(Left) A lithograph of a woman diagnosed with mania. (Right) A lithograph of a woman diagnosed with depression. 1892, after J. Williamson, 1890.<unk>  Disorder is characterized by marked swings in mood, activity, and behavior.<unk>  is characterized by periods of hypomania, which may occur before, after, or independently of a depressive episode. Hypomania Hypomania is the signature characteristic of<unk> , defined by an experience of elevated mood. A patient's mood is typically cheerful, enthusiastic, euphoric, or irritable. In addition, they can present with symptoms of inflated self-esteem or grandiosity, decreased need for sleep, talkativeness or pressured speech, flight of ideas or rapid cycling of thoughts, distractibility, increased goal-directed activity, psychomotor agitation, and/or excessive involvement in activities that have a high potential for painful consequences (engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments.) Hypomania is distinct from mania. During a typical hypomanic episode, patients may present as upbeat, may show signs of poor judgement, or display signs of increased energy despite lack of sleep, but do not meet the full criteria for an acute manic episode. Patients may display elevated confidence, but do not express delusional thoughts as in mania. They can experience increase in goal-directed activity and creativity, but do not reach the severity of aimlessness and disorganization. Speech may be rapid, but interruptible. Patients with hypomania never present with psychotic symptoms and do not reach the severity to require psychiatric hospitalization. For these reasons, hypomania commonly goes unnoticed. Individuals often will only seek treatment during a depressive episode, and their history of hypomania may go undiagnosed. Although hypomania may increase functioning, episodes require treatment as they may indicate increasing instability and can precipitate a depressive episode. Depressive episodes It is during depressive episodes that<unk>  patients often seek help. Symptoms may be syndromal or subsyndromal. Depressive episodes in<unk>  can present similarly to those experienced in unipolar depressive disorders. Patients characteristically experience a depressed mood and may describe themselves as feeling sad, gloomy, down in the dumps, hopeless, or for most of the day, nearly every day. In children, this can present with an irritable mood. Most patients report significant fatigue, loss of energy, or tiredness. Patients or their family members may note diminished interest in usual activities such as sex, hobbies, or daily routines. Many patients report a change in appetite along with associated weight change. Sleep disturbances may be present, and can manifest as problems falling or staying asleep, frequent awakenings, excessive sleep, or difficulties getting up in the morning. Around half of depressed patients develop changes in psychomotor activity, described as slowness in thinking, speaking, or movement. Conversely, they may also present with agitation, with inability to sit still or wringing their hands. Changes in posture, speech, facial expression, and grooming can be observed. Other signs and symptoms include changes in posture and facial expression, slowed speech, poor hygiene, unkempt appearance, feelings of guilt, shame, or helplessness, diminished ability to concentrate, nihilistic thoughts, and suicidal ideation. Many experts in the field have attempted to find reliable differences between BP-I depressive episodes and episodes of major depressive disorder, but the data is inconsistent. However, some clinicians report that patients who came in with a depressive episode, but were later diagnosed as having<unk>  disorder often presented with hypersomnia, increased appetite, psychomotor retardation, and a history of antidepressant-induced hypomania. Evidence also suggests that<unk>  is strongly associated with atypical depression. Mood episodes with mixed features A mixed episode is defined by the presence of a hypomanic or depressive episode that is accompanied by symptoms of the opposite polarity. This is commonly referred to as a mood episode with mixed features (e.g. depression with mixed features or hypomania with mixed features), but can also be referred to as mixed episodes or mixed states. For example, a patient with depression with mixed features may have a depressed mood, but has simultaneous symptoms of rapid speech, increased energy, and flight of ideas. Conversely, a patient with hypomania with mixed features will present with the full criteria for a hypomanic episode, but with concurrent symptoms of decreased appetite, loss of interest, and low energy. Episodes with mixed features can last up to several months. They occur more frequently in patients with an earlier onset of<unk>  disorder, are associated with higher frequency of episodes, and are associated with a greater risk of substance use, anxiety disorders, and suicidality. In addition, they are associated with increased treatment resistance compared to non-mixed episodes. Relapse<unk>  disorder is often a lifelong condition, and patients should be followed up regularly for relapse prevention. Although<unk>  is thought to be less severe than BP-I in regard to symptom intensity,<unk>  is associated with higher frequencies of rapid cycling and depressive episodes. In the case of a relapse, patients may experience new onset sleep disturbance, racing thoughts and/or speech, anxiety, irritability, and increase in emotional intensity. Family and/or friends may notice that patients are arguing more frequently with them, spending more money than usual, are increasing their binging on food, drugs, or alcohol, and may suddenly start taking on many projects at once. These symptoms often occur and are considered early warning signs. Psychosocial factors in a person's life can trigger a relapse in patients with<unk> . These include stressful life events, criticism from peers or relatives, and a disrupted circadian rhythm. In addition, the addition of antidepressant medications can trigger a hypomanic episode. Comorbid conditions Comorbid conditions are extremely common in individuals with<unk> . In fact, individuals are twice as likely to present a comorbid disorder than not. These include anxiety, eating, personality (cluster B), and substance use disorders. For<unk> , the most conservative estimate of lifetime prevalence of alcohol or other substance use disorders is 20%. In patients with comorbid substance use disorder and<unk> , episodes have a longer duration and treatment compliance decreases. Preliminary studies suggest that comorbid substance use is also linked to increased risk of suicidality.
Bipolar II disorder
Bipolar I disorder
Bipolar disorder
Bipolar disorder not otherwise specified
Major depressive disorder
Major depressive episode
Cyclothymia
Dysthymia