What is the official definition of Bipolar II?

Hypomania

Technically, this is literally a “little” mania — the familiar symptoms but less so:
•Mood much better than normal
•Rapid speech
•Little need for sleep
•Racing thoughts, trouble concentrating
•Continuous high energy
•Overconfidence

You may have noticed that “delusions” have disappeared from the list: these are by definition not found in Bipolar II. A patient who has had the above symptoms repeatedly, without having delusions, is much less likely to ever lose contact with reality (including weird experiences like auditory hallucinations, which are common in bipolar mania) than a patient who has experienced delusions.

“Bipolar II” is technically the combination of hypomanic phases with separate phases of severe depression If the depressive phases are only mild, the term “cyclothymia” is used. Getting confused? I certainly was, until I began to think of these variations as points on a continuous spectrum. I hope the following discussion will impress you as simpler.

What is the “mood spectrum?” (references updated 4/2008)

Until very recently, depression and “manic-depressive illness” were understood as completely independent: a patient either had one or the other. Now the two are seen by many mood specialists as two extremes on a continuum, with variations found at all points in between, as in the graph below (e.g. Ghaemi; Pies; Moller; Birmaher; Skeppar; Mackinnon; Angst and Cassano; Akiskal to name just a few important articles since 2001; and finally, my ISBD review in 2008):

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“manic-depressive” extreme is defined by the presence of manic episodes, just the kind that most people have seen or heard of: full delusional mania. But in between these extremes is a large area which some mood experts think includes more people than either extreme. In other words, it might be the most common form of bipolar disorder, this middle group.Angst

Consider the following points A and B on this spectrum:

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Point A on the continuum describes people who have a complex depression but who still respond well to antidepressant medication or psychotherapy. Around point B, however, there is some sort of threshold where these approaches are no longer completely or continuously effective: either they don’t work at all, offer only partial relief, or help for a while then “stop working” (which may account for some or much of “Prozac poop-out”, now regarded as a “soft sign” of bipolar disorder, described below).

Until 1994 and the publication of the DSM-IV, there was no official name for all the variations between B and the “manic-depressive” extreme. It was as though these variations did not exist. In the minds of a few, they still don’t, including some psychiatrists who have not adopted this new “spectrum” way of thinking about diagnosis. The DSM-IV itself does not describe this “spectrum” concept. In it, the entire span between blue and green is still “Major Depression”, the same as the violet end to your left. Only the orange and red zones are clearly “bipolar”. Light green and yellow is BP NOS, Bipolar Not Otherwise Specified. That diagnosis means you have something that looks like bipolar disorder but does not meet the criteria for BP II or BP I. Isn’t it simpler just to think of it as a continuum? That is much closer to reality. We see all sorts of variations in between these named points on the graph above.

What do “bipolar variations” look like?

Warning: The following represents my clinical experience taking referrals from primary care physicians. Most patients I see have been on 3 or more antidepressants before I see them. This selects very directly for “bipolar spectrum” patients. However, note that none of these descriptions are found in the DSM, nor are they widely spoken of by mood experts. This is my personal formulation based on almost 15 years of full-time selection for such patients.

Roller coaster depression

Many people have forms of depression in which their symptoms vary a lot with time: “crash” into depression, then up into doing fine for a while, then “crash” again — sometimes for a reason, but often for no clear reason at all. They feel like they are on some sort of mood “roller coaster”. They wonder if they have “manic-depression”. But, most people know someone or have heard of someone who had a “manic” episode: decreased need for sleep, high energy, risky behaviors, or even grandiose delusions (‘I can make millions with my ideas”; “I have a mission in space”; “I’m a special representative for God”). So they think “well, I can’t have that — I’ve never had a manic episode”.

However, the new view of bipolar disorder means it’s time to reconsider that conclusion. Hypomania doesn’t look or feel at all like full delusional mania in some patients. Sometimes there is just a clear sense of something cyclic going on. (For a striking version of this, read a patient’s account). Some mood disorder experts consider depression that occurs repeatedly to have a high likelihood of having a manic phase at some pointFawcett, especially if the first depression occurred before age twenty.Geller, Rao These two features–repeated recurrence, and early onset–are also included among the bipolar “soft signs” below: not enough to make a diagnosis, but suggestive, especially if they occur with several other such signs, even if “hypomania” is not detectable at all.Ghaemi

Depression with profound anxiety

Many people live with anxiety so severe, their depression is not the main problem. They seem to handle the periods of low energy, as miserable as they are. Often they sleep for 10, 12, even 14 hours a day during those times. But the part they can’t handle is the anxiety: it isn’t “good energy”. Many say they feel as though they just have too much energy pent up inside their bodies. They can’t sit still. They pace. And worst of all, their minds “race” with thoughts that go over and over the same thing to no purpose. Or they fly from one idea to the next so fast their thoughts become “unglued”, and they can’t think their way from A to C let alone A to Z.

