre delusions, meaning the situation may be possible. Mood episodes can be present but they are brief in duration relative to the delusion.

Depression

The one thing that distinguishes depressive disorders (unipolar depression) from bipolar disorder is mania/hypomania. If a patient with depression swings into an episode of mania, the diagnosis becomes bipolar disorder. Many people who have undiagnosed bipolar disorder are found to have the disorder when medications such as some antidepressants are started and precipitate mania.

Eating Disorders

It is not uncommon for those with bipolar disorder to experience eating disorders. Moreover, depression, anxiety and irritability often result from eating disorders. Anorexia nervosa is an eating disorder characterized by an extreme fear of gaining weight or getting fat.

Those with this disorder often have a body weight of less than 85 percent of that which is considered normal. Bulimia nervosa is typified by periods of binge eating followed by purging (purposely vomiting).

Panic Disorder

Panic disorder is characterized by recurrent, spontaneous panic attacks. Panic disorder is often comorbid (occurs together) with mood and other psychiatric disorders. Furthermore, panic attacks are also common in those with bipolar disorder.

Schizophrenia

Schizophrenia is a mental disorder that causes intense disturbances in cognition (thinking), behaviors, and emotions. It consists of two classifications of Symptoms—positive and negative. Positive symptoms include delusions, hallucinations, disorganized speech and thinking, disorganized behavior, catatonic behavior, and inappropriate moods. Negative symptoms are flattened emotions, lack of speech and a reduction in goal-directed behavior. The symptoms of schizophrenia are easily confused with those of bipolar disorder.

Schizoaffective Disorder

A diagnosis of schizoaffective disorder is given when there are symptoms of major depression or mania, along with certain symptoms of schizophrenia. However, the delusions or hallucinations must persist for periods when the mood symptoms aren’t present. As you might expect, there is a great deal of confusion and controversy surrounding differentiating this disorder from bipolar disorder. 

Diagnostic Challenges

While specific, the assessment of bipolar criteria is also highly subjective. As such, cases are often missed. One study presented at the Royal College of Psychiatry’s Annual Meeting in 2009 reported that more than 25 percent of people with bipolar disorder were incorrectly diagnosed and treated when seeking help from a mental health professional.

On the other hand, over-diagnosis of bipolar disorder is also a concern.

A 2013 review of clinical studies demonstrated that bipolar disorder was incorrectly diagnosed in:

  • 42.9 percent of substance abuse treatment centers
  • 40 percent of patients with borderline personality disorder
  • 37 percent of cases where a clinician inexperienced in bipolar disorder made the call

A study released in 2010 showed that, of 528 people receiving Social Security disability for a bipolar disorder, only 47.6 percent met the strict diagnostic criteria.

Caveats When Diagnosing the Type

There are two important caveats that may further complicate the process of distinguishing the two types of bipolar disorder.

One is that although present psychotic symptoms are one of the things that differentiate bipolar I mania from bipolar II hypomania, someone with bipolar II may experience hallucinations or delusions during depressive episodes without the diagnosis changing to bipolar I.

The second is that someone with bipolar I disorder may also have hypomanic episodes. In fact, they commonly do. But, someone with bipolar II does not ever have a manic episode. If a manic episode occurs in someone with bipolar II, the diagnosis will be changed.

A Word From Verywell

If you or someone you know is experiencing symptoms of bipolar disorder, it's important to talk to your physician. Your physician may want to rule out any potential physical health issues that could be contributing to your symptoms.

Your physician may refer you to a mental health professional for an evaluation. The treatment provider can assess your symptoms and, once a proper diagnosis is made, can assist with developing a treatment plan.

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