David Baxter PhD
Late Founder
Types of Bipolar Disorder
Bipolar Chick Blog
Sunday, March 15th, 2009
The bipolar classifications in this post are loosely paraphrased from the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) published by the American Psychiatric Association, research by the National Institute of Mental Health, and interviews with leading bipolar experts.
Bipolar I
This is the most severe type of bipolar disorder and the classic type. A diagnosis of Bipolar I requires at least one full-blown manic episode some time during a per-son?s life that doctors cannot attribute to another cause, such as a medication or substance abuse. The manic episode must last at least one week, or be serious enough to require hospitalization or cause functional impairment in some aspect of a person?s life (marriage, career, finances, etc.). Interestingly, a major depressive episode is not required to be diagnosed with this form of bipolar disorder, but it is almost always present and usually even much more common than the manic episodes.
Bipolar II
Most experts agree that there are versions of bipolar disorder that don?t produce full mania, yet respond very well to mood-stabilizing medications. People whose symptoms fit this category are often diagnosed with Bipolar II, sometimes called ?soft? bipolar. According to Dr. Ghaemi, the primary difference between Bipolar I and Bipolar II is that the manic symptoms of the latter are not severe enough to cause functional impairment.
?With Bipolar II, the sufferer won?t become so grandiose that he or she loses his job,? says Dr. Ghaemi. ?They will be much more active than normal, but they won?t have problems due to those activities.?
To be diagnosed with Bipolar II, a person must experience at least one major depressive episode that doctors can?t attribute to another cause and at least one episode of hypomania during his or her lifetime. People with Bipolar II never experience a full-blown manic episode. If they do, their diagnosis would likely be upgraded to Bipolar I. Again, usually there are many more depressive than hypomanic episodes.
Cyclothymic Disorder
Sometimes called ?bipolar lite,? this diagnosis requires multiple depressive and hypomanic episodes not extreme enough to warrant a diagnosis of Bipolar I or II. In some cases, depression and mania occur simultaneously, resulting in a state of chronic irritability. A person?s symptoms must last for at least two years with no more than two months of stable mood during that time. Some people with Cyclothymic disorder go on to develop a full-blown mixed or depressive episode, which usually leads doctors to upgrade their diagnosis to Bipolar I or II. Usually these symptoms are so mild that persons with this condition do not seek treatment. This variety can be seen as the personality manifestation of bipolar disorder in some people. If symptoms are severe enough to cause problems, then Cyclothymia usually is not the diagnosis, but rather type I or type II Bipolar Disorder.
Bipolar NOS (Not Otherwise Specified)
This form of bipolar requires manic or depressive episodes that doctors can?t categorize as unipolar depression. The episodes also can?t fit into any of the other bipolar categories. The Bipolar NOS label often applies in the following circumstances:
Rapid-Cycling
Rapid-cycling isn?t a separate type of bipolar disorder; it is a descriptor of the course of bp. It is more common in women than in men. To qualify as rapid-cycling, a person must experience four or more episodes (depression, mania, hypomania, or mixed state) in a year. The episodes must be full-blown and, in the case of mania or mixed state, last at least one week or result in hospitalization. A depression must last at least two weeks and a person?s hypomania must last at least four days. This term does NOT mean that one?s moods fluctuate on a day by day, or hour by hour basis. Such short-term mood shifts are common in mania and mixed episodes, and are not themselves diagnostic of anything.
Major Depressive Episode
To have a major depressive episode, a person must have five or more of the following symptoms that last for at least two weeks:
A manic episode isn?t ?official? unless it lasts for at least one week or requires hospitalization. The episode also must be characterized by an ?abnormally and persistently elevated, expansive, or irritable mood.? In order to qualify as a bona fide manic episode, the mania must be severe enough to cause harm to some aspect of a person?s life, such as their interpersonal relationships, job, or physical functioning. The mania also must not be substance-induced. Three of the following symptoms must also be present during the week; four if a person?s mood is irritable rather than euphoric.
