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Bipolar Disorder: Why It’s Often Misdiagnosed

And how behavioral treatment, along with medicine, improves outcomes

Writer: Caroline Miller

Clinical Expert: Jill Emanuele, PhD

en Español

Bipolar disorder is a mood disorder characterized by dramatic highs and lows — periods of depression alternating with mania, or extremely elevated mood.

Bipolar disorder is most often diagnosed in adolescence or early adulthood, though it can be diagnosed in childhood or in later adulthood. The mean age of onset is 18, and between 15 and 19 is the most common period of onset. But the disorder’s first signs are very often overlooked or mischaracterized. At the outset, bipolar symptoms are commonly mistaken for ADHD, depression, anxiety, borderline personality disorder and, in its more severe manifestations, as schizophrenia.

That’s because the first symptoms of this disorder are unusually varied. Only over time does the pattern of alternating high and low moods become clear, meaning that in many cases people with bipolar disorder are left waiting months, or even years, for an accurate diagnosis. And that waiting can have serious consequences, including treatment that’s not effective.

What does onset of bipolar disorder look like?

In some patients, the first sign of bipolar disorder is what appears to be a major depressive episode.  Others experience full-blown mania or hypomania — a less extreme form of mania. Still others experience a confusing combination of symptoms called a “mixed episode,” which has elements of both depression and mania.

Here is a closer look at what a first episode might look like:

Depression: When the first episode of bipolar disorder is depression, symptoms can develop slowly, reports Michael Strober, PhD, who is Distinguished Professor of Psychiatry, and Senior Consultant to the Youth Mood Disorders Treatment and Research Program at the David Geffen School of Medicine at UCLA. Bipolar depression usually includes not only the sadness or irritability we associate with depression, but delusions of failure, exaggerated feelings of guilt, mental confusion and profound physical slowness.

Despite these differences, Dr. Strober notes that symptoms of bipolar depression are often misdiagnosed as major depressive disorder early on, because alternating periods of mania (or hypomania) may not appear until months or years later.

Mania: Unlike the gradual descent into depression, when the initial episode is mania the onset can be “like a thunderclap,” says Wendy Nash, MD, a child and adolescent psychiatrist. An initial manic episode might be characterized by grandiose thinking, risk-taking, accelerated speech and thought, and euphoria or irritability.

It’s not unusual for the behavior to be so extreme that the patient ends up hospitalized — or even arrested. Dr. Nash gives an example of a college student who inexplicably shifts from normal behavior to overdrive: Suddenly they’re up all night, hyper-talkative, loud, and combative, maybe even getting into fights, acting so rashly and erratically that police are called.

In younger children, mania may be misinterpreted as the hyperactivity and impulsivity of ADHD.

Hypomania: Sometimes the initial episode of bipolar disorder is the less extreme form of mania called hypomania, and these episodes are often missed, Dr. Nash notes. The person may be talkative, grandiose, highly productive, a little moody and irritable, but the symptoms aren’t as disruptive or dangerous as in full-blown mania, and patients themselves don’t perceive themselves as disordered.

“Hypomania is trickier to diagnose,” adds Jill Emanuele, PhD, Senior Director of the Mood Disorders Center at the Child Mind Institute. “Adolescents with hypomania aren’t as flagrantly out of control as those with full-fledged mania, who can be dangerously impulsive and reckless.”

Mixed episode: Finally, some people with bipolar disorder experience what’s called a mixed episode, which includes characteristics of both depression and mania. In a mixed episode, a patient has a depressed mood but racing thoughts and speech, agitation, and anxious preoccupations — what one patient describes as being over-caffeinated and tired at the same time.

In a mixed episode, obsessive negative thoughts can be misdiagnosed as anxiety, notes Dr. Strober.

Psychosis: Some first episodes of either mania or depression can be so severe they include psychotic symptoms — breaks from reality such as hallucinations or delusions. When this happens, it can be misdiagnosed as schizophrenia.

How is bipolar disorder diagnosed?

A diagnosis of bipolar disorder is based on a detailed history that tracks changes in mood over time; as one expert puts it, think of it as a movie, not a snapshot.

“You need to get the timeline of mood shifts,” notes Dr. Emanuele, “and that takes a very careful diagnostic assessment.” Without treatment, bipolar episodes usually last from several weeks to several months. Periods in between episodes, without symptoms of either mania or depression, can last weeks, months or years.

Interviewing family members or friends can be important, since patients themselves may not recognize manic or hypomanic symptoms as harmful or disordered. Eliciting a family history is also important because bipolar disorder is more common in people who have first-degree relatives (a parent or sibling) with the disorder.

