Bipolar I disorder: symptoms, mania, treatment (and difference with type II)
Bipolar I disorder — the classic form of bipolar disorders — is recognised by the DSM-5-TR and by the ICD-11 (code 6A60). It is defined by at least one manic episode (≥1 week), with or without depressive phases. This guide covers the 3 types (I, II, cyclothymia), symptoms by phase, causes (70% heritability), treatments (mood stabilisers, IPSRT), and the difference with unipolar depression, borderline, and ADHD. With adapted treatment, 70% of patients maintain a normal quality of life between episodes (Goodwin & Jamison, 2007).
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Bipolar I disorder (DSM-5-TR, ICD-11 6A60) is defined by at least one manic episode (≥1 week), with or without depression. It is the classic form of bipolar disorders, distinct from type II (hypomania) and cyclothymia. It is treatable: lithium + psychoeducation → 70% normal quality of life preserved.
En 30 secondes
Bipolar disorder is a mood disorder characterised by alternating manic episodes (or hypomanic) and depressive episodes, interspersed with euthymic periods. Recognised by the DSM-5-TR (APA, 2022) and ICD-11 (WHO, 2019) under codes 6A60 (type I), 6A61 (type II), and 6A62 (cyclothymia). Type I is distinguished by the presence of at least one complete manic episode.
- DSM-5-TR / ICD-11 codes: 6A60 type I, 6A61 type II, 6A62 cyclothymia
- First-line treatment: mood stabiliser (lithium) + psychoeducation + IPSRT (Frank)
- Quality of life preserved: 70% between episodes with adapted treatment (Goodwin & Jamison, 2007)
Bipolar disorder: what are we really talking about?
The word "bipolar" has entered everyday language — often wrongly, to describe ordinary mood swings. The clinical reality is precise. In 2026, bipolar I disorder is defined by the DSM-5-TR (APA, 2022) and by the ICD-11 (WHO, 2019, code 6A60). It affects approximately 1-2% of the adult population and 40 million people worldwide (WHO, 2024). It is neither a character flaw nor a pop-psychology label — it is a measurable psychiatric disorder, with diagnostic criteria, documented causes, and effective treatments.
From Kraepelin to the ICD-11: 125 years of clinical construction
The concept dates back to Emil Kraepelin (1899), who described "manic-depressive insanity" as a cyclical entity distinct from dementia praecox (schizophrenia). The DSM-III (1980) introduced the modern term "Bipolar Disorder". The ICD-11 (WHO, 2019) reclassified the entire cluster under codes 6A60 (bipolar type I), 6A61 (type II), and 6A62 (cyclothymic disorder). In parallel, Hagop Akiskal proposed the concept of the bipolar spectrum — a continuum that includes clinically relevant sub-threshold forms (bipolar III, IV, etc.) and sheds light on why so many patients are first diagnosed with "unipolar depression".
DSM-5-TR and ICD-11: the codes to know
In francophone clinical practice, two systems coexist. The DSM-5-TR (APA, 2022) distinguishes bipolar I (at least one complete manic episode), bipolar II (at least one hypomania + one depressive episode, never full mania), and cyclothymic disorder (sub-threshold fluctuations ≥2 years). The ICD-11 (WHO, 2019) uses codes 6A60 / 6A61 / 6A62 — the official coding used by health insurance and medical records. Both systems describe the same entities with slightly different vocabulary.
Prevalence: 1-2% of the population, 40 million worldwide
According to the WHO (2024), bipolar disorders affect approximately 40 million people worldwide (~1-2% of the adult population). First symptoms appear on average between 15 and 25 years, but diagnosis is made ~10 years later (Ameli; HAS, 2009). The male/female ratio is roughly equal, but men more often begin with a manic episode, women with a depressive episode. Heritability is estimated at ~70% (Smoller et al., Lancet, 2013) — the highest among psychiatric disorders.