Hypomanic Episode
Hypomania is a less-intense mania that doesn?t last as long as a full-blown mania and doesn?t cause significant problems with interpersonal relationships or one?s job. Hypomania may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. A person?s mood must be elevated above his or her normal state and display characteristics that others believe are slightly out of character for the person. The episode must last at least four days. Hypomania presents in two forms-euphoric and dysphoric-and can last for a few hours or several weeks. According to Jim Phelps, MD, an Oregon-based psychiatrist and author of Why Am I Still Depressed? Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorder, euphoric hypomania feels good and is sometimes productive, but dysphoric hypomania produces irritability, impulsiveness, uncontrollable temper, and impaired judgment. The hypomania frequently alternates with episodes of depression; it almost always accompanies mood instability.
Mixed Manic Episode
Mixed states are found in Bipolar I, Bipolar II, and Bipolar spectrum disorders. They are more common in women and are often associated with thyroid abnormalities, lack of response to lithium (the standard treatment for Bipolar I disorder), and antidepressant-induced worsening of symptoms. To qualify, an episode must simultaneously meet the requirements stipulated for a major depressive episode and a manic episode. A person?s symptoms must occur nearly every day for a week straight.
Diagnosis of mixed states is most likely to be made after a patient fails to respond to outpatient treatment, or becomes worse on antidepressant medications and is subsequently admitted to the hospital for closer observation. Misdiagnosis of these conditions is common, leading to delays in effective treatment and a higher risk of suicide. Thus, any depressed patient should be carefully assessed for manic symptoms too: they could be suffering from a mixed episode in disguise.
Psychosis
This can accompany depression or mania, but is not required to receive a bipolar diagnosis. Psychosis is marked by delusional thinking, paranoia, and visual or auditory hallucinations. It can accompany either an extremely high or extremely low mood episode. The extremes of depression and, more often, mania can shock the mind to such a degree that it begins to experience self-destructive or grandiose beliefs, becomes obsessed with fears that have no basis in reality, or sees or hears things that are not real. Although psychosis sounds dramatic and easily identifiable, it can be subtle and blended with enough reality to make ?psychotic? seem more like ?unusually perceptive.? It can include:
Some people with bipolar disorder become suicidal. Risk for suicide appears to be higher earlier in the course of the illness. Therefore, recognizing bipolar disorder early and learning how best to manage it may decrease the risk of death by suicide. Signs and symptoms that may accompany suicidal feelings include:
Bipolar Chick Blog
Sunday, March 15th, 2009
The bipolar classifications in this post are loosely paraphrased from the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) published by the American Psychiatric Association, research by the National Institute of Mental Health, and interviews with leading bipolar experts.
Bipolar I
This is the most severe type of bipolar disorder and the classic type. A diagnosis of Bipolar I requires at least one full-blown manic episode some time during a per-son?s life that doctors cannot attribute to another cause, such as a medication or substance abuse. The manic episode must last at least one week, or be serious enough to require hospitalization or cause functional impairment in some aspect of a person?s life (marriage, career, finances, etc.). Interestingly, a major depressive episode is not required to be diagnosed with this form of bipolar disorder, but it is almost always present and usually even much more common than the manic episodes.
Bipolar II
Most experts agree that there are versions of bipolar disorder that don?t produce full mania, yet respond very well to mood-stabilizing medications. People whose symptoms fit this category are often diagnosed with Bipolar II, sometimes called ?soft? bipolar. According to Dr. Ghaemi, the primary difference between Bipolar I and Bipolar II is that the manic symptoms of the latter are not severe enough to cause functional impairment.
?With Bipolar II, the sufferer won?t become so grandiose that he or she loses his job,? says Dr. Ghaemi. ?They will be much more active than normal, but they won?t have problems due to those activities.?
