Bipolar: understanding it

Mania is a period when mood is unusually high, excited or very irritable, and energy and activity are far above normal. It can feel amazing at first, but it often leads to choices the person later regrets.

It can look like

• Sleeping only a few hours but not feeling tired
• Talking fast, jumping from topic to topic, hard to interrupt
• Thoughts racing so quickly they are hard to follow
• Feeling unusually important, gifted or powerful
• Big, unrealistic plans, or starting many projects at once
• Spending sprees, risky driving or other impulsive choices
• Saying or doing things that are out of character

In severe mania, some people lose touch with reality. They may hear or see things others don’t, or hold strong false beliefs, like having special powers. This needs urgent care.

Hypomania is like mania but milder. The person may feel great, confident and productive, and may still manage work and social life. Because it feels good, they often don’t see a problem, but family and friends may notice they are “not themselves”.

It can look like

• Needing less sleep than usual
• Being chattier, more sociable or more irritable
• Lots of ideas and plans
• Being more impulsive, like spending more
• Feeling unusually confident

A low period often follows a hypomanic one. Hypomania can also be missed by doctors, because people tend to ask for help when they feel low, not when they feel good.

The low times of bipolar are a form of depression. Mood is low, hopeless or anxious, and energy and activity drop sharply. Even simple tasks can feel impossible.

It can look like

• Losing interest in things you usually enjoy
• Feeling tired and slowed down, or restless
• Sleeping much more, or much less
• Changes in appetite
• Trouble thinking, remembering or making decisions
• Feeling worthless, guilty or hopeless
• Pulling away from people
• Thoughts of death or suicide

Low periods are often more common than highs, and many people are first seen by a professional during a low. You can read more in the Depression: understanding it guide.

Sometimes signs of a high and a low happen together. A person might feel hopeless and sad, but also restless, agitated and full of racing thoughts. Doctors call these mixed episodes or mixed features.

Many people find mixed times especially distressing, because there is low mood with the energy of a high. This can be a riskier time for suicidal thoughts, so it is important to reach out early.

Between mood episodes, most people return to their usual mood. These steady times can last weeks, months or years.

Steady times are the best time to learn about your patterns, build routines, and make a plan for what to do if a high or low starts. Some people still have milder ups and downs in between, and that is worth talking about with a professional too.

In this pattern, a person has had at least one manic high, which may be strong enough that they need hospital care to stay safe. Most people also have low periods.

Between episodes, many people feel like their usual selves. With support and a good plan, episodes can become less frequent and less severe.

In this pattern, a person has low periods and milder highs (hypomania), but not full mania. It is not a “milder” condition overall: lows can be long and heavy, and many people spend long stretches feeling low.

Because the highs can feel good or go unnoticed, people often only ask for help with the lows. Diagnosis can take years.

Cyclothymia is a milder form of bipolar. Mood swings up and down often, between mild lows and hypomanic highs, for a long time (usually two years or more in adults). The swings are smaller than full episodes, but they keep coming back.

Many people don’t seek help because the highs feel good, so cyclothymia often goes unnoticed. But the constant changes, irritability and impulsive choices can strain relationships and daily life.

Talking therapy, especially CBT, is usually the first approach. People with cyclothymia are at risk of developing bipolar disorder, so getting help early is a good idea.

Some people have many episodes close together: four or more in a year. This is called rapid cycling. It is a pattern, not a separate condition, and it can happen with any type of bipolar.

Rapid cycling can be exhausting and confusing. Tracking mood, sleep and triggers can help you and your care team spot what makes episodes more likely.

Symptoms can appear in childhood. In young people, a high can look like unusual silliness, a very short temper, fast talking, little need for sleep and risky behaviour. A low can look like sadness, irritability, stomachaches or other body complaints, sleeping a lot and low energy.

What sets it apart from ordinary moods is that the swings are more extreme, often happen without a clear reason, and last for days or weeks for most of the day.

What parents and carers can do

• Be patient, and listen to your child
• Help your child stick with the plan their care team suggests
• Learn their triggers and calm ways to handle big emotions
• Look after your own wellbeing too, for example in a support group
• Make time for enjoyable things together
• Watch moods closely and note big changes to share with their provider

Bipolar most often starts in the late teens or early adult years. In one national U.S. survey, adults aged 18–29 were the age group most likely to have had bipolar in the past year.

This is also a time of late nights, exams, moving away and new jobs, which can all shake up sleep and routines. Learning about mood patterns early can make a big difference over a lifetime.

The weeks after giving birth can be a higher-risk time for people with bipolar. A rare but serious illness called postpartum psychosis affects about 1 in 1,000 people who have a baby, but the chance is much higher for people with bipolar I.

The Royal College of Psychiatrists estimates the chance at about 1 in 5 for someone with bipolar I having a first baby, and higher if a mother or sister has had postpartum psychosis. For bipolar II, the risk is likely much lower.

The good news is that planning helps. If you have bipolar and are thinking about a baby, tell your care team before you start trying, and ask for specialist advice. If a pregnancy is unexpected, let them know as soon as you can. For anything medical, talk with your clinical provider.