- DSM-5-TR / ICD-11: 3 entities — type I (6A60), type II (6A61), cyclothymia (6A62)
- 1-2% of the population — 40 million people worldwide (WHO, 2024)
- Heritability ~70% — Smoller et al., Lancet, 2013
- Not a shifting mood — it is a measurable and treatable biological cycle
The 3 types of bipolar disorder (DSM-5-TR and ICD-11): bipolar I, type II, cyclothymia
Bipolar disorder is not a single block: the DSM-5-TR and ICD-11 distinguish three distinct clinical entities, with different criteria and intensities. Understanding them is the first key to avoiding confusion between bipolar I, bipolar II, and cyclothymia — with their possible specifiers (mixed episode, rapid cycling ≥4 episodes/year).
1. Bipolar I disorder (DSM-5-TR / ICD-11 6A60)
The classic form. Diagnosis requires at least one complete manic episode (≥1 week, or any duration if hospitalisation is needed). Depression is not required for diagnosis but occurs in the vast majority of patients. Manic episodes are often a medical emergency (behavioural, financial, and loss-of-reality risks) and frequently lead to hospitalisation. Specifiers complete the diagnosis: mixed episode (manic and depressive symptoms simultaneously) and rapid cycling (≥4 episodes over 12 months).
Au quotidien
- • At least 1 manic episode (≥1 week) with euphoria or irritability
- • Psychotic episodes possible (grandiosity, auditory hallucinations)
- • Hospitalisation frequent in manic phase
2. Bipolar II disorder (DSM-5-TR / ICD-11 6A61)
Alternation of hypomanias (≥4 days, less intense than mania, no psychosis, no hospitalisation) and major depressive episodes. Never a complete mania — this is the criterion separating type II from type I. Often underdiagnosed because hypomania is experienced as "a good period" — the patient only consults during the depressive phase and first receives a unipolar depression diagnosis. Suicide risk is equivalent to type I.
Au quotidien
- • At least 1 hypomania (≥4 days) + at least 1 major depressive episode
- • No complete mania, no hospitalisation during high phase
- • Often labelled "depression" for years before the correct diagnosis
3. Cyclothymic disorder — cyclothymia (DSM-5-TR / ICD-11 6A62)
Sub-threshold fluctuations over at least 2 years (1 year in adolescents): periods of hypomanic symptoms + depressive periods that never meet full episode criteria. Chronic mood instability, but less intense than types I and II. Risk of progression to bipolar I or II: 15-50% of cyclothymias progress to a complete type (Akiskal).
Au quotidien
- • Fluctuations ≥2 years without ever a complete episode
- • Chronic instability of mood, perceived as "temperament"
- • Risk of progression to type I or II — psychiatric follow-up useful
The 3 phases of bipolar disorder: mania, hypomania, depression
Bipolar disorder alternates mood episodes (high or low) and euthymic periods (stable mood). Each phase has precise duration criteria per the DSM-5-TR. Below are the clinical markers to know — but only a psychiatrist can make a diagnosis.
Manic episode (≥1 week) — type I only
Abnormally elevated, expansive, or irritable mood with marked increase in energy, for at least 1 week (or any duration if hospitalisation). Social, professional, and family rupture common. Psychotic symptoms may appear (delusional grandiosity, hallucinations). It is a psychiatric emergency.
Au quotidien
- • Logorrhoea, flight of ideas, racing thoughts
- • Reduced need for sleep (2-3h are enough), grandiosity
- • Excessive spending, risky sexuality, reckless driving
Hypomanic episode (≥4 days) — types I and II
Attenuated version of mania, for at least 4 consecutive days. Same qualitative symptoms, but no major functional impairment, no psychosis, no hospitalisation. The most deceptive phase: experienced as a "good period" by the patient, it is rarely reported to the doctor — which partly explains the average 10-year diagnostic delay.
Au quotidien
- • Overflowing energy without major disorganisation
- • Increased productivity, creativity, moderate euphoria
- • Reduced sleep but no exhaustion — perceived as positive
Major depressive episode (≥2 weeks)
Depressed mood and/or anhedonia (loss of pleasure) nearly daily for at least 2 weeks, with ≥4 associated symptoms. In bipolar disorder, depressive phases are 2 to 3 times longer than manic phases (Vidal; Akiskal). Maximum suicide risk: up to 25% of untreated patients attempt suicide, up to 15-20% die by it (Baldessarini; MSD). If you have dark thoughts, call 3114 (France).
