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Bipolar disorder can be severe and long-term or it can be mild with infrequent episodes. On the average, the individual with bipolar disorder has approximately four episodes of mania and/or depression within the 10 years following the first episode or 8-10 manic or depressive episodes over a lifetime, but some may experience more. As an individual with bipolar disorder becomes older, episodes occur with increasing frequency and greater severity unless properly treated.

There is wide variability regarding type of first episode which can take the form of depression, mania or a mixed episode. Although depression is most likely to be the first episode, men are more likely than women to experience mania as the first episode. Some people experience several episodes of depression before their first manic episode. Although as many as 4 years can separate the first episode from the second, subsequent episodes are likely to occur with shorter intervals between them.

Episodes can last weeks or months. It is estimated that depressive states can last for over 6 months while manic states usually do not last as long. Many people recover completely between episodes but some experience residual low-grade depression or mild fluctuations of emotion. Between episodes, most people are symptom free although as many as 33% of individuals with bipolar experience some residual or low-level symptoms of mania or depression. There are a small number of people who do not experience any relief from symptoms despite treatment.

If a person with bipolar does not seek treatment, episodes usually become more frequent and may lead to rapid cycling. Hypomania can develop into severe mania or can switch to depression. This reduces the individual's ability to function and increases the risk for violence, psychosis (hallucinations, delusions) and suicide. Death from cardiovascular and pulmonary disorders is also high among people who do not receive treatment.

Bipolar patients who experience mania exhibit behavior that can be erratic and irrational. Frenetic energy levels cause the bipolar patient to participate in activities that can cause significant harm and have long term consequences (e.g., damaging relations with family and friends, or jeopardizing or losing a job). Some of these behaviors include:

• Poor judgment
• Excessive spending sprees
• Long periods of uncharacteristic behavior
• Committing sexual indiscretions
• Abuse of drugs, especially alcohol, cocaine, and sleep medications
• Provocative or aggressive behavior
• Denial that anything is wrong

Additional comorbidities that can cause harm to the bipolar patient include:

• Anorexia and/or bulimia
• Attention deficit with hyperactivity disorder (ADHD)
• Anxiety disorders
• Social phobias
• Obsessive-compulsive disorder (OCD)
• Substance abuse
• Abnormal thyroid hormone levels

Psychosis, defined as a mental state in which the perception of reality is distorted, is sometimes present in severe episodes of either depression or mania.

• Hallucinations - hearing, seeing or sensing the presence of things not actually present
• Delusions - false, strongly held beliefs that are not modified by logic, such as delusions of grandiosity and/or delusions of guilt and worthlessness.

The American Psychiatric Association notes that psychosis occurs in more than 50% of manic episodes and that up to 30% of patients experience catatonia (mutism, motor excitement) during mania.