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In severe cases, the individual may develop symptoms of psychosis, a condition also known as severe bipolar disorder with psychotic features. These symptoms include delusions and hallucinations.

A major depressive episode persists for at least two weeks, and may result in suicide if left untreated. The relatively low concordance between fraternal twins brought up together suggests that shared family environmental effects are limited, although the ability to detect them has been limited by small sample sizes.

The risk of bipolar disorder is nearly ten-fold higher in first degree-relatives of those affected with bipolar disorder when compared to the general population; similarly, the risk of major depressive disorder is three times higher in relatives of those with bipolar disorder when compared to the general population. The of reported stressful events in childhood is higher in those with an adult diagnosis of bipolar spectrum disorder compared to those without, particularly events stemming from a harsh environment rather than from the child's own behavior.

In adults with the condition, bipolar disorder is often accompanied by changes in cognitive processes and abilities.

There are several common childhood precursors seen in children who later receive a diagnosis of bipolar disorder; these disorders include mood abnormalities, full major depressive episodes, and attention deficit hyperactivity disorder ADHD. Since a diagnosis of bipolar disorder requires a manic or hypomanic episode, many affected individuals are initially misdiagnosed as having major depression and then incorrectly treated with prescribed antidepressants.

Associated features are clinical phenomena that often accompany the disorder but are not part of the diagnostic criteria.

A combination of bipolar I, II, and cyclothymia similarly produced rates of 42 percent and 11 percent identical and fraternal twins, respectivelywith a relatively lower ratio for bipolar II that likely reflects heterogeneity. There is overlap with major unipolar depression and if this is also counted in the co-twin the concordance with bipolar disorder rises to 67 percent in identical twins and 19 percent in fraternal twins. The decision has been broadly welcomed by CEOP, the UK organisation tasked with policing the online world for child abuse: "This is a landmark case [and] a good opportunity from a law enforcement point of view.

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