Mania and depression seem like opposites, and in many ways, they are. One involves high energy and a lifted mood, and the other involves low energy and mood. However, they’re both symptoms of bipolar disorder. The human brain is complex, and so are the symptoms of manic and depressive episodes. But is it possible to experience both of these extreme moods at the same time?
The answer to that question is complicated, but it helps to understand the criteria for what qualifies as mania and depression. It also involves an important change in the diagnosis of bipolar disorder in the leading diagnostic tool that doctors and clinicians use: Diagnostic and Statistical Manual of Mental Disorders. Learn more about manic and depressive episodes and how they can sometimes mix.
What is Bipolar Disorder?
Bipolar disorder is a mood disorder that’s characterized by extremely low or high moods. In many cases, it can cause shifts between high and low moods. Bipolar disorder is often thought of as a disorder that causes frequent and sudden mood changes. However, low and high moods can last for weeks before you experience a shift in mood, and the shift can be extreme. One week, you may feel extremely high energy levels and hyperactivity, while the next, you could feel tired and depressed. There is more than one type of bipolar disorder.
Bipolar I Disorder
According to the DSM-5, bipolar I is identified by at least one manic episode, whether or not you also experience a depressive episode. The manic episode must last at least one week, or it must be severe enough to require hospitalization. Bipolar I may also involve hypomanic and depressive phases, but as long as a manic episode occurs, it qualifies as bipolar I.
Bipolar II Disorder
Bipolar II can feel very different when compared to bipolar I. To qualify as bipolar II, you have to meet the criteria for a major depressive episode and a hypomanic episode. Hypomania is similar to mania, but it’s less severe and may not include as many manic symptoms. Hypomania may also occur over a short period. To qualify as hypomania, you just have to feel symptoms for four days instead of seven.
Other Related Disorders
Cyclothymia is a disorder that involves low and high moods and shifts between them. However, it doesn’t meet the criteria for either bipolar I or bipolar II. You may experience hypomania or depression that doesn’t meet the criteria for a full manic or major depressive episode. Still, cyclothymia and other disorders that may be related to bipolar disorder may require help from doctors or therapists to effectively address.
What is a Manic Episode?
Mania is a period of elevated mood, increased energy levels, restlessness, a sense of empowerment, increased activity, and irritability. It is sometimes thought to be a plus side to bipolar disorder because it causes a lifted mood and increased energy. However, these symptoms can also lead to serious consequences.
People tend to make dangerous decisions during a manic phase. They may spend all their money on a project they can’t possibly finish. In severe cases, mania can also cause psychotic symptoms like delusions or hallucinations.
To qualify as having manic episodes, you have to have three or more of the seven common symptoms that are associated with mania. The symptoms include:
- Inflated self-esteem. This isn’t just a positive view of yourself. The DSM uses the word “grandiosity.” You may feel that you have superpowers or that you’re a god. You may also feel uniquely qualified to handle a threat that is real or imagined.
- Decreased need for sleep. Unlike people with anxiety who can also experience sleeplessness, people in a manic phase don’t feel the need for sleep. They may sleep less and maintain high energy levels until their mania ends.
- Increased talkativeness. You may articulate a constant stream of thoughts. You may also talk more quickly and feel pressure to continue talking to fill the silence. This may be related to other symptoms like racing thoughts.
- Flight of ideas. You have many ideas that seem important one after another. It may be difficult to focus on one idea or task.
- Distractibility. This may be related to a flight of ideas. You may have trouble focusing on a task or obligation because you have other ideas. You may also be drawn to other stimuli, even if you feel that it’s unimportant or irrelevant to your thoughts.
- Increased activity. This can be related to putting your flight of ideas into action, but it can also be related to psychomotor agitation. You may increase activity to accomplish tasks that you keep thinking of, but you can also feel restless and unable to sit still.
- Involvement in risky activities. You spend more time involved in activities that have a high chance of causing consequences. Examples are spending sprees, risky sexual behavior, of high-risk business practices.
Unlike a depressive episode, a manic episode can feel fine while it’s happening unless you become irritable. But most people who experience a manic episode report feeling embarrassed or uncomfortable with the consequences of a manic episode once it’s over. Mania is an important factor in identifying bipolar disorder in general. Otherwise, major depressive episodes may be better explained by another mood disorder like major depression.
What is a Major Depressive Episode?
Major depression is a mood state that’s characterized by low energy levels, low mood, and feelings of despair or hopelessness. Depression is one of the most common mental health issues in the United States after anxiety disorders.
When it comes to bipolar disorder, major depression is identified by a set of symptoms similar to a manic episode. The DSM outlines nine symptoms of depression, and you need to experience five or more of them for it to be considered a major depressive episode. The symptoms include:
- Depressed mood. Most people who experience a major depressive episode will experience these symptoms. You may have a low mood that can be self-reported or noticed by other people. Children can experience this as irritability.
- Loss of interest in most activities. Hobbies, work, and other things that may have been interesting to you no longer hold your attention. Even if you continue to do them, you don’t get pleasure out of them.
- A significant weight shift. If you lose or gain 5% of your total body weight within a month unintentionally because of appetite changes, it’s a sign of depression. In children, this can manifest in lower weight gain.
- Sleep disturbances. Changes in your sleep schedule are common when it comes to mental health. Insomnia can happen when you have depression, but you may also experience hypersomnia, which is sleeping for an excessive length of time each day, not wanting to get out of bed.
- Psychomotor activity changes. You may be fidgety or agitated, causing you to move more. You may also be slower to move with delayed movements. These changes are usually severe enough to be noticed by other people.
- Low energy. This can include tiredness, fatigue, slow movement, and lethargy.
- A sense of worthlessness. You may also feel hopelessness or a sense of excessive or inappropriate guilt.
- Poor concentration. You may find it difficult to concentrate on tasks or feel like your thinking is impaired. You might also feel like you’re unable to make decisions.
- Thoughts of death. You may experience frequent thoughts of death, not just centered around the fear of death. You can also experience suicidal thoughts or ideation.
In addition to experiencing at least five of these symptoms, one of them has to be the first or second symptom. A low mood and the loss of interest in activities are definitive symptoms of a major depressive episode.
What is a Mixed Episode?
A mixed episode, in the context of bipolar disorder, is a mood state that involves both mania and depression symptoms. Still, mixed episodes are separated into two major categories: depression with mixed features and mania with mixed features.
To qualify as a depression with mixed features, you will meet the criteria for a major depressive episode and also experience three symptoms of mania or hypomania in the same period. To qualify as mania or hypomania with mixed features, you need to qualify for either mania or hypomania and have three symptoms of major depression.
Not only is it possible to experience mania and depression at the same time, but it may also even be relatively common. According to a 2015 paper, around 40% of bipolar disorder patients experience a mixed episode at some point in their lives. Since mixed symptoms are so common, it makes sense that a change in the DSM expanded the qualification of depression and mania to include mixed symptoms.
The fourth edition of the DSM had a caveat in the criteria for both major depressive episodes and manic episodes that said, “The symptoms do not meet criteria for a mixed episode.” In other words, if symptoms were mixed, they don’t fall under the category of a major depressive or manic episode. Those words were dropped in the fifth edition, which means people that experience mixed episodes can still be diagnosed with bipolar I or bipolar II.