Types of bipolar disorder

Bipolar disorder is not one single pattern. Doctors sort it into types based on how high the "up" times go, how long they last, and whether there are deep lows too.¹ The type helps guide treatment and tells you what to watch for.

This page explains the main types in plain words. It also covers rapid cycling, and what it can mean when mania shows up for the first time later in life. To learn what mania, hypomania and bipolar depression look like, see signs of mania, hypomania and bipolar depression.

A few words first

Two terms come up again and again:

• Mania is a time of very high, wired or irritable mood with much more energy than usual. It lasts at least a week, or it is so severe the person needs a hospital.^1,3 Severe mania can include psychosis (losing touch with reality, such as false beliefs or hearing things).³
• Hypomania is a milder "up" time. It lasts at least four days in a row. It does not usually cause major problems in daily life.³

A major depressive episode lasts at least two weeks. It brings low mood or loss of interest, plus other symptoms like sleep changes and low energy.³

Doctors in the United States use a manual called the DSM-5-TR to name these types.⁶ The table below gives a quick view.

Sources for the table: NIMH, the American Psychiatric Association and the Merck Manual.^1,3,6

Bipolar I disorder

A person has bipolar I if they have had at least one manic episode.⁴ The mania lasts at least seven days most of the day, nearly every day. If it is so severe that the person needs hospital care, it counts even if it is shorter.^1,4

Most people with bipolar I also have depressive episodes. These often last at least two weeks.¹ But depression is not needed for the diagnosis. One manic episode is enough.⁴ Some people also have hypomanic times, and most have stretches of steady, usual mood in between.³

During severe mania, some people have psychosis.³ They may believe they have special powers or a special mission, or they may hear things others do not. This is one reason mania can be dangerous and may need urgent care.

Bipolar II disorder

Bipolar II means a person has had at least one hypomanic episode and at least one major depressive episode. They have never had full mania.^3,4 If a full manic episode ever happens, the diagnosis becomes bipolar I.^4,5

Bipolar II is not simply a "milder" bipolar I. The highs are milder, but the lows can be long and heavy. Many people with bipolar II spend long stretches in depression.¹

Bipolar II is often missed for years.¹ Hypomania can feel good. A person may feel creative, confident and productive, so they do not see it as a problem.³ They go to the doctor for depression, and the "up" times are never mentioned. That is one reason a doctor may ask family members what they have noticed. Our page on getting diagnosed explains more. Bipolar II seems to be somewhat more common in women than in men.⁵

Cyclothymic disorder (cyclothymia)

Cyclothymia is a long-lasting pattern of frequent mood swings. The person has times of hypomanic symptoms and times of depressive symptoms. But the swings are never strong enough or long enough to count as full episodes.^1,3

To be called cyclothymia:^3,6

• The pattern lasts at least two years in adults (one year in children and teens).
• Symptoms are present at least half the time.
• The person is never free of symptoms for more than two months at a time.
• The ups and downs cause real distress or trouble in daily life.

Estimates suggest that somewhere between less than 1 in 100 and about 2 or 3 in 100 people have cyclothymia at some point. It affects women and men at similar rates.⁶ It often comes before bipolar I or bipolar II, though some people never develop a full mood episode.⁶

Because the swings are smaller, people may think it is just their personality. Treatment usually starts with learning about the condition and getting support. Some people also take a mood stabilizer.⁶ See therapy for bipolar disorder and medicines for bipolar disorder.

Other specified and unspecified types

Some people have clear periods of abnormal high mood that do not fit any of the patterns above.^1,4 Doctors may then use the label "other specified" or "unspecified" bipolar and related disorder.^1,4 This is still a real diagnosis, and it still deserves care and follow-up.

When something else causes the mania

Sometimes mania or hypomania is caused by a substance, a medicine or a physical illness. Doctors have separate names for these:⁵

• Substance- or medication-induced bipolar disorder. Mood symptoms are caused by a drug or medicine. Stimulants such as cocaine or amphetamines, corticosteroids (steroid medicines such as prednisone), and dopamine agonists (a type of Parkinson's medicine) can all cause manic symptoms.⁵ Antidepressants and steroids can also trigger mania in some people.⁸
• Bipolar disorder due to another medical condition. The cause is a body illness. Examples include an overactive thyroid, Cushing syndrome (too much of the stress hormone cortisol), and brain injury.⁵

Finding the cause matters, because treating it may end the mania.⁹ That is why a doctor will ask about every medicine and check for other illnesses.

