In December 1888, Vincent van Gogh lost his ear after an argument with Paul Gauguin. Whether he cut it off or it was the result of the altercation with his colleague is still debated. But what is certain is that days later, he was admitted to a psychiatric hospital.
In his letters to his brother Theo, he described periods of overflowing creative euphoria, followed by deep falls into despair, exhaustion, and emptiness. He would paint without sleeping for days on end and, shortly afterward, be unable to get out of bed.
Although the diagnosis did not exist at the time, one of the most thorough studies conducted to date concluded that these letters likely reflected the phases of bipolar disorder: moments of intense energy, racing thoughts, and extreme creativity that alternated with episodes of dejection, guilt, and severe psychological suffering.
This is the challenge faced by the approximately 37 million people living with bipolar disorder worldwide, according to recent WHO data. Understanding the phases of this disorder helps us grasp how extreme mood swings affect their daily lives.
The manic phase of bipolar disorder
During this phase, people experience a very positive mood, including increased self-esteem and a sense of uniqueness. They often overestimate their abilities and the quality of their ideas.
In that state, their judgment deteriorates, and they feel powerful because they are unable to objectively assess the consequences of their actions. They believe they are invincible or “bulletproof” and show very little remorse or concern for their actions.
During this phase, they often have many ideas and boundless energy to pursue them. In fact, it’s common for them to undertake several activities simultaneously, although they may not complete any of them. In some cases, they may only sleep two or three hours a day.
Obviously, for those around them, such a rapid pace of thought and hyperactivity is often difficult to manage. To begin with, a person with bipolar disorder often speaks too quickly and mixes up their ideas. In some cases, they might talk for hours without giving others a chance to participate. Essentially, their mind works so fast that others struggle to keep up and to organize their thoughts coherently.
As a result of this state of nervous hyperexcitation, daily behavior can become disorganized or even dangerous, to the point that some people require hospitalization.
In fact, psychotic symptoms can appear during manic episodes of bipolar disorder (psychosis is a state in which a person is unable to distinguish between reality and fantasy). In these cases, the person may experience hallucinations or believe they have special powers (for example, superhuman strength or X-ray vision). Psychotic symptoms indicate a severe mood episode that requires immediate attention, as it is a psychiatric emergency.
The depressive phase of bipolar disorder
The depressive phase of bipolar disorder is one of the most difficult times, both for the person experiencing it and for those around them. During these episodes, the person may stay in bed for much of the day, feeling unable to do anything.
The demotivation and lack of energy are so intense that even simple tasks like getting up, showering, or preparing food seem impossible. This often leads to progressive isolation, making it difficult to communicate and interact with family and friends.
During this phase of bipolar disorder, thoughts also slow down, and it becomes extremely difficult to concentrate or make decisions. Activities that were so engaging just days before completely lose their appeal. This anhedonia and abulia are not simply “laziness,” but rather a core symptom of bipolar depression that reflects a profound shift in brain chemistry and perception of the world.
Emotionally, the person may feel worthless or guilty. They often think their life lacks meaning. This hopelessness not only affects their self-esteem but also disrupts their relationships. Friends and family may feel helpless or frustrated at not being able to “cheer up” the affected person. This can lead to family conflicts or misunderstandings that ultimately deepen the isolation.
The person may begin to overeat and, given their low activity level, experience significant weight gain. Suicidal thoughts are also common, making emergency care crucial for their safety. As in a manic episode, psychotic symptoms with delusions and hallucinations may also occur, intensifying their suffering.
