Bipolar disorder

People with bipolar disorder experience extreme fluctuations in their mood. They alternate between episodes of feeling elated and full of enthusiasm and episodes of feeling depressed and emotionally empty. The disorder is usually permanent but medication and psychotherapy often greatly improve quality of life.

At a glance

  • People with bipolar disorder experience extreme fluctuations in mood. Their moods may alternate between manic episodes (when they feel “up”) and depressive episodes (when they feel “down”).
  • These episodes cause stress because they often impact important life decisions and relationships.
  • The precise causes of bipolar disorder are unknown. However, it is likely that genetic predisposition plays a role.
  • Most people with bipolar disorder require life-long treatment.
  • A combination of medication and psychotherapy can significantly improve their quality of life.

Note: The information in this article cannot and should not replace a medical consultation and must not be used for self-diagnosis or treatment.

A woman experiencing a range of moods – active, thoughtful, sad.

What is bipolar disorder?

Bipolar disorder is a mental illness. It can take many different forms. However, all sufferers typically experience fluctuations in mood, where the person seems to swing between two different poles, i.e. between feeling in the best of spirits, confident and full of energy (manic) and feeling dejected, apathetic and empty (depressed).

Individuals may experience only a few symptoms or none at all in the periods between these two extremes. Most people with bipolar disorder have manic and depressive episodes that are severe enough to have a serious impact on their lives, as they overestimate what they can do when feeling manic and completely lack motivation when feeling depressed. As a result, problems in their professional and family lives are common.

In most cases, bipolar disorder develops gradually. While it is a chronic illness, a combination of psychotherapy and medication can significantly improve a person’s quality of life.

What symptoms can occur with bipolar disorder?

Alternating phases of mania, hypomania (mild mania) and depression are typical of bipolar disorder. There may sometimes also be mixed affective states, with manic and depressive symptoms occurring at the same time.

People with bipolar disorder alternate between episodes of mania and episodes of depression or they have mixed affective states with symptoms of both.

Manic episodes

During an episode of mania, people feel disproportionately self-confident and energized but sometimes also agitated. They may overestimate their capabilities and behave erratically. They often have a reduced need for sleep and only sleep a few hours at night but are still full of energy and motivation the next day. They may also become unusually talkative and experience a heightened sexual drive (libido). They tend to lose their social inhibitions, behave inappropriately and increasingly recklessly. Psychotic symptoms may also occur, including paranoia, hallucinations or delusions.

Depressive episodes

A manic episode is followed either immediately or eventually by a depressive episode. When this happens, the manic mood swings to the other extreme, so that people feel tired, exhausted, lacking in motivation, despondent or sad and become socially withdrawn. Their self-esteem also drops, they constantly think negative thoughts and they lose interest in sex. Thoughts of suicide may come to the fore.

Mixed episodes

When people experience mixed affective states (mixed episodes), their mood swings rapidly between mania and depression or, alternatively, they have symptoms of both at the same time. In other words, a person may experience a burst of energy while also having depressive symptoms. The risk of suicide is particularly high during such phases.


Hypomania is similar to mania but is much milder and is sometimes interspersed with depressive phases.

What causes bipolar disorder?

The precise causes of bipolar disorder remain unclear. It seems likely that a congenital (family) predisposition contributes to development of the illness. In this case, traumatic events, emotional stress or other factors may trigger the disorder.

Which risk factors affect the severity of bipolar disorder?

Certain factors make it more likely that a person will develop a severe form of bipolar disorder. These include:

  • emotionally difficult life events (trauma)
  • drug use
  • psychotic symptoms

Severe forms of the disorder are more common among women and in people who develop the illness at a young age.

How common is bipolar disorder?

Globally, around 2 percent of the population has bipolar disorder. Most people experience their first episode before the age of 25.

Globally, around 2 percent of the population has bipolar disorder.

What is the outlook for people with bipolar disorder?

The outlook for bipolar disorder differs between individuals. Relapses are common. Most people experience only a small number of episodes in their lifetime, although some have more than 10.

In most cases, manic (feeling “up”) phases alternate with depressive (feeling “down”) episodes or people experience mixed phases. This form of the illness is known as bipolar I disorder.

However, a person may only have recurring episodes of mania. Alternatively, they may experience alternating hypomanic and depressive phases but never have manic phases. Doctors refer to this as bipolar II disorder.

If a person has at least four separate episodes of mania, hypomania and/or depression in the course of one year, they have a severe form of the disorder that involves a very large number of episodes. Due to the rapid fluctuations in mood, this is known as “rapid cycling”.

How is bipolar disorder diagnosed?

Neurologists or psychiatrists diagnose bipolar disorder based on in-depth consultations with the patient and a physical examination.

An accurate report of their life history and details of any mood fluctuations experienced in the past are important for diagnosis. Patients are also asked if they have any family members with bipolar disorder.

Many people with bipolar disorder are only diagnosed 5 to 10 years after the onset of their illness. This is because, during the initial episodes they experience, the symptoms may have other possible explanations. For example, their first depressive episode may be classified as depression, while a manic phase with psychotic symptoms may be diagnosed as schizophrenia. Moreover, a hypomanic phase may not even be diagnosed because mild manic symptoms often have no major impact on the sufferer.

Getting diagnosed as early as possible and beginning treatment without delay can help prevent bipolar disorder from developing into a chronic illness. The better a person responds to treatment, the fewer episodes they will experience.

How is bipolar disorder treated?

There are no treatments to eliminate the causes of bipolar disorder. However, if the illness is detected at an early stage and treated properly, episodes can be delayed or avoided.

Essentially, two types of treatment are used:

  • acute treatment, which aims to relieve depressive or (hypo)manic symptoms as quickly as possible
  • episode prevention, which aims to reduce and ideally prevent the occurrence of further episodes

Various medicinal and non-medicinal treatments are used – usually in combination – to treat bipolar disorder, depending on the form of the illness and which symptoms are predominant. These include:

  • Medicinal treatment: antidepressants and mood-stabilizing drugs used to treat depression are also used to treat depressive episodes of bipolar disorder. Atypical neuroleptics (antipsychotics) used to treat patients with schizophrenia are beneficial in the treatment of psychotic symptoms.
  • Psychotherapy to accompany treatment with medication: approaches such as psychoeducation and cognitive behavioral therapy have proven to be particularly effective. As well as educating the patient about the disorder, they also seek to help them change their behavior and thought patterns in order to be able to live well with the illness and avoid relapse. Family therapy is also effective.
  • Electroconvulsive therapy (ECT): ECT is normally only considered for treating severe depression that has not responded to other treatments. Under general anesthetic, a weak electrical current is passed through the brain to induce a brief seizure. This type of therapy usually involves 6 to 12 sessions at most. ECT can be effective in treating both depressive and manic symptoms. Medication and psychotherapy are also used to prevent relapses.
  • Sleep restriction: this type of therapy can be used for an acute, severe depressive episode. It involves the patient staying awake for an entire day and entire night or sleeping only for half a night for a specific period of time. Many people find it beneficial. However, the relief from symptoms is often only temporary. For this reason, it is most useful when used in tandem with medication.

What advisory services are available to people with bipolar disorder?

Support groups offer many types of support. They provide people with bipolar disorder and their loved ones with a source of information and advice, as well as a forum in which to share their personal experiences.

You can find suitable self-help via a database on the National Contact and Information Point For Encouraging and Supporting Self-Help Groups (NAKOS) website.

In cooperation with the Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen – IQWiG).

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