Types of Bipolar Episodes
The main difference between bipolar disorder and conditions like unipolar depression is the possibility of experiencing the overly excited state called mania, says Amit Anand, MD, a professor at Harvard Medical School of Medicine in Boston and a leading researcher on mood disorders and behavioral health.
People who are experiencing a manic episode have a cluster of symptoms, which may include an unusually elevated or extremely irritable mood, a decreased need for sleep, rapid speech and racing thoughts, excessive interest in pleasurable activities, or feeling overly important and powerful.
By contrast, during depressive episodes, individuals may experience depressed mood, intense sadness or loss of interest or pleasure in activities, sleep disturbance, fatigue, and trouble concentrating, and they may feel hopeless or worthless, with thoughts of death or suicide.
It is notable that in severe episodes of mania or depression, an individual may also experience psychotic symptoms.
Complicating matters is that it’s possible to experience both symptoms of mania and depression at the same time: This is known as a bipolar episode with mixed features. When this happens, you may feel overly energized while also feeling extremely irritable, sad, hopeless, or empty.
You do not have to experience mania to have bipolar disorder. Some people may experience a less severe form of mania, known as hypomania. Because the symptoms of hypomania are less severe, they may not cause as many serious problems. And so people experiencing hypomania may not identify anything being wrong, making a bipolar diagnosis more difficult.
Understanding and Managing Bipolar Triggers
Bipolar episodes can be triggered by lifestyle and environmental factors. Recognizing your triggers and avoiding them, Dr. Anand says, is often a key to managing bipolar disorder and can be an important addition to your treatment by a trained mental health professional.
Here’s a closer look at seven factors that may worsen bipolar symptoms or trigger an episode:
1. Stress
In many cases, a major life change or stressful event, such as losing a loved one or having severe financial troubles, can trigger a bipolar episode. How an individual copes with stress can also affect how bipolar disorder progresses.
According to a meta-analysis published in 2017, people with bipolar disorder who were having a relapse of their condition reported experiencing more stressful life events compared with those who were in a more stable mood phase. The researchers concluded that individuals with bipolar disorder tend to be more sensitive to stressors, suggesting that psychosocial treatments are an important component of successfully managing the condition and should be used in addition to mood-stabilizing medications prescribed by a trained psychiatrist.
Psychosocial treatments include psychotherapy and support groups, and education regarding the condition for the individual as well as for loved ones is important so that people can spot the signs of relapse, according to NAMI.
2. Poor Sleep
Lack of sleep is a frequent trigger of bipolar mood episodes, Anand says. Poor sleep or a disruption in normal sleeping patterns, including jet lag, can trigger these intense mood swings. But there is evidence that increased awareness of this elevated risk combined with psychological treatment may help.
In a study published in 2015, researchers treated half of the 58 study participants who had bipolar disorder and insomnia with a bipolar-specific modified form of cognitive behavioral therapy (CBT) that involved incorporating good sleep habits, relaxation, and dim lights at bedtime, and reducing anxiety about sleep into daily routines. The other half of the study participants were given information about how sleep, stress, diet, exercise, and mood are related to each other, but were given no plan or intervention designed to change behavior.
The results were eye-opening: Six months after these interventions, the people who received the CBT approach had experienced just 3.3 days spent in a bipolar episode compared with 25.5 days for those who were given only educational materials. The CBT group also had a lower rate of relapse and less severe insomnia. These results show that it may be beneficial for you to ask your doctor for a plan to ensure you’re getting enough quality sleep if you have bipolar disorder.
3. Seasonal Changes
For some people with bipolar disorder, there’s a seasonal pattern to mood episodes. Anand says there’s some evidence that more manias occur during the spring and summer months, while more episodes of depression take place in the fall and winter. But some people experience the opposite, and gender seems to play a role as well.
Ina study from 2013 that followed 452 participants with bipolar disorder, the researchers reported that 23 percent of the participants displayed a seasonal pattern in their bipolar episodes — a significant percentage that was consistent with the findings of earlier research. The authors also noted that the participants with seasonal patterns had a significantly higher number of major depressive episodes, and there were differences in the types and timing of episodes based on gender.
Because of these findings — that 1 in 4 people with bipolar disorder display seasonal patterns and also may be at risk for more severe episodes — the researchers concluded that regular screening for seasonal patterns should be an important part of treatment.
