Bipolar disorder is an episodic and recurrent disorder in which the psychotic symptoms are associated with severe alterations in mood—at times elated, agitated episodes of mania, at other times depression, with physical and mental slowing, despair, guilt feelings and low self-esteem.
Auditory hallucinations may occur in bipolar disorder, just as they can in schizophrenia. In the manic phase of bipolar disorder, the hallucinations may be congratulatory or paranoid but in the depressive phase they are likely to be critical, abusive or guilt-inducing. In schizophrenia, they are more likely to be neutral – commenting on the person’s thoughts and actions or conversing one with another.
Delusions, also, can occur in bipolar disorder or in schizophrenia. In mania, they may be grandiose or ecstatic, leading the person to feel he or she has achieved, or will achieve, magnificent things, or has a special connection to God or the universe. In depression they often focus on death, disease or guilt.
In the manic phase of bipolar disorder the person is likely to be energetic and need little sleep. He or she may be exhilarated or ecstatic, talkative and argumentative, and enthused about his or her plans, many of them unrealistic. The person may be impatient, impulsive, and resist any attempts to dissuade him or her from irrational plans or from dangerous or harmful behavior. He or she may have grandiose or paranoid delusions and experience hallucinations that reinforce the delusions.
When the episode is milder and the person’s judgment is less severely impaired and no hallucinations or delusions are present, the episode is referred to as “hypomania.”
In the depressed phase of the disorder the person is likely to be slowed down, lacking in energy and unwilling to get out of bed or leave the house. Sleep may be excessive or disturbed. The person often wakes feeling unrested. He or she may ruminate about negative events in his or her life, feel helpless and hopeless, have low self-esteem, and think, plan or attempt suicide.
The depressive episode may be free of psychotic symptoms but, when delusions are present, they often focus on death, disease, or guilt about some imagined offence, and hallucinations are likely to be critical or abusive in nature.
Confusion has arisen regarding the diagnosis of bipolar disorder in recent years due to the practice among child psychiatrists in the U.S of diagnosing aggressive and irritable children with volatile emotions as suffering from “bipolar disorder.” The vast majority of these children never go on to develop bipolar disorder, with the features described above, in adulthood. However, the practice has led to an expansion of the rate of diagnosis of bipolar disorder to 40 times the previous prevalence.
The American Psychiatric Association has rectified this error with the publication, in 2013, of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). The revised manual requires emotionally volatile children of this type to be diagnosed as suffering from “disruptive mood dysregulation disorder.” With this change, it again becomes clear that “bipolar disorder” is a distinct entity and follows the description above.