Bipolar disorder

Bipolar disorder is a serious mental illness where sometimes someone will experience extreme changes in mood and energy.

Bipolar disorder used to be called ‘manic depression’ because people with bipolar disorder can experience ‘manic’ symptoms (feeling extremely overexcited and energetic) and ‘depressive’ symptoms (feeling extremely sad and low).

People with bipolar disorder experience some of the following symptoms at different times:

Low or 'depressive'	You feel extremely low and depressed.
High or 'manic'	You feel extremely happy and become very overactive. You might develop very unrealistic and extreme ideas about yourself and your abilities.
Hypomanic	Your mood is high, but not as extreme as in mania
Mixed	You have a mixture of mania and depression at the same time. For example, you feel very depressed, but also have the restlessness and overactivity of mania.

To help explain the extremes of mood, the charity Bipolar UK uses a mood scale.

There are different types of bipolar disorder, though they are sometimes called different things. What is most important is understanding how your symptoms affect you or the person you know.

Bipolar I

• Where someone has had at least one high or manic episode that lasts for longer than a week (usually much longer).
• Some people with bipolar I will only have manic episodes, but most people with bipolar I also have low or depressive episodes.
• If the person doesn’t receive treatment, the manic episode will generally last between three and six months, while the depressive episode might last from six to 12 months.

Bipolar II

• Where someone has at least one depressive episode and a less extreme manic episode (called ‘hypomania’)

Cyclothymia

• Where someone’s mood swings are less severe than people with bipolar I or II, but last for longer.
• Over time, this can develop into ‘full’ bipolar disorder.

Rapid cycling

• Rapid cycling bipolar is a ‘sub category’ of bipolar I and bipolar II.
• Someone with rapid cycling bipolar has four or more episodes (manic, depressive or mixed) within in a year.
• This affects around 1 in 10 people with bipolar disorder.

Below is a list of the sort of symptoms that someone might experience during an episode. For someone to be diagnosed with bipolar, they need to have at least one manic or hypomanic episode, and need to experience several symptoms at the same time for at least several days.

High or ‘manic’ symptoms

When someone is manic, they might experience the following symptoms:

Mental:

• feeling extremely happy or 'high', or being very excited
• feeling irritable
• having racing thoughts
• finding it difficult to concentrate
• feeling overly confident and having inflated ideas about themselves or their abilities
• having an increased sex drive

Physical:

• talking much more than usual
• being more active and restless than usual
• changing plans and decisions constantly
• feeling like they need much less sleep
• not looking after themselves
• being more sociable or overly familiar than usual
• spending more money than usual or taking part in other types of reckless or extreme behaviour

Hypomania

Hypomania is a less extreme form of mania, which means it is less severe and lasts for shorter periods of time. During these periods people can be very productive and feel very creative, so might see their hypomania as a positive thing.

However, if hypomania is left untreated it can become more severe and develop into mania.

If mania is left untreated, at the extreme end, some people also develop psychosis. You can read more about psychosis in our resource on this topic.

Mania, or hypomania, is commonly followed by an episode of depression.

Low or ‘depressive’ symptoms

When someone is depressive, they might experience the following symptoms:

• feeling very sad most of the time
• having less energy than usual, and being less active
• not being able to enjoy things they normally like doing
• eating less or eating more than usual
• having disturbed sleep
• experiencing thoughts of self-harm or suicide
• If left untreated, people with depressive symptoms can end up developing psychosis. You can read more about psychosis in our resource on this topic.

Mixed symptoms

If someone is experiencing mixed symptoms, they will experience some of the high and low symptoms at the same time.

How often someone experiences the symptoms of bipolar disorder will depend on the type of bipolar they have and on them as an individual.

For example, someone who has rapid cycling bipolar might go from feeling low to feeling high within hours or days, while someone with bipolar I might feel manic or depressed for weeks or months.

In between manic and depressive episodes someone will usually have ‘normal’ periods that can last for weeks, months or years. However, in some people who have bipolar disorder these periods might be shorter and less noticeable due to the duration of time of time since receiving a diagnosis and or due to untreated illness.

When thinking about the causes of developing bipolar disorder, it is important to remember that lots of different things are involved, and that no single risk factor causes bipolar disorder.

There are lots of different genetic and environmental risk factors involved in whether someone develops bipolar disorder. These risk factors can interact with each other to increase or decrease someone’s risk of developing the condition.

For example, you might have genetic risk factors that mean you are more likely to develop bipolar disorder. However, if you grow up or live in a stable and positive environment this may reduce your risk of developing a serious mental illness.

Having a parent with a serious mental illness like bipolar is the strongest known risk factor for someone developing a serious mental illness.

If someone has a parent who has a serious mental illness, they have a 1 in 3 chance of developing a serious mental illness themselves. However, this does not mean that they definitely will get bipolar or another mental illness.

A survey taken in 2014 showed that around 2% of the population in England has bipolar disorder. That’s over 1 million people.

Bipolar disorder usually starts between the ages of 15 and 25, but is extremely rare in young children. 

When bipolar disorder goes untreated, it can lead to someone:

• losing a sense of control over their lives
• losing their confidence
• experiencing poor concentration, making it hard to focus on school or college, or to do the things they used to enjoy
• developing difficult relationships with family, friends or partners
• taking part in risky behaviour that puts their life in danger, like drinking alcohol, using drugs or driving dangerously

If you think that you or someone you know might be experiencing the symptoms of bipolar disorder, speak to someone you trust. Other people, especially close family or friends, will probably have noticed that you or the person you know seem different than usual.