To be diagnosed with Bipolar II, a person must experience at least one major depressive episode that doctors can?t attribute to another cause and at least one episode of hypomania during his or her lifetime. People with Bipolar II never experience a full-blown manic episode. If they do, their diagnosis would likely be upgraded to Bipolar I. Again, usually there are many more depressive than hypomanic episodes.
Cyclothymic Disorder
Sometimes called ?bipolar lite,? this diagnosis requires multiple depressive and hypomanic episodes not extreme enough to warrant a diagnosis of Bipolar I or II. In some cases, depression and mania occur simultaneously, resulting in a state of chronic irritability. A person?s symptoms must last for at least two years with no more than two months of stable mood during that time. Some people with Cyclothymic disorder go on to develop a full-blown mixed or depressive episode, which usually leads doctors to upgrade their diagnosis to Bipolar I or II. Usually these symptoms are so mild that persons with this condition do not seek treatment. This variety can be seen as the personality manifestation of bipolar disorder in some people. If symptoms are severe enough to cause problems, then Cyclothymia usually is not the diagnosis, but rather type I or type II Bipolar Disorder.
Bipolar NOS (Not Otherwise Specified)
This form of bipolar requires manic or depressive episodes that doctors can?t categorize as unipolar depression. The episodes also can?t fit into any of the other bipolar categories. The Bipolar NOS label often applies in the following circumstances:
- Rapid mood fluctuations intense enough to qualify as manic, hypomanic, or depressive, but that don?t meet the duration requirements for a Bipolar I, Bipolar II, or Cyclothymic disorder diagnosis
- Hypomania without depression
- Mania or Cyclothymic disorder that occurs simultaneously with schizophrenia, psychotic disorder NOS, or delusional disorder (a disorder characterized by psychoses, hallucinations, and delusional thinking)
- Chronic depression or dysthymia (long-term, low-level depression) accompanied by hypomanic episodes.
Rapid-Cycling
Rapid-cycling isn?t a separate type of bipolar disorder; it is a descriptor of the course of bp. It is more common in women than in men. To qualify as rapid-cycling, a person must experience four or more episodes (depression, mania, hypomania, or mixed state) in a year. The episodes must be full-blown and, in the case of mania or mixed state, last at least one week or result in hospitalization. A depression must last at least two weeks and a person?s hypomania must last at least four days. This term does NOT mean that one?s moods fluctuate on a day by day, or hour by hour basis. Such short-term mood shifts are common in mania and mixed episodes, and are not themselves diagnostic of anything.
Major Depressive Episode
To have a major depressive episode, a person must have five or more of the following symptoms that last for at least two weeks:
- Depressed mood-feeling hopeless, sad, discouraged, or empty
- Markedly diminished interest in activities previously considered pleasurable, including sex
- A decrease or increase in appetite that lasts for two weeks
- Sleeping too much or too little
- Moving uncharacteristically slowly, both in mind and body
- Fatigue
- Feelings of worthlessness, excessive guilt, or inappropriate guilt
- Uncharacteristic indecisiveness or diminished ability to think clearly or concentrate on a given task
- Recurrent thoughts of death or suicide.
- Something terrible happened before a person became depressed, such as the death of a loved one, a divorce, or a job loss. (In other words, the person has a good reason to feel depressed.)
- A person is dealing with substance abuse, such as heavy drinking.
- The depression is a component of a mixed episode.
A manic episode isn?t ?official? unless it lasts for at least one week or requires hospitalization. The episode also must be characterized by an ?abnormally and persistently elevated, expansive, or irritable mood.? In order to qualify as a bona fide manic episode, the mania must be severe enough to cause harm to some aspect of a person?s life, such as their interpersonal relationships, job, or physical functioning. The mania also must not be substance-induced. Three of the following symptoms must also be present during the week; four if a person?s mood is irritable rather than euphoric.
