Symptoms of the depressive phase are similar to those of unipolar depression (see above), except that psychomotor retardation, hypersomnia, and, in extreme cases, stupor are more characteristic.
In full-blown manic psychosis, the mood is usually elation, but irritability and frank hostility with cantankerousness are not uncommon. Typically, manic patients are exuberant and flamboyantly or colorfully dressed; they have an authoritative manner with a rapid, unstoppable flow of speech. They tend to believe they are in their best mental state. Their lack of insight and their inordinate capacity for activity can lead to a dangerously explosive psychotic state. Interpersonal friction results and may lead to paranoid delusions that they are being unjustly treated or persecuted.
Accelerated mental activity is experienced as racing thoughts by the patient, is observed as flights of ideas by the physician, and, in its extreme form, is difficult to distinguish from the loose associations of the schizophrenic. Easily distracted, patients may constantly shift from one theme or endeavor to another. Thoughts and activities are expansive and may progress into frank delusional grandiosity (ie, false conviction of personal wealth, power, inventiveness, and genius or temporary assumption of a grandiose identity). Some patients believe they are being assisted by external agents. Auditory and visual hallucinations sometimes occur. The need for sleep is decreased. Manic patients are inexhaustibly, excessively, and impulsively involved in various activities without recognizing the inherent social dangers. In the extreme, psychomotor activity is so frenzied that any understandable link between mood and behavior is lost; this senseless agitation is known as delirious mania, which is the counterpart of depressive stupor. Rarely seen in psychiatric practice today, delirious mania constitutes a medical emergency, because patients may die from sheer physical exhaustion.
Mixed states are blends of depressive and manic (or hypomanic) manifestations and distinguish bipolar disorders from their unipolar counterparts. The most typical examples include momentary switches to tearfulness during the height of mania or racing thoughts during a depressive period. In at least 1/3 of persons with bipolar disorders, the entire attack—or a succession of attacks—occurs as a mixed episode. A common presentation consists of a dysphorically excited mood, crying, curtailed sleep, racing thoughts, grandiosity, psychomotor restlessness, suicidal ideation, persecutory delusions, auditory hallucinations, indecisiveness, and confusion. This presentation is referred to as dysphoric mania, ie, prominent depressive symptoms superimposed on manic psychosis. Dysphoric mania often develops in women and in persons with a depressive temperament. Alcohol and sedative-hypnotic abuse contributes to the development or aggravation of mixed states.
Depressive mixed states, which are not specifically characterized in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, are best regarded as intrusions of hypomanic symptoms or hyperthymic traits into a retarded major depressive episode. Antidepressant drugs may aggravate these states by producing a subacute irritable depressive state that lasts many months. The clinical picture consists of irritability, pressure of speech against a background of retardation, extreme fatigue, guilty ruminations, free-floating anxiety, panic attacks, intractable insomnia, increased libido, histrionic appearance yet genuine expressions of depressive suffering, and, in the extreme, suicidal obsessions and impulses. Patients with a depressive mixed state and those with dysphoric mania are at high risk of suicide and require expert clinical management.
Mortality from cardiovascular causes is modestly increased in patients with bipolar disorder; the increase is not explained by cardiotoxicity from lithium or tricyclic antidepressants and tends to also occur in first-degree biologic relatives who do not have frank affective episodes. The increase is probably related to comorbid hypertension, diabetes, and coronary artery disease, all of which are aggravated by nicotine and alcohol dependence, which are prevalent in patients with bipolar disorder.