With Current Severity

Nerdyssey October 28, 2025

🧠 Overview

“Current Severity” in Bipolar I Disorder refers to assessing how severe the patient’s current mood episode is—whether Manic or Depressive—and classifying it as Mild, Moderate, or Severe (if Psychotic Features are present, it is classified as Severe automatically). Stating the severity level directly guides treatment planning and prognosis.

Assessment of Current Severity considers the number of symptoms, their intensity, and the impact on functioning or safety. For example, someone who can still work to some extent may be Moderate, whereas someone who has lost control or is at risk of harm is Severe.

This severity level helps clinicians (1) assess risk of harm to self/others, (2) set the level of care (e.g., outpatient vs. hospitalization), and (3) track clinical progress over time.

It is also a standard metric in research, health insurance, and psychiatric follow-up systems, because it aligns communication across providers and accurately reflects overall illness course.

🧩 Core Symptoms

The core picture of Bipolar I Disorder alternates between Manic Episodes (elevated/irritable energy) and Depressive Episodes. The Current Severity depends on the number of symptoms, the intensity of mood changes, and the real-world impact on functioning or safety.

⚡ Manic Episode (elevated/expansive energy)

A state in which dopamine and norepinephrine surge abnormally, producing an expansive mood and excess energy. Patients often feel “on top of the world” or “in total control,” along with impulsive behaviors that can cause real harm.
Key feature: abnormally elevated or irritable mood for at least 1 week (or shorter if hospitalization is required).
At least 3 accompanying symptoms (or 4 if irritability predominates):

  • Pressured, nonstop, or intrusive speech
  • Racing thoughts (“brain racing”)
  • Decreased need for sleep without fatigue
  • Inflated self-esteem or grandiosity
  • Distractibility
  • Risky behaviors (e.g., overspending, irrational investments, disinhibited sexual behavior)

Result: loss of social inhibition, impaired judgment, and potential danger to life or property.

🌑 Depressive Episode (low mood/energy)

The other pole is markedly low mood and depleted energy, often following a manic episode. Sadness or a sense of “feeling nothing” predominates for at least 2 weeks.
At least 5 DSM-5 symptoms such as:

  • Hypersomnia or insomnia
  • Loss of appetite or overeating
  • Fatigue, loss of motivation
  • Feelings of worthlessness, guilt, or hopelessness
  • Poor concentration, psychomotor retardation or agitation
  • Suicidal ideation or attempts

Depressive episodes frequently cause loss of work capacity, social withdrawal, and in some cases, serious self-harm thoughts.

Manic and Depressive episodes may alternate, or Mixed Features can occur, which complicates emotion regulation and behavior even further.

🧾 Diagnostic Criteria (diagnosis and severity assessment)

1️⃣ Bipolar I Disorder requires at least one Manic Episode in a lifetime.
A Depressive Episode is not required (though most patients experience both poles over time).

2️⃣ Specify the Current or Most Recent Episode as:

  • Manic
  • Depressed
  • (Mixed if both poles’ symptoms clearly co-occur)

3️⃣ Rate Current Severity for the current episode as:

  • Mild: symptoms just meet threshold; some control remains
  • Moderate: more pronounced symptoms with partial role impairment
  • Severe: intense symptoms, marked functional loss, safety risk, and/or Psychotic Features

4️⃣ If Psychotic Features (delusions or hallucinations) are present, classify as Severe automatically, regardless of other counts.

5️⃣ You can add other Specifiers, e.g.:

6️⃣ Assess severity using the combined view of symptom counts, functional impact, and safety risk.

7️⃣ Use standard rating scales—YMRS (Young Mania Rating Scale) for mania; HDRS/MADRS for depression—to ensure consistent measurement and long-term tracking.

Subtypes or Specifiers (used alongside “Current Severity”)

Used to profile the current episode more precisely to guide treatment and prognosis.

For the current episode

  • With Mixed Features: manic/depressive episode with prominent opposite-pole symptoms (like hitting accelerator and brake at once)
  • With Catatonia: marked motor/behavioral abnormalities (stupor, posturing, mutism)
  • In Partial/Full Remission: prior episode currently partly/fully remitted (applies to “most recent episode”)

Severity levels (Current Severity)

  • Mild: symptoms just meet threshold; low intensity; minimal functional impact
  • Moderate: symptoms/impact moderate; some work/school/self-care possible
  • Severe: intense symptoms; clear occupational/social impairment; safety risk; or Psychotic Features

🧬 Brain & Neurobiology

Brain structure and neurochemistry in Bipolar I Disorder show imbalances across systems that regulate mood, energy, and motivation, directly linked to Current Severity.

A key hub is the frontolimbic circuit—the prefrontal cortex (control/inhibition) and amygdala + ventral striatum (emotion/reward). When this balance fails, mood becomes excessively accelerated or braked.

  • Mania: a hyperdopaminergic state—excess dopamine → racing thoughts, risk seeking, abnormally high energy, with reduced prefrontal inhibition.
  • Depression: reduced dopamine/reward activity → anhedonia, low drive.

Major neurotransmitters:

  • Dopamine ↑ in mania
  • Glutamate ↑ / GABA ↓ → over-excitation
  • Serotonin ↓ in depression → impaired mood regulation

The circadian–sleep system is crucial: sleep loss or abrupt sleep-schedule shifts can directly trigger mania.

HPA axis dysregulation and chronic low-grade inflammation correlate with episode frequency and severity; patients often show higher cortisol and inflammatory markers than controls.