- Euphoric mood, feeling ?high,? or excessively optimistic
- Inflated self-importance or grandiosity
- Extreme irritability, exhibiting behavior that is aggressive, provocative, or intrusive
- Decreased need for sleep (feeling well-rested after just a few hours of sleep)
- Extremely talkative and sociable, pressure to keep talking
- Increased activity
- Racing thoughts
- Inability to concentrate
- Easily distracted by insignificant external stimuli
- Significant increase in goal-directed activity or significant speeding up of thoughts and physical movement (such as planning to remodel the kitchen in less than a week, or moving on a whim to Nashville to become a country singer)
- Excessive involvement in risky, potentially self-destructive activities, including sexual indiscretions, gambling, unrestrained shopping sprees, and investments in pyramid schemes
- Impaired judgment, i.e., no perception that the mood and behaviors are abnormal.
Hypomanic Episode
Hypomania is a less-intense mania that doesn?t last as long as a full-blown mania and doesn?t cause significant problems with interpersonal relationships or one?s job. Hypomania may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. A person?s mood must be elevated above his or her normal state and display characteristics that others believe are slightly out of character for the person. The episode must last at least four days. Hypomania presents in two forms-euphoric and dysphoric-and can last for a few hours or several weeks. According to Jim Phelps, MD, an Oregon-based psychiatrist and author of Why Am I Still Depressed? Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorder, euphoric hypomania feels good and is sometimes productive, but dysphoric hypomania produces irritability, impulsiveness, uncontrollable temper, and impaired judgment. The hypomania frequently alternates with episodes of depression; it almost always accompanies mood instability.
Mixed Manic Episode
Mixed states are found in Bipolar I, Bipolar II, and Bipolar spectrum disorders. They are more common in women and are often associated with thyroid abnormalities, lack of response to lithium (the standard treatment for Bipolar I disorder), and antidepressant-induced worsening of symptoms. To qualify, an episode must simultaneously meet the requirements stipulated for a major depressive episode and a manic episode. A person?s symptoms must occur nearly every day for a week straight.
Diagnosis of mixed states is most likely to be made after a patient fails to respond to outpatient treatment, or becomes worse on antidepressant medications and is subsequently admitted to the hospital for closer observation. Misdiagnosis of these conditions is common, leading to delays in effective treatment and a higher risk of suicide. Thus, any depressed patient should be carefully assessed for manic symptoms too: they could be suffering from a mixed episode in disguise.
Psychosis
This can accompany depression or mania, but is not required to receive a bipolar diagnosis. Psychosis is marked by delusional thinking, paranoia, and visual or auditory hallucinations. It can accompany either an extremely high or extremely low mood episode. The extremes of depression and, more often, mania can shock the mind to such a degree that it begins to experience self-destructive or grandiose beliefs, becomes obsessed with fears that have no basis in reality, or sees or hears things that are not real. Although psychosis sounds dramatic and easily identifiable, it can be subtle and blended with enough reality to make ?psychotic? seem more like ?unusually perceptive.? It can include:
- A person thinks he or she has special powers.
- They hear voices that other people can?t.
- They believe that people can read their mind.
- They think that the television or radio is sending them special messages.
- They believe people are following them or trying to harm them when they?re not.
- They believe that they can accomplish things that they can?t.
- They believe they are someone they are not-like God or a famous person in history.
Some people with bipolar disorder become suicidal. Risk for suicide appears to be higher earlier in the course of the illness. Therefore, recognizing bipolar disorder early and learning how best to manage it may decrease the risk of death by suicide. Signs and symptoms that may accompany suicidal feelings include:
- Talking about feeling suicidal or wanting to die
- Feeling hopeless, believing that nothing will ever change or get better
- Feeling helpless, believing that nothing one does makes any difference
- Feeling like a burden to family and friends
- Abusing alcohol or drugs
- Putting affairs in order (such as organizing finances or giving away possessions to prepare for one?s death)
- Writing a suicide note
- Putting oneself in harm?s way, or in situations where there is a danger of being killed.
I've never understood that it was part of bipolar disorder. 