To determine whether elevated or depressed moods meet the criteria for bipolar disorder, a clinician looks for these criteria:

 Signs of mania:

  • Drastic personality changes
  • Excitability
  • Irritability
  • Inflated self-confidence
  • Extremely energetic
  • Grandiose/delusional thinking
  • Recklessness
  • Decreased need for sleep
  • Increased talkativeness
  • Racing thoughts
  • Scattered attention
  • Psychotic episodes, or breaks from reality

Signs of depression:

  • Depressed or irritable mood
  • Loss of interest or pleasure in things once enjoyed
  • Marked weight loss or gain
  • Decreased or increased need for sleep
  • Prolonged sadness
  • Restlessness
  • Lethargy
  • Fatigue
  • Feelings of hopelessness, helplessness, worthlessness
  • Excessive or inappropriate guilt
  • School avoidance
  • Avoids friends
  • Cloudy or indecisive thinking
  • Preoccupation with death, plans of suicide or an actual suicide attempt
  • Psychotic episodes — breaks from reality

These criteria describe the most severe form of the disorder, called bipolar I disorder. People may also be diagnosed with bipolar II disorder, in which less severe episodes of hypomania replace manic episodes.

One of the most concerning things about bipolar disorder is that the lifetime suicide risk is 15 times that of the general population. Factors which elevate this risk for individuals include the severity and persistence of depression and the presence of mixed episodes, which combine depressive symptoms and the activation of mania.


While medication has for many years been the first-line treatment for bipolar disorder, over the last several decades specialized forms of psychotherapy have been developed to work alongside medication. Research shows that the most effective treatment for bipolar disorder combines medication and psychotherapy.

Medication: The go-to treatment for bipolar disorder is usually a group of medications called mood stabilizers, including lithium and some drugs called anticonvulsants. Mood stabilizers are generally effective at treating manic symptoms and lowering the frequency and severity of both manic and depressive episodes. But the depression is tougher to treat than the mania, and antidepressants are sometimes added to treat bipolar depression. Given alone, antidepressants can trigger manic symptoms, so they need to be prescribed with great care.

Atypical antipsychotics are also used, especially in adolescents, Dr. Nash reports. While mood stabilizers are very effective in adults, she says, in adolescents an atypical antipsychotic is often more effective.

Many people with bipolar disorder take more than one medication and the drugs can have complex interactions, leading to significant side effects if they are not effectively monitored by an experienced clinician.

Therapy: Several forms of psychotherapy adapted for bipolar disorder have been shown to speed recovery from an acute episode of mania or depression, delay recurring episodes, decrease suicide attempts, and increase medication adherence.

“A major challenge to treatment is compliance with medication,” notes Dr. Emanuele, and psychotherapy increases compliance. It also helps people make changes in their lives to avoid triggering symptoms. “Psycho-education helps people manage their lives with the disorder, and psychotherapy helps them deal with thoughts and feelings.”

An NIMH-funded study of bipolar patients found that treatment with one of three psychotherapies along with medication “significantly enhance a person’s chances for recovering from depression and staying healthy over the long term.”

The three therapies are:

  • Family-focused therapy (FFT): FFT engages parents and other family members in keeping track of symptoms and improving communication and problem-solving in the home, to avoid spikes in family stress, which can lead to episodes.
  • Cognitive behavioral therapy (CBT): CBT focuses on helping the patient understand distortions in thinking and activity, and learn new ways of coping with the illness
  • Interpersonal and social rhythm therapy (IPSRT): IPSRT focuses on helping the patient stabilize daily routines and sleep/wake cycles, and solve key relationship problems, to avoid triggering an episode.

IPSRP, the most recent of these therapies, is based on the concept that a healthy person has regular social rhythms — when you get up, eat meals, go to school or work, see other people, sleep, etc. — and bipolar disorder may be caused by those rhythms being destabilized.

IPSRT focuses on helping patients reduce interpersonal stressors and disruptions to a stable lifestyle, in order to forestall new episodes of mania or depression. Patients learn to improve relationship skills and keep regular patterns of eating, socializing and sleeping.

While IPSRT was developed for adults, it has been adapted for adolescents and is especially suited to the latter, notes Ellen Frank, an expert in mood disorders treatment at the University of Pittsburgh who, with colleagues, developed the therapy. Adolescence is a particularly sensitive period for interpersonal turmoil, and adolescents are prone to chronic sleep deprivation and radical shifts in sleep patterns, she writes. “They often have very dysregulated sleep and social routines that would be especially harmful for a teenager with BD.”

Contrary to earlier thinking, research shows that the course of the disorder is no different whether it develops before or after age 18, Dr. Strober reports.

Bipolar disorder is a chronic disorder, but with a combination of medications, psychotherapy, stress-management, a regular schedule and early identification of symptoms, many people live very well with the diagnosis.

This article was last reviewed or updated on August 25, 2023.