Au quotidien
- • Anhedonia, psychomotor slowing, insomnia or hypersomnia
- • Extreme fatigue, guilt, dysphoria
- • Recurrent suicidal ideation — call 3114 if needed
Do you recognise yourself in several of these phases?
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Causes of bipolar disorder: biopsychosocial model
Science no longer speaks of a "single cause" for bipolar disorder, but of a biopsychosocial model. Genetics prepares the ground, neurobiology provides the mechanisms, environment triggers the episodes. None of these factors acts alone — it is their interaction that produces the illness.
Genetics: ~70% heritability (Smoller, Lancet, 2013)
The heritability of bipolar disorder is estimated at ~70% (Smoller et al., Lancet, 2013 — Identification of risk loci with shared effects on five major psychiatric disorders). It is the highest among common psychiatric disorders. Having a first-degree relative affected multiplies the risk by 7 to 10. Caveat: heritability ≠ fate — it indicates predisposition, not certainty. Many relatives never develop the illness.
Neurobiology: monoaminergic axis and circadian rhythms
The reference works of Goodwin & Jamison (2007, Manic-Depressive Illness) highlight anomalies in the monoaminergic axis (dopamine, serotonin, noradrenaline) and in circadian rhythm (sleep, cortisol, melatonin secretion). This explains why sleep deprivation is a major trigger of manic episodes, and why interpersonal and social rhythm therapy (IPSRT, Frank et al.) — which stabilises daily rhythms — is part of first-line treatment.
Environment: stress, trauma, substances, SSRI switching
Triggering factors do not cause the disorder but precipitate episodes in predisposed individuals: acute stress, sleep deprivation, trauma, substance use (cannabis, cocaine, amphetamines), and — critical — manic switching under SSRI antidepressant prescribed alone. This is why psychiatric assessment is needed before prescribing an antidepressant to someone with bipolar family history.
- Genetics: ~70% heritability (Smoller, Lancet, 2013)
- Neurobiology: monoaminergic axis + circadian rhythms (Goodwin & Jamison, 2007)
- Triggers: stress, sleep deprivation, substances, SSRI switching
- No factor acts alone — it is the biology × environment interaction that matters
Why bipolar disorder diagnosis takes on average 10 years
Ameli cites the figure — ~10 years between first symptoms and diagnosis — but no one explains why. It is the most useful information for a reader asking the question. Here are the 4 mechanisms documented, aligned with DSM-5-TR, HAS, and Akiskal.
1. Hypomania is experienced as "a good period"
The hypomanic phase (≥4 days) produces no subjective suffering: overflowing energy, creativity, productivity, reduced sleep but no exhaustion, self-confidence. The patient never spontaneously reports it to the doctor. They only consult when the depressive phase arrives — and then, they describe "a depression", not "a cyclical disorder".
2. Consultation happens in the low phase → "unipolar depression" label
The doctor sees a patient in a major depressive episode (≥2 weeks) and makes the most likely diagnosis: unipolar depression. Prior hypomanic episodes are not systematically explored if the patient does not mention them. As a result, the correct diagnosis waits for the first complete manic episode — sometimes 10 years later.
3. Manic switching under SSRI prescribed alone
In an unidentified bipolar patient put on an SSRI antidepressant alone, a manic switch may occur within a few weeks. It is often this event that flips the diagnosis from "treatment-resistant depression" to "bipolar disorder". International guidelines now require systematically associating a mood stabiliser with the antidepressant when in doubt.
4. Masking comorbidities (anxiety, addictions, ADHD, borderline)
Comorbidities are the rule rather than the exception: ≥50% with anxiety, 30-50% with addictions, common with ADHD and borderline. These diagnoses often take priority, delaying identification of the underlying disorder. Bipolar disorder is then treated as "depression + anxiety + addictions" for years.
- Invisible hypomania: produces no suffering, is not reported
- Consultation in low phase: automatic "unipolar depression" label
- SSRI switch alone: often the revealing event
- Masking comorbidities: anxiety, addictions, ADHD, borderline divert attention
Bipolar disorder treatments: what does science say?