Rapid cycling

Rapid cycling is not a separate type. It is a pattern that can happen with bipolar I or bipolar II. It means a person has four or more mood episodes in 12 months.^1,7 These can be any mix of mania, hypomania, depression or mixed episodes (when highs and lows happen at the same time).⁷

A large review of studies found that:⁷

• About 1 in 6 people with bipolar disorder have rapid cycling in a given year. About 1 in 3 have it at some point in their life.
• It is more common in women. In many studies, roughly 7 in 10 people with rapid cycling were women.
• It is linked to a harder course, and many studies found more suicidal behavior.
• It is usually a phase, not a fixed trait. In one long-term study, about 1 in 3 people went on to have a full year without mood episodes.

Researchers have looked at low thyroid levels and at antidepressants as possible causes. So far, the evidence is mixed. Antidepressants may play a role for some people, but not most.⁷ If you have many episodes a year, tell your doctor. They may check your thyroid and review your medicines with you.

When mania first appears later in life

Most people with bipolar disorder notice the first signs in their teens or 20s. The average age when it starts is about the mid-20s.^3,4 Bipolar disorder often continues into later life. About 1 in 4 people with bipolar disorder are 50 or older.¹¹ In a U.S. survey, about 7 in 1,000 adults age 60 and older had bipolar disorder in the past year.²

Most older adults with bipolar disorder have had it since they were young. A smaller group has a first mania later in life. Studies suggest about 5 to 10 in 100 people with bipolar disorder have their first manic episode at age 50 or older.¹⁰ This is sometimes called late-onset bipolar disorder.

Mania that starts late is more often tied to a problem in the brain or body. Compared with people who got sick young, people with late onset:^10,11

• More often have stroke, blood vessel disease in the brain or other brain conditions
• Less often have a family history of mood disorders
• More often have problems with memory and thinking, even between episodes

When mania is caused by another illness or a medicine, doctors call it secondary mania.⁹ In one study of 50 people over age 65 who were in the hospital for mania, about 7 in 10 also had a brain or nerve disorder. Among those having mania for the first time, most cases were tied to a brain illness or an infection. Stroke was the most common.⁹ Mania happens after roughly 1 in 100 strokes.⁹

Some medicines older adults often take can also set off mania. These include steroids, some antibiotics such as clarithromycin, some antidepressants and some Parkinson's medicines.^5,9

Signs that point to another cause

A doctor will look harder for a medical cause when:⁹

• The first manic episode happens late in life
• The person has never had mental health problems before
• The change starts suddenly, especially soon after a new medicine
• The person has had a stroke, other brain disease, or risks like high blood pressure
• There is confusion, memory loss or psychosis along with the mood change

What the check-up may include

A full workup for new mania in an older adult often includes:⁹

• A careful review of every medicine, including recent antibiotics and antidepressants
• Blood and urine tests, such as thyroid tests, blood counts, liver tests and a drug screen
• A brain scan (CT or MRI) to look for a stroke, tumor or bleeding. See brain scans.
• An EEG (a test of the brain's electrical activity) if seizures are a concern
• A memory and thinking test. See memory and thinking tests.

Doctors also need to tell mania apart from delirium (sudden confusion from an illness) and from dementia. Delirium comes on fast, and the person's alertness goes up and down. In dementia, memory problems usually come first and build slowly over time.⁹ Some dementias change personality and behavior. Read about frontotemporal dementia. See treatable conditions that look like dementia.

If a medicine or illness is the cause, treating it may clear the mania. People with secondary mania may not need long-term mood medicines.⁹ For more on this age group, read bipolar disorder in later life.

When to get help

See a doctor soon if you or someone close to you has mood swings that affect sleep, work, money or relationships. Bring notes about past "up" times, not only the lows. A mood chart can help.

If you are supporting a family member, see supporting someone with bipolar disorder. For the big picture, return to the bipolar disorder overview.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.