Bipolar I Disorder

Bipolar I Disorder is defined by the occurrence of at least one manic episode. A manic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

During a manic episode, you may experience:

• Inflated self-esteem or grandiosity. You might feel capable of things beyond your actual abilities or believe you have special powers.
• Decreased need for sleep. Feeling rested after only 3 hours of sleep is common.
• Pressured speech. You may be more talkative than usual or feel a pressure to keep talking.
• Racing thoughts or flight of ideas. Your thoughts may move so quickly it's hard to keep up with them.
• Distractibility. Your attention may shift rapidly from one thing to another.
• Increased goal-directed activity or psychomotor agitation. You might take on multiple projects at once or feel physically restless.
• Excessive involvement in activities with high potential for painful consequences. This includes unrestrained spending, reckless investments, or sexual indiscretions.

Mania causes marked impairment in social or occupational functioning, may require hospitalization to prevent harm, or may include psychotic features. While mania defines the disorder, most individuals with Bipolar I also experience major depressive episodes. Some experience mixed episodes with symptoms of both mania and depression occurring together.

While Bipolar I is specifically defined by at least one manic episode, the course of the disorder can vary considerably. Differences exist in how often episodes occur (some have frequent episodes, while others have long intervals between them), and in the predominance of manic versus depressive episodes.

The Bipolar Spectrum

Bipolar I is distinguished from Bipolar II by the presence of full manic episodes. In Bipolar II, hypomanic episodes occur but never escalate to full mania. This distinction is clinically important because:

• Mania can include psychotic features while hypomania does not. During mania, you may experience delusions or hallucinations.
• Mania causes severe functional impairment or hospitalization while hypomania does not. Mania disrupts your ability to work, maintain relationships, and care for yourself.
• Mania lasts at least 7 days while hypomania lasts at least 4 days. The duration requirement reflects the severity difference.

Rapid Cycling

Some individuals may experience "rapid cycling," defined as four or more mood episodes (of any type) within a 12-month period. Rapid cycling is associated with a more treatment-resistant course and often develops after years of illness. It occurs more commonly in women and in those with Bipolar II. Effective treatment often requires careful medication management and lifestyle stabilization.

Mixed Features

Mixed episodes or mixed features, where symptoms of mania and depression are present simultaneously, can occur and are particularly distressing and dangerous. You might feel extremely energized yet profoundly hopeless at the same time, or experience racing thoughts combined with deep despair. Mixed states carry heightened suicide risk because you have the energy and agitation of mania combined with the dark thoughts of depression.

Course and Prognosis

Bipolar I typically emerges in late adolescence or early adulthood (average age of onset around 18). It is considered a lifelong condition with recurrent episodes—90% of individuals who have a single manic episode will have future episodes. While mania defines the disorder, depression is often more burdensome than mania over the lifespan. High comorbidity with substance use disorders (over 50%) is common. The condition carries elevated suicide risk (15-20 times the general population), making consistent treatment and monitoring essential.

Bipolar I Disorder requires ongoing, often lifelong, treatment. A combination approach is typically most effective.

Medication

Medication is considered essential:

• Mood stabilizers, such as lithium and certain anticonvulsants like valproate and lamotrigine, are foundational for preventing mood swings. These medications help maintain more stable moods over time.
• Atypical antipsychotics are frequently used, especially for acute mania or as long-term maintenance. They can quickly reduce manic symptoms and prevent future episodes.
• Antidepressants may be used cautiously for depressive episodes, typically in combination with a mood stabilizer to prevent triggering mania. Using antidepressants alone carries the risk of switching into a manic episode.

Therapy

Psychotherapy plays a crucial adjunctive role alongside medication. While medication is essential for managing the biological aspects of bipolar disorder, therapy addresses the psychological, social, and behavioral factors that influence the course of the illness.

• Psychoeducation helps you and your family understand the illness, recognize early warning signs of episodes, understand the importance of medication adherence, and develop strategies for sleep hygiene and stress management. This knowledge empowers you to become an active partner in your own treatment.
• Cognitive Behavioral Therapy for Bipolar addresses depressive cognitions, helps identify and manage early warning signs, and reduces residual symptoms between episodes. It teaches practical skills for challenging negative thought patterns that can trigger or worsen depressive episodes.
• Interpersonal and Social Rhythm Therapy (IPSRT) focuses on stabilizing daily routines and sleep-wake cycles to prevent episodes triggered by circadian disruption. Because sleep disruption is one of the most potent triggers for mood episodes, establishing consistent daily rhythms is particularly protective.
• Family-Focused Therapy educates family members about the disorder, improves communication patterns, and reduces high expressed emotion (criticism, hostility, emotional over-involvement) that can trigger relapse. Family support and understanding significantly improve outcomes.

Lifestyle Management

Lifestyle management is crucial, including regular sleep schedules, stress management, and avoiding substance use.

Looking for more guidance? Visit our Learn center for information about starting therapy, or explore helpful resources including crisis support, recommended reading, and wellness tools.