Speak to your GP about your concerns. They can then refer you or the person you know to your local child and adolescent mental health service (CAMHS) who can offer more specialist help.

If you have a school counsellor/nurse or learning mentor, they can be a useful person to talk to and may also be able to refer you or the person you know to the local CAMHS.

In the short term, the kind of treatment someone needs will depend on whether they are high or low and how severe their symptoms are.

When someone has severe symptoms, they might need medication and to be admitted to hospital to help their symptoms improve and to keep them safe.

In the long term, the goal of treatment is to help people with bipolar disorder to have healthy, balanced and productive lives.

If you have bipolar disorder, your mental health team can work with you and your family to help you understand your condition, manage your symptoms and stay well. Below are some of the different treatments used to support people with bipolar disorder:

Help with understanding yourself and the condition (psychoeducation)

It is very important that you and your family are helped to understand bipolar disorder, how best to cope and what to do to reduce the chances of you getting unwell again.

You and your family may notice ‘triggers’ to your episodes or early warning signs that an episode is starting.

Being aware of these can help reduce the chance of episodes occurring. Getting help in the earliest stages of an episode can stop it from getting worse.

Psychological therapies

Also known as talking therapies, these include:

• Cognitive-behavioural therapy (CBT) – You will learn to understand the links between your feelings and thoughts and how this affects your behaviour (see our factsheet on CBT). Sometimes this will be done with your family.
• Family-focused treatment (family therapy) - The whole family can be supported to reduce stress, solve problems and communicate better.

Medication

Medication plays an important role in the treatment of bipolar disorder, especially if someone’s episodes are severe.

The medication you’re given can depend upon the type of episode you’re having. Everyone is different, and so the type of medication that is recommended will depend on your unique circumstances. Types of medication used to treat bipolar disorder include:

• Antipsychotic medication - usually used for high/manic episodes
• Antidepressant medication - used for the low/depressive episodes
• Mood stabilizers (e.g. lithium) help to keep your mood stable both during and between episodes

All medications have side-effects. Some are mild and not so noticeable, and some are very unpleasant. The impact of side-effects needs to be balanced against the impact that bipolar disorder would have on your life without the medication. Your psychiatrist should explain to you what side-effects you might get and what can be done to help manage them.

You may need a physical assessment and some tests (eg. a blood test) before starting medication and at regular intervals while you are taking it. If you are prescribed medication, it is important that you are seen regularly by your doctor or psychiatrist.

It is important that medication is not taken only when the problems are serious. Bipolar disorder is a lifelong condition. If you have had more than one serious episode, it is important to stay on medication to reduce the risk of having another episode.

You might need to take medication for anything from several months to several years. If someone has been well for a long time, they might be able to come off their medication under medical supervision. It is important to not stop taking any medication without speaking to your doctor first.

There are lots of things you can do to help yourself to stay well:

• Self-monitoring - Learn how to recognise the signs that you are getting unwell so that you can get help early. Keeping a mood diary can help to identify the things in your life that help you – and those that don't.
• Knowledge – Find out as much as you can about your condition through reliable sources. There are sources of further information at the end of this resource.
• Stress – Try to avoid particularly stressful situations. It's impossible to avoid all stress, so it may be helpful to learn ways to manage it. You can do relaxation or meditation exercises or seek advice from a mental health professional.
• Relationships – Try to be open with people about how you are feeling and how your bipolar disorder is affecting you. This can help them to understand your condition and to support you in a meaningful way.
• Activities – Try to make time for activities that you enjoy, while taking plenty of time to relax and unwind. This could mean picking up a new hobby or restarting an old one, spending time with friends or joining a club at school.
• Exercise – Try to stay active by doing a form of exercise that you enjoy for about 20 minutes three times a week. Exercising regularly has been shown to be good for your mood.
• Continue with your medication – Keep taking your medication as prescribed by your doctor. It can feel tempting to stop taking it, especially if you are feeling well, but always speak to your doctor, friends and family before making any changes to your medication.

“I was a happy, confident person studying for 11 GCSEs, and enjoying a good social life with a large circle of friends.  All seemed well in my life.

“Suddenly from feeling really cheerful, happy and full of energy, I withdrew to my room, stopped eating and stopped talking to everybody, even my parents. I was having vivid hallucinations, became paranoid and even thought about hurting myself. 

“My parents became really worried and eventually I was admitted to a child and adolescent psychiatric unit.

“I now realise that I was manic before I plunged into black depression. Once I was diagnosed with bipolar, I was able to understand and come to terms with my illness. Medication was given to me to deal with the mood swings, together with a talking therapy.

“With support from my family and friends, I am now back at school and I hope to go to medical school in the next couple of years.”

• Bipolar UK  - A charity that helps people with bipolar disorder, their relatives, friends and others, and educates the public and professionals about bipolar disorder. They offer support for anyone affected by bipolar with a moderated eCommunity, a support line and support groups.
• Rethink Mental Illness- A charity that helps people affected by a severe mental illness to recover a better quality of life. There is a section on the website for young people.
• Sane - A national charity that improves the quality of life for people affected by mental illness.
• Young Minds - A charity committed to improving the emotional wellbeing and mental health of children and young people.

This information was written by the Royal College of Psychiatrists’ Child and Family Public Engagement Editorial Board (CAFPEB).

Originally authored by Dr Virginia Davies and Dr Vasu Balaguru.

Expert editor: Dr Aditya Sharma

Special thanks to the charity Bipolar UK who helped to review this resource.

This resource reflects the best possible evidence at the time of writing.