David Baxter PhD
Late Founder
Bipolar I and Its Smaller Sibling: Distinctions between I and II
by Russ Federman, Ph.D.
February 18, 2010
The Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association is the manual guiding all psychiatric diagnosis in the United States and around the world. When DSM III transitioned to DSM IV in 1994, manic depression became bipolar disorder and the disorder became further defined into category I and category II.
To meet criteria for Bipolar I an individual must have had a major depressive episode plus manic symptoms which have lasted one week, or any duration if severe enough to require hospitalization. Most readers are familiar with acute symptoms of depression: very low energy, low self-worth, low motivation, suicidal thoughts, etc. But what about mania? Mania represents a set of distinct symptoms many of which often occur together. These are: elevated, expansive or irritable mood, inflated self-esteem, increased physical energy, decreased need for sleep, racing ideas, rapid speech, distractibility, intensification of goal directed behavior and excessive involvement in pleasurable activity that has high potential for negative consequences (spending sprees, sexual indiscretions, etc.). Within the wide range of behaviors just listed some aren't that unusual and in fact may be experienced by anyone from time to time.
But what truly places behavior in the realm of "mania" is the following description from DSM IV: "The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in social activities or relationships with others or to necessitate hospitalization... (Am. Psychiatric Assoc., 1994)." Essentially, as a function of mental activity that is so accelerated and/or agitated the individual no longer has the capacity to exercise good judgment, plan effectively and withstand impulsive action. The individual in the midst of mania is truly out of control.
The smaller sibling of Bipolar I disorder is Bipolar II. The list of symptoms for II are the same as I, though they need be present for only 4 days instead of a week. But in contrast to Bipolar I, "the episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization (Am. Psychiatric Assoc., 1994)." The symptoms are referred to as "hypomanic" or below manic.
What's important to recognize is that these are not distinctly different entities. Instead they represent two different ranges of intensity on the continuum of mood. With greater acuity and accompanying dysfunction we see more serious mental illness. With milder symptoms we still see mood variability but the individual's overall functioning usually remains intact.
Generally speaking the milder symptoms of Bipolar II provide a better prognosis for longer-term stability. If the bipolar roller coaster provides a milder ride during the first several years after the diagnosis is made then the longer-term ride may indeed turn out to be smoother. Conversely if there are steep highs and lows within the first several years of the disorder, then the longer-term prognosis is not good. The ride may never smooth out; or if it does, it may not remain that way for long.
So is it a safe assumption that those with Bipolar II can be more relaxed with their treatment and their continued efforts to maintain stability? Unfortunately, no. You see sometimes Bipolar II can be a precursor of Bipolar I with hypomania representing an early phase of what will eventually become Bipolar I.
Let's consider an analogy from the earth sciences: sometimes an active volcano will vent smoke and ash without an accompanying volcanic eruption. In fact, the venting may actually lessen the likelihood of an eruption because underground pressure is being released. But, there are also times when venting can herald the approach of a full eruption. It's more of an indication that a big blow is brewing. Same with bipolar. During the early years of the disorder, there's no way of easily discerning Bipolar II symptoms which don't escalate from those that will progress to Bipolar I. However, if over the course of the next 10 years one's hypomania has not transitioned to full mania, then we could more safely conclude that a full eruption is unlikely.
Bottom line: Individuals with Bipolar II should do everything in their power to protect against a more substantial eruption. Putting an active volcano back to sleep is no small undertaking.
Russ Federman is co-author of Facing Bipolar: The Young Adult?s Guide to Dealing with Bipolar (New Harbinger Publications). See also Bipolar Young Adult: Facing Bipolar | Russ Federman & Andy Thomson.
by Russ Federman, Ph.D.
February 18, 2010
The Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association is the manual guiding all psychiatric diagnosis in the United States and around the world. When DSM III transitioned to DSM IV in 1994, manic depression became bipolar disorder and the disorder became further defined into category I and category II.
To meet criteria for Bipolar I an individual must have had a major depressive episode plus manic symptoms which have lasted one week, or any duration if severe enough to require hospitalization. Most readers are familiar with acute symptoms of depression: very low energy, low self-worth, low motivation, suicidal thoughts, etc. But what about mania? Mania represents a set of distinct symptoms many of which often occur together. These are: elevated, expansive or irritable mood, inflated self-esteem, increased physical energy, decreased need for sleep, racing ideas, rapid speech, distractibility, intensification of goal directed behavior and excessive involvement in pleasurable activity that has high potential for negative consequences (spending sprees, sexual indiscretions, etc.). Within the wide range of behaviors just listed some aren't that unusual and in fact may be experienced by anyone from time to time.
But what truly places behavior in the realm of "mania" is the following description from DSM IV: "The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in social activities or relationships with others or to necessitate hospitalization... (Am. Psychiatric Assoc., 1994)." Essentially, as a function of mental activity that is so accelerated and/or agitated the individual no longer has the capacity to exercise good judgment, plan effectively and withstand impulsive action. The individual in the midst of mania is truly out of control.
The smaller sibling of Bipolar I disorder is Bipolar II. The list of symptoms for II are the same as I, though they need be present for only 4 days instead of a week. But in contrast to Bipolar I, "the episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization (Am. Psychiatric Assoc., 1994)." The symptoms are referred to as "hypomanic" or below manic.
What's important to recognize is that these are not distinctly different entities. Instead they represent two different ranges of intensity on the continuum of mood. With greater acuity and accompanying dysfunction we see more serious mental illness. With milder symptoms we still see mood variability but the individual's overall functioning usually remains intact.
Generally speaking the milder symptoms of Bipolar II provide a better prognosis for longer-term stability. If the bipolar roller coaster provides a milder ride during the first several years after the diagnosis is made then the longer-term ride may indeed turn out to be smoother. Conversely if there are steep highs and lows within the first several years of the disorder, then the longer-term prognosis is not good. The ride may never smooth out; or if it does, it may not remain that way for long.
So is it a safe assumption that those with Bipolar II can be more relaxed with their treatment and their continued efforts to maintain stability? Unfortunately, no. You see sometimes Bipolar II can be a precursor of Bipolar I with hypomania representing an early phase of what will eventually become Bipolar I.
Let's consider an analogy from the earth sciences: sometimes an active volcano will vent smoke and ash without an accompanying volcanic eruption. In fact, the venting may actually lessen the likelihood of an eruption because underground pressure is being released. But, there are also times when venting can herald the approach of a full eruption. It's more of an indication that a big blow is brewing. Same with bipolar. During the early years of the disorder, there's no way of easily discerning Bipolar II symptoms which don't escalate from those that will progress to Bipolar I. However, if over the course of the next 10 years one's hypomania has not transitioned to full mania, then we could more safely conclude that a full eruption is unlikely.
Bottom line: Individuals with Bipolar II should do everything in their power to protect against a more substantial eruption. Putting an active volcano back to sleep is no small undertaking.
Russ Federman is co-author of Facing Bipolar: The Young Adult?s Guide to Dealing with Bipolar (New Harbinger Publications). See also Bipolar Young Adult: Facing Bipolar | Russ Federman & Andy Thomson.