Bipolar disorder can be treated. With adapted treatment — mood stabiliser + psychoeducation + interpersonal and social rhythm therapy (IPSRT) — approximately 70% of patients maintain a normal quality of life between episodes (Goodwin & Jamison, 2007). No specific medication is recommended here: the choice belongs to the psychiatrist after personalised assessment.
First line: mood stabilisers (lithium and alternatives)
Mood stabilisers (normothymics) are the backbone of treatment. Lithium remains the reference for type I — the only medication with a demonstrated effect on suicide prevention (Baldessarini). Other mood stabilisers used: valproate, lamotrigine (especially in depressive type II), carbamazepine. Second-generation antipsychotics are added in acute phase (mania, mixed episode). Only a psychiatrist can prescribe and adjust — never self-medicate.
Psychoeducation + IPSRT (Frank) + CBT
Beyond medications, psychoeducation — learning to recognise prodromes, keep a mood chart, identify triggers — drastically reduces relapses. Interpersonal and social rhythm therapy (IPSRT, Frank et al.) stabilises sleep-wake cycles and routines. CBT adapted to bipolar disorder treats associated dysfunctional cognitions. These approaches are complementary to medications, not alternatives.
ECT as last resort — high efficacy
Electroconvulsive therapy (ECT) is reserved for severe resistant episodes (mania with life-threatening risk, depression with imminent suicide, catatonia). Performed under general anaesthesia, it remains the most rapidly effective treatment for severe episodes — modern techniques have considerably reduced cognitive side effects compared with the 1950s.
- First line: mood stabiliser (lithium), adjusted by a psychiatrist
- Psychoeducation + IPSRT + CBT: complementary to medications
- ECT: severe resistant episodes — under anaesthesia, well tolerated
- No medication to self-prescribe — only a psychiatrist guides the choice
Bipolar vs borderline vs unipolar depression vs ADHD
Bipolar disorder is often confused with borderline (both involve mood variations), unipolar depression (patient consults in low phase), or ADHD (impulsivity, logorrhoea, distractibility). Management differs radically — here is the grid to situate the 4 profiles. Only a psychiatrist can make the diagnosis.
| Bipolar | Borderline | Unipolar depression | ADHD | |
|---|---|---|---|---|
| Episode duration | Weeks to months | Hours to a few days | ≥ 2 weeks (DSM-5 criterion) | Chronic (≥ 6 months, onset in childhood) |
| Main trigger | Endogenous (biological cycle) | Relational (abandonment, rejection) | Loss, prolonged stress, biological | Chronic, non-episodic |
| Baseline mood between episodes | Euthymia (normal mood) | Unstable, empty, chronic anger | Euthymia if isolated (dysthymia if chronic) | Stable but distractible |
| Lithium response | Good (DSM-5-TR reference) | Poor | Moderate (add-on) | None |
| First-line treatment | Mood stabiliser (lithium) | DBT (psychotherapy, Linehan) | SSRI + CBT | Stimulant + CBT |
| Common comorbidities | Anxiety, addictions, ADHD | BPD, depression, PTSD | Anxiety, addictions | ADHD, anxiety, learning issues |
Warning sign for missed bipolar diagnosis: if you have already experienced high phases (overflowing energy, reduced sleep, racing thoughts) before your depressions, bipolar II disorder is likely — SSRIs taken alone may then trigger a manic switch. If your "episodes" last hours and are triggered by rejection, look towards borderline disorder. These disorders can co-exist — ask for psychiatric reassessment if you recognise yourself in several columns.
5 myths about bipolar disorder
False. What changes in hours is borderline disorder (BPD), not bipolar. Bipolar episodes last weeks to months (≥1 week for mania, ≥4 days for hypomania, ≥2 weeks for depression per DSM-5-TR). If your variations last hours and are triggered by rejection, consult a psychiatrist — it is not the same disorder, not the same treatment.
False. An SSRI antidepressant taken alone in a bipolar person may trigger a manic switch within weeks. International guidelines require systematically combining a mood stabiliser (lithium, valproate, lamotrigine) if an antidepressant is needed. This is why psychiatric assessment precedes prescription in patients with bipolar family history.
