Everyone experiences emotional highs and lows throughout their lives. When we receive the call that we got the job, we are happy and may want to celebrate. When we hear that our company will be issuing layoffs, we become dismayed. Buying a new car generally produces a good feeling, but when it breaks down on the side of the road, we may experience a sense of anger and frustration. When we hear that a good friend and his wife just had their first child, we are excited for the new parents, but when we get the news that a friend or loved one was just rushed to the hospital, a feeling of dread overcomes us. 

Things like this happen every day, and as adults, we understand that good news and bad news are simply part of life. But generally, we operate somewhere in between—not overly elated and not in the depths of despair. Yes, we can unexpectedly hit the lottery and be ecstatic at the good fortune that suddenly comes our way. And we can experience a great deal of grief at the news of the passing of a loved one. These two experiences can push us from a stable, normal mood to a much higher or lower state. The two examples above are not everyday occurrences, nor do they produce mild emotions. The surprise and shock they generate can take us from a place of stability to the outer reaches of high and low. 

However, with bipolar disorder (formerly called manic depression), extreme levels of elevated mood and feelings of lethargy and sadness can cycle throughout one’s lifetime. Bipolar disorder is a complex mental illness that can send one to incredible highs or the lowest of lows. The onset of bipolar disorder can vary, but a majority of those eventually diagnosed experience their first symptoms in youth or early adulthood. In a study of 1,665 adult, DSM-IV BPD-I patients, onset was 5 percent in childhood, 28 percent in adolescence, and 53 percent for ages fifteen to twenty-five.

 A person’s behavior at the “first break” stage may change dramatically. For example, they may engage in excessive spending, poor judgment, inappropriate sexual encounters, risky engagements, and other behaviors not typical of their overall character. A person who experiences a manic episode may also become psychotic and need to be hospitalized. Someone who is in a major depressive state may feel hopeless, helpless, sad, lethargic, and barely have the energy to get out of bed. This person may also be in so much pain they do not want to go on living. This is the point where professional help is needed. 

There are three main types of bipolar disorder as outlined in the Diagnostic and Statistical Manual (DSM-V). All three types involve clear changes in mood, energy, and activity levels. These moods range from periods of extremely “up,” or elated, irritable, or energized behavior (known as manic episodes) to very “down,” or sad, indifferent, hopeless periods (known as depressive episodes). The mood disturbance is sufficiently severe to cause marked impairments in social or occupational functioning and may necessitate hospitalization. 

Bipolar I is defined by manic episodes that last at least seven days or by manic symptoms so severe the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least two weeks. Episodes of depression with mixed features (exhibiting depressive symptoms and manic symptoms at the same time) are also possible. 

Bipolar II is defined by a pattern of depressive episodes and hypomanic occurrences, though not the full-blown manic episodes typical of bipolar I. 

Cyclothymia is defined by periods of hypomanic symptoms as well as periods of depressive symptoms lasting for at least two years. However, the symptoms do not meet the diagnostic requirements for a manic episode and a depressive event. Below are some of the symptoms associated with bipolar disorder: 

Mania—describes when someone with bipolar disorder feels overly excited or confident. These feelings can also involve irritability, grandiosity (an exaggerated sense of self-importance, power, or knowledge) and may lead to inappropriate behaviors. About half of all people with bipolar disorder also experience psychosis. 

Hypomania—describes milder symptoms of mania in which someone does not experience psychosis and can function in their everyday lives. Other symptoms include: 

  • Abnormally upbeat, jumpy, or wired 
  • Increased activity, energy, or agitation 
  • Risky behaviors that show poor judgment; for example, drinking, drug use, or driving recklessly 
  • Decreased need for sleep 
  • Irritability 
  • Grandiosity (feelings of invincibility and power) 
  • Unusual talkativeness 
  • Racing thoughts 
  • Distractibility 
  • Poor decision-making; for example, buying sprees, sexual risks, or foolish investments

 Depressive episodes—when a person with bipolar disorder feels sad, lethargic, and hopeless. They may start to cry for no apparent reason, and they may not be able to function in their everyday lives. Characteristics of these episodes include: 

  • Marked loss of interest or feeling no pleasure in life 
  • Feeling empty or hopeless 
  • Significant weight loss when not dieting, weight gain, or decrease or increase in appetite 
  • Insomnia or sleeping too much 
  • Restlessness or slowed behavior 
  • Fatigue or loss of energy 
  • Feelings of worthlessness or excessive or inappropriate guilt 
  • Decreased ability to think and concentrate or indecisiveness 
  • Thinking about, planning, or attempting suicide (If you hear a loved one or friend talk about wanting to hurt themselves, call 911 or take them to the nearest emergency department.) 

