Going from a sleepless night, feeling unstoppable, making grand plans and spending money without limits… to, weeks later, being unable to even get out of bed, feeling deep existential pain and losing interest in everything. If this pattern sounds familiar (for you or someone close), we could be talking about bipolar disorder, one of the most serious mental illnesses, most stigmatized, and at the same time most treatable when it receives appropriate care.
According to the World Health Organization (WHO), bipolar disorder affects approximately 40 million people worldwide. In Spain, prevalence is between 1% and 3% of the population. Despite this, it is an underdiagnosed illness: on average, 8 to 10 years pass from the first episode to correct diagnosis, during which the person may receive inadequate treatments.
What is bipolar disorder?
Bipolar disorder, formerly known as manic-depressive psychosis, is a mood disorder characterized by alternating episodes of mania or hypomania (elevated mood, overflowing energy) and depressive episodes. Between these episodes there may be periods of stability (euthymia) lasting months or years.
It is not simply "having mood swings" — it is a neurobiological disorder with a genetic basis, alterations in neurotransmitters (dopamine, serotonin, norepinephrine), and structural and functional changes in the brain. It is considered one of the top 10 causes of disability worldwide and has a suicide risk 15-30 times higher than the general population.
Types of bipolar disorder
The DSM-5 distinguishes three main forms of bipolarity, each with different characteristics and implications:
Bipolar disorder type I
The "classic" and most severe form. Characterized by at least one complete manic episode lasting 7 days or more (or requiring hospitalization). Complete mania involves extreme activity, euphoria or marked irritability, grandiose ideas, impulsive or dangerous behaviors, and often psychotic symptoms (delusions, hallucinations). Usually alternates with major depressive episodes.
Bipolar disorder type II
Defined by hypomanic episodes (milder form of mania, shorter duration and without psychotic symptoms) alternating with major depressive episodes. The person doesn't need hospitalization and often hypomania may seem "feeling good" or being very productive, but depressive episodes can be severe. More frequent than type I and often more underdiagnosed.
Cyclothymic disorder (cyclothymia)
Characterized by chronic but less intense changes in mood for at least two years. The person alternates subthreshold hypomanic periods with subthreshold depressive periods, without meeting criteria for a major episode. Despite being "milder", it significantly impacts quality of life and can evolve to bipolar I or II over time.
Symptoms of bipolar disorder
Bipolar disorder manifests through three main phases, with clearly differentiated symptoms:
Mania or hypomania: persistently elevated, expansive or irritable mood (at least 7 days in mania, 4 days in hypomania); greatly increased energy; decreased need for sleep (can sleep 2-3 hours and feel rested); talkativeness (rapid speech, difficult to interrupt); flight of ideas and accelerated thinking; exaggerated self-esteem or grandiosity; impulsive behavior (compulsive shopping, hypersexuality, risky financial decisions); disproportionate irritability or euphoria.
Bipolar depression: low mood, deep sadness or feeling of emptiness; loss of interest or pleasure in previously rewarding activities; significant changes in appetite and weight; insomnia or hypersomnia; extreme fatigue; feeling of worthlessness or excessive guilt; difficulty concentrating or making decisions; recurrent thoughts of death or suicide. Usually more severe and treatment-resistant than unipolar depression.
Mixed episode: simultaneous presence of manic and depressive symptoms (e.g., low mood but with agitation, insomnia and accelerated thinking). Mixed episodes have an especially elevated suicide risk and require urgent attention.
Causes of bipolar disorder
Bipolar disorder doesn't have a single identifiable cause. Current hypothesis describes it as the result of a biological vulnerability on which environmental factors act.
Genetic factor: one of the psychiatric disorders with the highest hereditary component. Having a first-degree relative with bipolarity increases risk by 5-10 times. Heritability is estimated at 60-85%.
Neurobiological alterations: brain imaging shows differences in the amygdala, prefrontal cortex and other regions involved in emotional regulation. There is also dysregulation of key neurotransmitters and alterations of circadian rhythms.
Triggering factors: stressful life events (loss of a family member, separation, job change), significant sleep deprivation, substance abuse (cocaine, amphetamines, alcohol), childbirth (postpartum depression can debut into bipolarity), or seasonal changes can precipitate the first episode in predisposed people.
