Bipolar Disorder is defined by oscillations in mood, thought, and behavior between phases of excitement (mania) and phases of inhibition (depression).
During excitement, energy levels are higher, thoughts are rapid, original, and rich, and the attitude is optimistic, proactive, exhibitionistic, or provocative. The environment is perceived as close and accessible, goals as achievable, and success as likely or certain. Obstacles are regarded as senseless, and people who do not go along with the individual’s plans may be criticized or attacked. If the person becomes delusional, the themes may involve grandiosity or persecution, mystical beliefs, or claims of being an inventor.
During the depressive phase, mood is sad, indifferent, discouraged, or melancholic. Energy is reduced, and the person becomes easily fatigued. Motivation decreases, initiatives become few and are approached with distrust, and there is often withdrawal because of fear of failure or the feeling that there are no positive ways forward. It becomes difficult to formulate thoughts and make plans, and the person may feel inadequate, as though they have lost their abilities or the drive necessary to act.
Depending on the intensity of the symptoms, different forms of Bipolar Disorder are distinguished. In Type I, or manic-depressive psychosis, there are so-called major episodes, meaning more severe episodes that may progress to loss of contact with reality and the appearance of hallucinations and delusions. In Type II, recurrent depression alternates with milder phases of excitement, without loss of contact with reality. In cyclothymia, both depression and excitement are attenuated.
More recently, Type III forms have been described, in which phases of excitement are induced by medications or drugs, and Type IV, consisting of depression occurring in individuals with an energetic-euphoric temperament. There is also Type II½, or cyclothymic depression, referring to recurrent or chronic depression in people whose mood is habitually unstable, including during the depressive phase itself.
The disorder consists neither in depression nor in excitement alone, but in a tendency toward cyclical mood instability, in which depression and mania may represent two moments of the same cycle.
The phases may also be mixed, meaning essentially phases of excitement in which mood, considered in isolation, is nevertheless melancholic, irritable, desperate, or otherwise negative, while behavior is agitated, excited, aggressive, or frantic.
The person may feel overwhelmed by a cruel destiny but nevertheless perceive a clear meaning in what is happening. Their attitude may be perplexed, while their subjective experience may involve an urgent need to resolve situations, even through extreme or negative actions, or to provoke something in an attempt to turn events in their favor.
Over time, Bipolar Disorder may follow two broad patterns of evolution.
In Type I, there may be a progressive detachment from the environment, especially when psychotic symptoms are frequent and symptom-free intervals are short. In such cases, the person’s life is continually interrupted by episodes of illness, often involving dangerous events or ruptures with the surrounding environment. These may lead to accidents, arrest, injuries, or other forms of damage, including financial losses.
In milder forms, the course is usually characterized by chronic dissatisfaction, dominated by boredom, disappointment, lack of motivation, and difficulty establishing stable relationships. People may remain socially adapted and productive while nevertheless being relatively unhappy or in constant conflict with family members, friends, or partners.
When untreated, Bipolar Disorder tends to produce episodes that become progressively more frequent and longer-lasting, eventually approaching a state of continuity between one mood swing and the next.
People with Bipolar Disorder are often creative, eccentric, or extreme in their choices. They may be intolerant of boredom and stability, tend not to be satisfied with their successes but continually push themselves further, and have difficulty adapting to situations of stagnation and relative tranquility.
Typically, people with milder forms of Bipolar Disorder do not recognize the excitatory component and instead focus on the depression.
Typically, during the phases of the disorder, the person lacks awareness of the alteration in their own mental state. Instead, they tend to attribute it to external events or to their environment, interpret it in existential terms, or deny that an alteration exists at all.