False. Lithium — prescribed since 1949 — has monitored side effects (tremor, weight gain, thyroid and renal function), but at adjusted dose it does not "zombify". Regular blood monitoring finds the therapeutic window. It is the only medication with a demonstrated suicide-prevention effect in bipolar disorder (Baldessarini).
False. ~70% heritability (Smoller, Lancet, 2013) indicates predisposition, not fate. With adapted treatment (mood stabiliser + psychoeducation + IPSRT), 70% of patients maintain a normal quality of life between episodes (Goodwin & Jamison, 2007). The illness does not "disappear" but it stabilises — working, building a family, having a rich life is entirely possible.
False. Bipolar II disorder lacks full mania, but it has the same suicide risk as type I, more time in depressive phase, and sometimes more marked chronicity. It is often underdiagnosed for years (labelled "unipolar depression") — one of the most costly diagnostic errors in terms of mortality.
Criteria aligned with DSM-5-TR and ICD-11 — clinical reference
Bipolar disorder is treatable — the numbers prove it
70% of patients maintain a normal quality of life between episodes with adapted treatment (Goodwin & Jamison, 2007). Lithium is the only medication with a demonstrated suicide-prevention effect (Baldessarini). You are not alone — 40 million people worldwide live with it (WHO, 2024).
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Do you recognise yourself? 4 concrete steps
A structured journey, at your pace — from mood chart to psychoeducation. Order matters: document first, consult next.
1. Keep a mood chart (4 weeks minimum)
For at least 4 weeks, note each day: mood (scale -5 to +5), hours of sleep, energy, triggering events, substance use (alcohol, substances), medications if already treated. The mood chart is the reference tool in bipolar psychoeducation — it reveals cycles, prodromes, and becomes a key piece for the psychiatrist. Free apps: eMoods, Daylio, paper notebook.
2. Consult a GP (first filter + somatic work-up)
A general practitioner is the first entry point: they rule out somatic causes (thyroid, neurological), verify medication interactions, and write the letter for the psychiatrist. Bring your mood chart and the list of your past episodes — that is the material the psychiatrist will use.
3. Refer to a psychiatrist (only one authorised to diagnose)
Only a psychiatrist can make a bipolar disorder diagnosis per DSM-5-TR or ICD-11 (6A60 / 6A61 / 6A62) criteria. Public wait times are often long (3-6 months) — CMPs (Centres médico-psychologiques) or the private sector accelerate. The psychiatrist assesses personal and family history, aligns episodes, and proposes adapted treatment (mood stabiliser where appropriate).
4. Start psychoeducation (ETP or peer-support group)
Psychoeducation is a pillar of treatment: learning to recognise prodromes, keep your mood chart, protect sleep, avoid manic switches. Therapeutic patient education (ETP) programmes and peer-support groups (Argos 2001, Unafam, France Dépression) complete the management. If comorbidity anxiety, depression, or ADHD, management adjusts.
Questions frequentes
Bipolar disorder alternates three types of phases. Manic episode (≥1 week, type I only): elevated or irritable mood, logorrhoea, flight of ideas, reduced sleep, grandiosity, impulsivity, sometimes psychosis. Hypomanic episode (≥4 days, types I and II): attenuated version, overflowing energy, productivity, no major impairment — often experienced as "a good period". Major depressive episode (≥2 weeks): anhedonia, psychomotor slowing, fatigue, dysphoria, suicidal ideation. Between episodes: euthymia (normal mood).
Biopsychosocial model. Genetics: ~70% heritability (Smoller et al., Lancet, 2013) — the highest among psychiatric disorders. Neurobiology: anomalies of the monoaminergic axis (dopamine, serotonin, noradrenaline) and of circadian rhythm (Goodwin & Jamison, 2007). Environment: stress, sleep deprivation, trauma, substances (cannabis, cocaine), manic switch under antidepressant prescribed alone. No factor acts alone — it is the biology × environment interaction that produces the illness.
