Bipolar disorder is a mental health condition defined by significant, distinct shifts in a person’s mood, energy, and activity levels. These dramatic changes are known as “mood episodes,” which represent periods of illness that differ markedly from an individual’s usual temperament. The episodes involve a spectrum of emotional states, ranging from intense highs to profound lows. These episodes can severely affect an individual’s ability to function in their daily life, including work, school, and relationships.
The High Side: Manic Episodes
A full manic episode is characterized by an abnormally and persistently elevated, expansive, or irritable mood, coupled with an increase in goal-directed activity or energy. This heightened state must last for at least one week and be present for most of the day, nearly every day, or for any duration if hospitalization is required. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning, often leading to serious consequences.
During this period, a person must exhibit three or more specific symptoms, or four if the mood is only irritable. One common symptom is inflated self-esteem or grandiosity, where the individual may believe they possess extraordinary talents or power. Sleep disturbance is often present, with a decreased need for sleep, meaning a person may feel completely rested after only three hours.
Speech patterns change, becoming more talkative than usual, often described as “pressured speech,” which is rapid and difficult to interrupt. Thoughts may race uncontrollably, called “flight of ideas” where topics shift quickly. Distractibility is prominent, with attention easily drawn to irrelevant external stimuli.
The increase in energy manifests as heightened goal-directed activity, such as starting numerous complex projects, or as psychomotor agitation, which is purposeless physical movement. This intense energy often leads to excessive involvement in activities that have a high potential for painful consequences. Examples include engaging in unrestrained spending sprees, making foolish business investments, or reckless driving.
The Milder High Side: Hypomanic Episodes
Hypomanic episodes share the same type of symptoms as mania, involving an abnormally and persistently elevated, expansive, or irritable mood and increased activity or energy. However, the defining difference is the intensity and duration of the symptoms. A hypomanic episode must last for at least four consecutive days, present for most of the day, nearly every day.
The symptoms themselves are milder and do not cause the marked impairment in functioning seen with a full manic episode. Individuals experiencing hypomania often feel especially productive, creative, or “on top of the world,” which can make it harder to recognize as an illness state. The changes in mood and function are noticeable to others, but they do not lead to a severe disruption of work or social life.
A crucial distinction is that hypomania, by definition, does not necessitate hospitalization to prevent harm to self or others. If the symptoms were severe enough to require an admission to the hospital, the episode would be classified as manic. The absence of psychotic features, such as hallucinations or delusions, further separates hypomania from the more severe presentation of mania.
The Low Side: Depressive Episodes
A major depressive episode in the context of bipolar disorder is marked by a period of at least two weeks where an individual experiences an intensely sad mood or a significant loss of interest or pleasure in nearly all activities. This loss of interest is clinically known as anhedonia and must be present almost every day. To meet the criteria, at least five symptoms must be present during the two-week period, with one of the core symptoms being either depressed mood or anhedonia.
A depressed mood is often reported as feeling sad, empty, or hopeless, and this may be observed by others as tearfulness. Physical changes are common, including significant changes in appetite or weight, which can manifest as either an increase or decrease. Sleep is frequently disturbed, leading to either insomnia (difficulty sleeping) or hypersomnia (sleeping too much) nearly every day.
The individual may experience psychomotor agitation, such as restlessness or pacing, or psychomotor retardation, which is a noticeable slowing of movement and speech. Fatigue and a profound loss of energy are typical, making even small tasks feel overwhelmingly difficult. Feelings of worthlessness or excessive, inappropriate guilt are common components of the episode.
Concentration and the ability to think are often impaired, making decision-making a struggle. The episode can also include recurrent thoughts of death, suicidal ideation without a specific plan, or a suicide attempt. The depth and persistence of this low mood causes clinically significant distress or impairment in functioning.
When High Meets Low: Episodes with Mixed Features
An episode with mixed features occurs when an individual experiences symptoms of both mania or hypomania and depression during the same period. This presentation is a simultaneous display of opposing mood characteristics. To qualify, the episode must meet the full criteria for either a manic or hypomanic episode, and at least three significant symptoms of the opposite polarity must also be present nearly every day.
For example, a person may be in a manic episode but also experience intense sadness, worthlessness, and suicidal thoughts. This combination is often described as feeling “wired and tired,” where the body has high energy but the mind is consumed by despair. The individual’s thoughts may be racing (a manic feature), but the content is dominated by hopelessness (a depressive feature).
Alternatively, a depressive episode with mixed features involves meeting the criteria for a major depressive episode while also experiencing at least three symptoms of mania or hypomania. This can manifest as feeling profoundly depressed while simultaneously having increased talkativeness, racing thoughts, or decreased need for sleep. The combination of high energy and profound low mood means that mixed episodes pose a greater risk for self-harm and suicide.