| MANIC PHASE | DEPRESSIVE PHASE | |
| MOOD | Euphoric, expansive, energetic | Sad, empty, hopeless |
| ACTIVITY LEVEL | Very high, hyperactivity | Very low, extreme fatigue |
| THOUGHT | In this accelerated environment, ideas jump out and mix together. | Slow, with difficulty concentrating |
| BEHAVIOR | Impulsive, risky, and intense | Minimal, withdrawn, and isolated |
| DREAM | He sleeps very little. | Hypersomnia |
| SELF-ESTEEM | Inflated with a sense of grandeur | Very low with a feeling of uselessness |
| PERCEPTION OF REALITY | Delusions and hallucinations may occur. | Delusions and hallucinations may occur in severe cases. |
| RISKS | Substance abuse and risky behaviors | Suicide and self-harm |
The mixed episode
A mixed episode is one of the most complex manifestations of bipolar disorder because it combines symptoms of both mania and depression. Instead of alternating between phases of euphoria and depression, the person may feel extremely agitated, irritable, or energetic while simultaneously experiencing hopelessness, profound sadness, or a sense of worthlessness.
This combination creates a feeling of internal chaos: the body and mind seem to go in opposite directions, making it extremely difficult to control emotions and make decisions.
During a mixed episode, a person may act impulsively , take unnecessary risks, or argue easily, while simultaneously feeling empty or depressed. This leads to a high level of emotional distress and increases the risk of self-harm or suicide attempts, as the energy of the manic phase amplifies the hopelessness of the depressive phase.
Furthermore, the intensity and contradictory nature of the symptoms often confuse both the affected person and those around them, hindering early detection and intervention. Frequently, people are hospitalized for their own safety and the safety of those around them, and they may require medication.
Rapid cycling in bipolar disorder
This term is used to describe the overall course of the illness over a 12-month period. A person with rapid-cycling bipolar disorder experiences four or more manic, hypomanic, depressive, or mixed episodes within a one-year period. As you might expect, rapid-cycling bipolar disorder is difficult to treat because the mood swings are more intense and frequent, and it generally responds less well to conventional medication.
Rapid-cycling bipolar disorder is more common in women, especially those with thyroid problems. One hypothesis is that a hormonal imbalance could mimic or intensify the symptoms of mania or depression, further complicating diagnosis and treatment.
It is estimated that between 5 and 43% of people with bipolar disorder will develop this rapid cycling pattern at some point in their lives. In addition to presenting a clinical challenge, rapid cycling has a significant impact on daily life: it causes emotional instability, affects relationships, and increases the risk of hospitalizations or complications associated with the disorder. Therefore, recognizing this pattern early and seeking treatment is crucial for improving the quality of life for those who experience it.
The seasonal pattern
This term describes mood disorders that appear to be linked to a specific season. For example, some people tend to become depressed during late fall and winter, and then regain a normal mood during spring and summer. This pattern suggests that environmental factors, such as the amount of sunlight, may influence the onset of depressive or manic episodes.
In bipolar disorder, the seasonal pattern means that mood episodes occur predominantly during a specific time of year, while the rest of the time the person maintains a stable mood. In other words, manic, hypomanic, or depressive episodes do not appear randomly, but rather recur cyclically according to the season, allowing for the recognition of a predictable pattern.
The most common pattern is depression during the fall and winter, when the days are shorter and there is less exposure to natural light. Less frequent, but also documented, is the spring/summer pattern, in which depressive episodes occur during the sunnier months.
This seasonal pattern has important implications: it not only helps anticipate and prevent episodes , but also affects suicide risk. Studies show that suicide rates increase particularly in March, April, and May, likely due to changes in daylight and the sudden surge of energy that can accompany the transition from a depressive episode to a more active or manic one.
Recognizing the seasonal pattern allows mental health professionals and the affected person to plan prevention strategies, adjust medication and therapies, and reduce the risks associated with seasonal changes, making the management of bipolar disorder more predictable and safe.
References:
Nolen, W. A. et. Al. (2020) New vision on the mental problems of Vincent van Gogh; results from a bottom-up approach using (semi-)structured diagnostic interviews. Int J Bipolar Disord; 8(1): 30.
Carvalho, A. F. et. al. (2014) Rapid cycling in bipolar disorder: a systematic review. J Clin Psychiatry; 75(6): e578-86.
Postolache, T. T. et. Al. (2010) Seasonal spring peaks of suicide in victims with and without prior history of hospitalization for mood disorders. J Affect Disord; 121(1-2): 88-93.
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