A more recent study, from 2019, examined data in over 60,000 people who were admitted to a hospital for a manic, depressive, or mixed featured episode between 2001 and 2014. The authors reported that seasonal patterns in hospitalization rates during manic episodes were evident for both men and women: Women were more likely to experience manic episodes in summer and autumn, depressive episodes in winter, and mixed features in summer; whereas men were more likely to experience manic episodes in summer. Women under age 35 were also more likely to have this seasonal pattern in manic and mixed episodes.
4. Medications
Treatment for bipolar disorder includes psychotropic medications, such as mood stabilizers, antipsychotics, and antidepressants, according to NAMI. But certain types of some antidepressants, such as SSRIs like fluoxetine (Prozac) andsertraline (Zoloft), may worsen bipolar disorder symptoms and possibly even trigger a manic episode in those with undiagnosed bipolar disorder. If you have bipolar disorder, you should not take an antidepressant without also taking a mood stabilizer or an antipsychotic medication, Anand says.
Additionally, stimulants — a class of medications used to treat conditions like attention deficit hyperactivity disorder (ADHD) — may also trigger a manic episode.
And there are other types of medications, such as corticosteroids or thyroid medication, that are prescribed for nonpsychiatric conditions but may also lead to hypomanic or manic symptoms, just as other medications may worsen symptoms of depression.
The bottom line: If you have bipolar disorder along with one or more other medical conditions (such as obsessive-compulsive disorder, ADHD, or nonpsychiatric conditions) that is treated with medication, NAMI recommends that you develop a treatment plan with your doctor to best manage all of the conditions and monitor your side effects.
5. Drug and Alcohol Use
Substance misuse is common among people with mental health conditions as a comorbid condition or as a way to cope with their symptoms. In fact, 30 to 50 percent of people with bipolar disorder will develop a substance use disorder, notes the Substance Abuse and Mental Health Services Administration (SAMHSA).
Anand cautions against using drugs or alcohol to “treat” symptoms of the condition. Drinking alcohol or taking drugs, he says, can worsen your bipolar mood swings and lead to an increase in suicidal thoughts or behaviors. As SAMHSA notes, substance use or withdrawal can cause symptoms attributed to bipolar disorder, including agitation, anxiety, paranoia, mania, or depression.
Drinking alcohol in particular can interfere with the metabolism of medications, making you less likely to respond to prescribed treatment, and it may increase the risk of psychiatric hospitalization. That’s why doctors strongly encourage people with bipolar disorder not to self-medicate and instead seek (or continue to get) professional help for management of their bipolar disorder using prescribed medications and psychosocial therapy to manage symptoms.
6. Caffeine
It’s important to note that caffeine is also considered a drug and a stimulant. As such, it may disturb sleep, change sleep patterns,and trigger hypomanic or manic episodes. It can also affect the way your body breaks down the medications you take to treat your condition (like lithium), which can trigger hypomanic or manic episodes, according to a 2021 review of 17 relevant studies. Talk to your doctor about your caffeine consumption and how it may affect your symptoms.
7. Childbirth
The link between childbirth and bipolar disorder has been well-documented in a number of scientific studies. A systematic review from 2016 of nine papers found that the risk for mood disorder episodes increases both during and after pregnancy, and the risk is especially high in the time after childbirth (the postpartum period) in women with bipolar disorder.
And women with a history of bipolar disorder are at especially high risk of postpartum psychosis, according to research published in 2021.The researchers noted that nearly 50 percent of women with bipolar disorder experienced at least one “mood episode” — for example, a manic, hypomanic, or depressive episode — during pregnancy or within 12 months after childbirth. Hormonal changes associated with pregnancy and the postpartum period for women also increase the risk of mood episodes. Further complicating things: Women often have an interruption to their psychiatric treatment and medications following the birth of a child.
It’s also worth noting that both men and women with bipolar disorder may have episodes triggered by the stress surrounding the birth of a child, coupled with potentially severely disturbed sleep. While there is very limited research examining the effects of a new baby on men, a study from 2017 found that some evidence suggests that fathers with bipolar disorder may have an increased risk of hypomanic episodes after their child is born.
Anticipating Triggers
While it is important to recognize potential triggers for a bipolar episode , it is also essential to keep in mind that episodes can occur even without a trigger. “Bipolar episodes can come out of the blue,” Anand notes.
Your best plan: Do what you can to manage your stress, get good sleep, avoid using alcohol or other risky substances, and work with your doctor to find the best strategies and treatments to manage your bipolar disorder.
Additional Reporting by Jessica Migala