Childhood trauma: having suffered abuse, neglect or significant adversity during childhood does not cause the disorder, but accelerates onset and worsens prognosis. In these cases, treating trauma with EMDR can be a valuable complement.
Impact and comorbidity
Untreated bipolar disorder has very important consequences:
- Elevated suicide risk: between 25% and 50% of people with bipolar attempt suicide during their lifetime; 15-20% complete it. It is the mental disorder with highest suicide risk.
- High comorbidity: frequent coexistence with anxiety disorders (50-60%), addictions (40-50%), ADHD (10-20%) and borderline personality disorder.
- Social consequences: high divorce rate, work problems (30% of patients on permanent disability), debts from impulsive behaviors during mania.
- Physical health: life expectancy reduced by 10-15 years due to cardiovascular disease, obesity and diabetes (medication effects + lifestyle).
- Cognition: persistent cognitive deficits despite being stable (memory, attention, executive functions) in a portion of patients.
Treatment of bipolar disorder
Treatment of bipolar disorder is always combined: medication prescribed by a psychiatrist + psychotherapy. Neither element alone is sufficient.
Pharmacological treatment: mood stabilizers are the basis. Lithium is the medication with most evidence (50+ years of use) and reduces suicide risk. Other options include valproate, lamotrigine, carbamazepine and atypical antipsychotics. In bipolar depressive episodes, traditional antidepressants are used with great caution (can induce mania). This part must be prescribed and monitored by a psychiatrist — not psychological matter.
Psychotherapy (my area): the approaches with most evidence are:
- Psychoeducation: understanding the illness, personal triggers, early warning signs of relapse and how to manage it. Reduces relapses by 30-40%.
- Cognitive-behavioral therapy (CBT): works on thoughts characteristic of each phase, modifies dysfunctional beliefs and teaches emotional regulation strategies.
- Interpersonal and social rhythm therapy (IPSRT): stabilizing circadian rhythms (sleep, eating, activity) is one of the highest-impact interventions in bipolarity.
- Family therapy: educating the family, reducing expressed emotion (criticism, overinvolvement) and improving communication significantly decreases relapses.
- EMDR: in patients with associated trauma, EMDR treatment processes painful experiences contributing to emotional instability, always in stable phases of the disorder.
According to the National Institute of Mental Health (NIMH) and the American Psychiatric Association, the combination of medication + psychotherapy + family support can reduce relapses by more than 50% and allow a full life.
Day-to-day recommendations
If you have a diagnosis of bipolar disorder or live with someone who does, these guidelines are key:
- Don't abandon medication: 70% of relapses are due to treatment abandonment in stable phases. Medication is preventive, not just curative.
- Inflexible sleep hygiene: sleep 7-9 hours each night, always at the same time. Sleep deprivation is one of the most powerful manic triggers.
- Stable routines: regular schedules for meals, work, activity and rest. Sudden changes destabilize.
- Avoid substances: alcohol, cannabis, cocaine and stimulants can precipitate episodes. None are innocuous.
- Recognize early signs: each person has their own patterns. Tracking them in a diary helps act in time.
- Social support: identify 2-3 trusted people who know what's happening and can alert to changes one cannot see oneself.
- Crisis plan: have in writing what to do if an episode occurs (whom to call, where to go, what to take, what to avoid).
When and how to seek help
Bipolar disorder requires specialized psychiatric diagnosis and follow-up, not something that can be managed only from psychology. If you suspect you or someone close may suffer from it, the first step is a psychiatric visit (through the family doctor or privately).
Once diagnosis and medication are established, psychotherapy is the other essential pillar. At my practice in Igualada, I work in coordination with the patient's psychiatrist, offering psychoeducation, CBT and emotional regulation techniques tailored to your case. For stable phases or remote follow-up, online therapy is also available.
Remember: bipolar disorder is not your fault nor a sign of weakness. It is a medical illness like any other, and with appropriate treatment you can have an equally rich and full life. If you've recognized yourself in this article, contact me for a first assessment with no commitment.