Structurally/connection-wise, differences in ACC, OFC, amygdala, and hippocampus—key regions for emotion control, memory, and salience—track with more severe episode expressions.

🧩 Causes & Risk Factors

Bipolar I arises from interactions among genetics, brain biology, hormones, and environment, all of which can amplify or attenuate Current Severity.

1️⃣ Genetics: risk increases 10–20× with first-degree relatives. Genes in dopamine/serotonin signaling (e.g., CACNA1C, ANK3) contribute to abnormal neuronal signaling.

2️⃣ Life stage & hormones: peripartum shifts, sleep deprivation, shift work, and seasonal changes can precipitate mania or depression.

3️⃣ Major life stressors: losses, relationship breakdown, financial strain can trigger episodes—especially in stress-sensitive brains.

4️⃣ Substances & medications: alcohol, stimulants, corticosteroids, and antidepressants without a mood stabilizer can induce mania.

5️⃣ Comorbid medical/psychiatric conditions: thyroid disorders, anxiety, PTSD, ADHD can increase episode frequency and slow response to treatment.

6️⃣ Dysregulated lifestyle: irregular sleep–wake times, chronic overwork, neglect of routines disrupt the circadian system, prolonging and intensifying episodes.

Overall, while Bipolar I has strong biological roots, Current Severity is shaped by lifestyle and stress-management—hence the central importance of sleep and rhythm care in long-term management.

Treatment & Management (linking “Current Severity” to care)

Principles by severity

  • Mild–Moderate (no psychosis, low risk): Outpatient care + standard pharmacologic adjustments + rhythm/schedule interventions and psychotherapy
  • Moderate–Severe or psychosis/high risk/marked decisional impairment: consider hospitalization, combination pharmacotherapy, close monitoring
  • Severe-resistant / catatonia / high suicidality: consider ECT per indications

Medications (main classes)

  • Mood stabilizers: Lithium (suicide risk reduction, long-term prevention), Valproate, Carbamazepine, Lamotrigine (strong for depression/prevention)
  • Atypical antipsychotics (mania; some also for depression): Quetiapine, Olanzapine, Risperidone, Aripiprazole, Ziprasidone, Asenapine, Lurasidone, Cariprazine
  • Benzodiazepines: short-term adjunct for acute agitation/insomnia
  • Bipolar Depression: Quetiapine, Lurasidone, Lamotrigine, Lithium; avoid antidepressant monotherapy (risk of switch to mania)
  • Catatonia: Lorazepam responsive; ECT if inadequate response

While on medication: monitor side effects and labs (e.g., lithium—renal/thyroid; valproate—liver/platelets; antipsychotics—metabolic syndrome).

Psychotherapy & behavior

  • Psychoeducation (illness model, early-warning signs, action plans)
  • CBT, IPSRT (social/circadian rhythm therapy), Family-Focused Therapy
  • Lifestyle: regular sleep–wake schedule, avoid caffeine/substances, appropriate exercise, balanced nutrition
  • Safety plan: suicide-prevention planning; train close contacts for warning signs
  • Pregnancy/lactation: coordinated perinatal–psychiatric medication planning

Examples of matching care to severity

  • Mild mania: lithium/valproate monotherapy or single antipsychotic + restore sleep + remove triggers
  • Moderate mania: mood stabilizer + antipsychotic; consider admission as needed
  • Severe mania/psychosis: therapeutic-dose antipsychotic + mood stabilizer; consider admission/ECT
  • Mild–Moderate depression: quetiapine/lamotrigine/lithium; psychotherapy alongside
  • Severe depression/high risk: escalate care intensity, appropriate antipsychotic adjuncts, ECT if treatment-resistant

Notes (practical tips for rating “Current Severity”)

  • Use three axes: (1) symptom count/intensity, (2) role functioning (work/school/family/self-care), (3) safety (debt/risk/self- or other-harm).
  • Any psychosis ⇒ Severe.
  • Apply standardized scales: YMRS (mania), HDRS/MADRS (depression), CGI-BP (global) at repeated intervals to track trends.
  • Record any specifiers (e.g., Mixed/Anxious/Catatonia), as they influence medication choices and prognosis.
  • Prioritize sleep: a sensitive, modifiable lever (sleep hygiene/IPSRT).
  • Prepare a relapse plan: personal warning signs, emergency contacts, safe medication-adjustment steps.
  • Use shared decision-making: explain benefits/risks of each option.

📚 References

American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.
Goodwin FK, Jamison KR. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression. 3rd ed. Oxford University Press; 2021.
Yatham LN, Kennedy SH, Parikh SV, et al. CANMAT and ISBD 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders. 2018;20(2):97-170.
National Institute for Health and Care Excellence (NICE). Bipolar disorder: assessment and management (CG185). London: NICE; updated 2020.
Grande I, Berk M, Birmaher B, Vieta E. Bipolar disorder. The Lancet. 2016;387(10027):1561-1572.
Phillips ML, Swartz HA. A critical appraisal of neuroimaging studies of bipolar disorder. Am J Psychiatry. 2014;171(8):829-843.
Stahl EA, et al. GWAS identifies 30 loci associated with bipolar disorder. Nature Genetics. 2019;51(5):793-803.
McCarthy MJ, et al. Sleep/circadian disruption in bipolar disorder: neurobiology and treatment implications. Transl Psychiatry. 2022;12(1):24.
Geddes JR, Miklowitz DJ. Treatment of bipolar disorder. Lancet. 2013;381(9878):1672-1682.
Post RM, et al. Neurobiology of the bipolar spectrum. Mol Psychiatry. 2021;26(1):350-365.

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