Other characteristics of a depressive episode can include: 

  • A false belief that one is financially ruined or penniless 
  • Believing one has committed a crime or done something terribly wrong 
  • Exaggerated guilt 
  • Believing one has a serious illness 

Rapid cycling-refers to a person with bipolar disorder who experiences four or more episodes of mania and depression in one year. This can occur at any point in the illness and can come and go over many years.

 As you can see, bipolar disorder is a complex illness that can bring a person to the highest highs or plummeting to the lowest of lows. 

Below, I would like to give a real case example about a patient with whom I worked in my first clinical job out of graduate school.  I will refer to her as Jane (not real name) and will describe the observable changes my coworkers and I noticed as her mood moved from a place of stability to an episode of mania. 

Jane was a thirty-five-year-old, petite Korean woman diagnosed with bipolar disorder. She came to the program every day but would sit through the group session without participating. She would eat lunch by herself, take breaks alone and, at the end of the day, go home. Her hair was relatively short and dark, and her clothes were mostly neutral. She wore no makeup or nail polish, nor did she wear any kind of jewelry. 

One day, I noticed something different about Jane. The once “plain” Jane began to wear brighter clothing, polished nails, and light-pink lipstick. She wore simple jewelry, put some blonde streaks in her hair, and carried a tasteful handbag. And she slowly began to interact with others in and outside the group setting. 

As time passed, her appearance became increasingly provocative. Her hair was now spiked and dyed an orangey-red, her makeup was flamboyant and heavily applied, she wore bright-red lipstick, her body was adorned with several necklaces, bracelets, and rings, and her new choice of clothing included abstract shapes in a multicolored style nothing short of racy. 

Jane’s behavior and appearance screamed mania. She now over engaged in the groups and needed constant redirection, and it seemed like she was everyone’s friend outside of group therapy. She also talked about her risky behaviors, which included approaching strangers in the street and attempting to befriend them. The other patients were surprised about the drastic change they were seeing in Jane. Talk about a total reversal of behavior from the quiet and introverted person she appeared to be a few weeks prior. Jane was in a manic state. 

Jane was sent to her psychiatrist right away. When her doctor saw her, she knew a medication adjustment was in order. It’s often a fine line finding the right balance of antidepressants and mood stabilizers needed to keep a patient from either going hypomanic or manic or spiraling into depression. Psychological, physiological, environmental, stressful situations, and relational factors can play a part in pushing a patient into a manic or depressive episode. Substance use can also play a role in the instability of a person’s mood. 

Once Jane’s doctor adjusted her medications to reduce the mania causing her to engage in risky and inappropriate behaviors, it wasn’t long before her flamboyant lifestyle began to diminish and she became stable. Her bright makeup and flashy clothing became toned down. She went back to wearing her hair short and dark, and her behavior became more appropriate. Jane was getting back to her old self—quiet, reserved, and polite—as she settled back into the program with the other patients. 

Often, when a patient experiences a manic episode and has their medications adjusted so that their mood falls within a “normal” range of highs and lows, they report they now feel depressed. Patients who’ve experienced the euphoria of a manic episode will tell their doctors that when they come down to a normal range of emotion, they feel sad, lethargic, and unhappy. With mania comes excitement, energy, and grandiose thinking, which can make a person feel like they’re on top of the world. Some patients will even stop taking their meds so that the feelings of hypomania or mania will return. But with that exciting feeling can come the poor decision-making that leads to situations that are detrimental to their health and well-being, including dangerous sexual encounters and financial ruin. In some cases, patients need to be hospitalized and then stepped down to an outpatient program where psychoeducation helps them begin to fully understand their illness.

This article was taken from my book When to Call a Therapist – Expanded Edition (2021),Chapter 6, Bipolar Disorder: The Challenges of Widely Fluctuating Moods. Robert C. Ciampi, LCSW