Three key indices. (1) Episode duration: weeks to months for bipolar, hours to a few days for borderline. (2) Trigger: endogenous biological cycle for bipolar, relational rejection for borderline. (3) Mood between episodes: euthymia for bipolar, chronic instability for borderline. First-line treatment: mood stabiliser (lithium) for bipolar, Linehan's DBT for borderline. The two can co-exist (~20% of cases) — hence the importance of thorough psychiatric assessment. Read the borderline guide to go further.
Yes — it stabilises durably. With adapted treatment (mood stabiliser + psychoeducation + IPSRT), approximately 70% of patients maintain a normal quality of life between episodes (Goodwin & Jamison, 2007). Lithium — prescribed since 1949 — remains the reference and is the only medication with a demonstrated suicide-prevention effect (Baldessarini). The illness does not "disappear" but becomes manageable — working, building a family, having a rich life is entirely possible.
No form is "minor". Type I is medically urgent in manic phase (risk of psychosis, hospitalisation, severe financial and social consequences). Type II, often perceived as "milder", in reality has the same suicide risk, more time in depressive phase, and sometimes more marked chronicity. Cyclothymia (6A62) is sub-threshold but may progress to a full type. Any suspicion justifies a psychiatric assessment — if you have dark thoughts, call 3114 (France).
On average, ~10 years between first symptoms and correct diagnosis (Ameli; HAS, 2009). Four reasons. (1) Hypomania produces no suffering, is not reported. (2) The patient consults in depressive phase → "unipolar depression" label. (3) A manic switch under SSRI prescribed alone is often the revealing event. (4) Masking comorbidities (anxiety, addictions, ADHD, borderline) divert attention. Keeping a mood chart and explicitly mentioning any "good period" episode reduces this delay — which is why the mood chart is step #1 of the care pathway.
You have read the guide. Move on to the self-assessment.
A structured first overview on DSM-5 criteria — to find out whether consulting a psychiatrist is appropriate. Free, confidential, non-judgemental.
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☎ Need urgent help? Bipolar disorder carries a major suicide risk — up to 25% attempts and 15-20% deaths by suicide without treatment, over-risk × 20 to × 60 vs the general population (Baldessarini; MSD). If you have dark thoughts or suicidal urges, call 3114 (France) — national suicide prevention helpline, free, 24/7, confidential. Outside France, contact your local emergency services. 3114
Avertissement
This guide is provided for informational purposes only. Bipolar disorder is a psychiatric diagnosis that can only be made by a psychiatrist under the DSM-5-TR (APA, 2022) or ICD-11 (WHO, 2019) criteria. No specific medication, no specific therapist is recommended here — the choice of treatment belongs to the psychiatrist after personalised assessment. If you recognise several phases (high and low) persistently over one year or more, consult — bipolar disorder stabilises durably with adapted treatment.
Sources
- APA — Diagnostic and Statistical Manual of Mental Disorders, 5th ed., Text Revision (DSM-5-TR, 2022) — Bipolar and Related Disorders criteria
- WHO / OMS — International Classification of Diseases, 11th revision (ICD-11, 2019) — codes 6A60 (bipolar I), 6A61 (bipolar II), 6A62 (cyclothymia)
- Kraepelin E. (1899) — Psychiatrie, 6th edition: founding description of "manic-depressive insanity"
- Goodwin F.K. & Jamison K.R. (2007) — Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd edition (Oxford University Press) — international reference
- Smoller J.W. et al. (2013) — Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis (The Lancet, 381(9875), 1371-1379) — ~70% heritability
- Akiskal H.S. — work on the bipolar spectrum and sub-threshold forms (cyclothymia, bipolar III/IV)
- Frank E. et al. — Interpersonal and Social Rhythm Therapy (IPSRT): validated social-rhythm therapy for bipolar disorder
- Baldessarini R.J. et al. — work on suicide mortality in bipolar disorder and the preventive effect of lithium
- HAS — ALD Guide: Bipolar disorders (Haute Autorité de Santé, 2009, under re-evaluation) — French clinical-practice reference
- WHO — Bipolar disorder fact sheet (WHO, updated 2024) — 40 million people worldwide
- Inserm — dossier Bipolar disorders: French institutional resource
- 3114 — France's national suicide prevention helpline (free, 24/7, confidential)