Some people are first diagnosed later in life. Older adults need a full medical check, because other illnesses can cause similar mood changes.

A specialist who knows bipolar well can help sort out what is going on. Steady routines, good sleep and staying connected matter at every age.

The specialist will ask about your moods, behaviour, general health and family history. They will want to know about both the low times and any times you felt unusually energetic or needed much less sleep.

There is no blood test or brain scan for bipolar. Tests may still be used to rule out other causes of mood changes.

Diagnosis can take time because bipolar affects people in different ways and its signs overlap with other conditions. A large research review found that, on average, people waited almost six years between their first symptoms and getting care for bipolar.

One big reason is that people usually ask for help when they feel low, not when they feel good. So highs, especially milder ones, can be missed.

Signs of bipolar can overlap with ADHD, anxiety, depression and behaviour problems, especially in young people. Some medical conditions and some drugs can also cause mood changes. That is why a careful assessment by an experienced professional matters.

Bipolar can also come with other challenges at the same time, like anxiety or substance use. Getting help for all of them together usually works best.

A mood chart or diary can help a professional see the full picture. Write down what your highs and lows look like, how long they last, and how your sleep changes.

Things worth bringing

• A few weeks of mood and sleep notes
• Any family history of mood conditions you know about
• Notes on times you felt unusually energetic, not just low
• Questions you want to ask
• Someone you trust, if you’d like, who has noticed changes in you

Psychoeducation means learning about the condition: what it is, how it affects you, and how to spot early warning signs. It also includes making a relapse prevention plan and keeping regular routines.

It can be done one-to-one or in groups. Structured group programmes have been found to lower the chance of new episodes compared with unstructured groups. The World Health Organization lists psychoeducation as an effective treatment.

CBT helps you look at your thinking patterns and change unhelpful habits. In bipolar, this can mean noticing very gloomy thoughts during lows and over-optimistic thoughts during highs, and building skills to prevent relapse.

CBT seems especially helpful for low moods. A version of CBT for sleep problems may be especially helpful for bipolar depression. For cyclothymia, CBT is usually the first approach.

IPSRT works on two things at once: your daily rhythms (sleep, meals, activity) and your relationships. It helps you keep routines steady and work through things like grief, conflict or big role changes.

In one two-year study, people who received IPSRT stayed well for longer, especially when they managed to steady their daily routines.

Family-focused therapy brings the person and their family together. It includes learning about bipolar, practising clearer, calmer communication, and solving problems as a team. A typical course is about 21 sessions over nine months.

It has been shown to help both teens and adults after an episode. People stayed well longer, and teens recovered faster from low periods.

Support groups let you hear from others with similar experiences and share coping tips. They are not a replacement for therapy, but they can be a powerful addition.

The Living well with bipolar guide lists free groups you can join.

People often say “I’m so bipolar” when they mean they changed their mind or felt cranky. Real bipolar episodes are big shifts in mood, energy, sleep and behaviour that can last weeks and affect every part of life.

Using the word casually can make it harder for people living with bipolar to be taken seriously.

Mood episodes in bipolar usually last at least several days, and often a week or two or longer. Many people have long steady periods in between.

Quick shifts within a day can happen, for example in cyclothymia or mixed times, but bipolar is not about being happy one minute and angry the next.

Highs may start out feeling wonderful, but they can bring irritability, anger, risky spending, accidents, and damage to relationships or jobs.

Many people feel embarrassed or exhausted after a high, and a low often follows.

This idea mostly comes from movies and headlines, and it adds to stigma. People living with bipolar are your co-workers, neighbours, friends and family. Many hold jobs, raise children and lead full lives.

Stigma can stop people from asking for help, so speaking kindly and accurately really matters.

Bipolar usually needs ongoing care, even during steady times. Sticking with a plan helps prevent future episodes. Without care, episodes can become more frequent over time.

If you want to change anything in your treatment, talk to your clinical provider first rather than stopping on your own.

Bipolar most often starts in the late teens or early adult years, but children can show signs, and some people are diagnosed later in life.

In children, a high may look more like irritability or rage. Older adults need a full medical check, because other illnesses can cause similar changes. A specialist who knows bipolar well can help.

A major research review found some link between bipolar and creative achievement. But the link was strongest for milder mood patterns (like cyclothymia) and for relatives of people with bipolar, not for severe episodes.

People with bipolar did not reliably score higher on creativity tests. Much of the old “mad genius” idea came from life stories of famous artists, which are not strong evidence.

During a high, people may talk and write more, but the quality of the work isn’t reliably better. Severe episodes can take away the focus, time and motivation that creative work needs.

Low moods were not linked to more creativity. Depression tends to make it harder to create.

Some people worry that getting help will “dull” their creativity. If you have this worry, share it openly with your clinical provider. A good care team will work with you to protect the things that matter to you.

Steady routines can actually give creative work a better foundation: more good days, more focus and more time to finish what you start.