When this is severe, people who enjoy books can find themselves completely unable to read: they just go over and over the same paragraph and it doesn’t “sink in”. They will get some negative idea in their head and go around and around with it until it completely dominates their experience of the world. Usually these “high negative energy” phases come along with severely disturbed sleep (see Depression with Severe Insomnia, below). Thoughts about suicide are extremely common and the risk may be high.Fawcett(B)

Depressive episodes with irritable episodes

Many people with depression go through phases in which even they can recognize that their anger is completely out of proportion to the circumstance that started it. They “blow up” over something trivial. Those close to them are very well aware of the problem, of course. Many women can experience this as part of “PMS”. As their mood problems become more severe, they find themselves having this kind of irritability during more and more of their cycle. Similarly, when they get better with treatment, often the premenstrual symptoms are the “last to go”. Others can have this kind of cyclic irritability without any relationship to hormonal cycles. Many men with bipolar variations say they have problems with anger or rage.

Depression that doesn’t respond to antidepressants (or gets worse, or “poops out”)

Many people have repeated episodes of depression. Sometimes the first several episodes respond fairly well to antidepressant medication, but after a while the medications seem to “stop working”. For others, no antidepressant ever seems to work. And others find that some antidepressants seem to make them feel terrible: not just mild side effects, but severe reactions, especially severe agitation. These people feel like they’re “going crazy”. Usually at this time they also have very poor sleep. Many people have the odd experience of feeling the depression actually improve with antidepressants, yet overall —perhaps even months later —they somehow feel worse overall. In most cases this “worse” is due to agitation, irritability, and insomnia.

In some cases, an antidepressant works extremely well at first, then “poops out”.Byrne The benefits usually last several weeks, often months, and occasionally even years before this occurs. When this occurs repeatedly with different antidepressants, that may mark a “bipolar” disorder even when little else suggests the diagnosis.Sharma

Depression with periods of severe insomnia

Finally, there are people with depression whose most noticeable symptom is severe insomnia. These people can go for days with 2-3 hours of sleep per night. Usually they fall asleep without much delay, but wake up 2-4 hours later and the rest of the night, if they get any more sleep at all, is broken into 15-60 minute segments of very restless, almost “waking” sleep. Dreams can be vivid, almost real. They finally get up feeling completely unrested. Note that this is not “decreased need for sleep” (the Bipolar I pattern). These people want desperately to sleep better and are very frustrated.

Want to see similar explanations from another source? Or more detail on the kinds of symptoms people with this illness can have? Here are another doctor’s observations on the issue of “soft” bipolar variations.

Unofficial but evidence-based markers of Bipolar Disorder

You have probably figured it out by now: making a diagnosis of bipolar disorder can be pretty tricky sometimes! You’re about to read a list of eleven more factors that have been associated with bipolar disorder. None of these factors “clinches” the diagnosis. They are suggestive of bipolarity, but not sufficient to establish it. They are best regarded as markers which suggest considering bipolar disorder as a possible explanation for symptoms. They are not a scoring system, where you might think “the more I have of these, the more likely it is that I have bipolar disorder.” That way of thinking about these factors has not been tested.

Here’s the list of items which are found with bipolar disorder more often than you would expect by chance alone. This list is adapted from a landmark article by Drs. Ghaemi and Goodwin and Ko. (Drs. Goodwin and Ghaemi are among the most respected authorities on bipolar diagnosis in the world. This important article is online).
1.The patient has had repeated episodes of major depression (four or more; seasonal shifts in mood are also common).
2.The first episode of major depression occurred before age 25 (some experts say before age 20, a few before age 18; most likely, the younger you were at the first episode, the more it is that bipolar disorder, not “unipolar”, was the basis for that episode).
3.A first-degree relative (mother/father, brother/sister, daughter/son) has a diagnosis of bipolar disorder.
4.When not depressed, mood and energy are a bit higher than average, all the time (“hyperthymic personality”).
5.When depressed, symptoms are “atypical”: extremely low energy and activity; excessive sleep (e.g. more than 10 hours a day); mood is highly reactive to the actions and reactions of others; and (the weakest such sign) appetite is more likely to be increased than decreased. Some experts think that carbohydrate craving and night eating are variants of this appetite effect.
6.Episodes of major depression are brief, e.g. less than 3 months.
7.The patient has had psychosis (loss of contact with reality) during an episode of depression.
8.The patient has had severe depression after giving birth to a child (“postpartum depression”).
9.The patient has had hypomania or mania while taking an antidepressant (remember, severe irritability, difficulty sleeping, and agitation may — but do not always — qualify for “hypomania”).
10.The patient has had loss of response to an antidepressant (sometimes called “Prozac Poop-out”): it worked well for a while then the depression symptoms came back, usually within a few months.
11.Three or more antidepressants have been tried, and none worked.

There is a very radical idea buried in these 11 items, which we should look at before going on, but you should be aware that this idea is likely be dismissed with a “hmmmph” by many practicing psychiatrists. The idea is this: Dr. Ghaemi and colleagues propose that there might be a version of “bipolar disorder” that does not have any mania at all, not even hypomania. They call it “bipolar spectrum disorder”.

This is strange, you are saying to yourself. “I thought bipolar disorder was distinguished from ‘unipolar’ depression by the presence of some degree of hypomania. Don’t you have to have some hypomania in order to be bipolar? How could it be ‘bi’ – polar if there is no other pole!?”

But Dr. Ghaemi and colleagues assert that there are versions of depression that end up acting more like bipolar disorder, even though there is no hypomania at all that we can detect (or, as in item #9, only when an antidepressant has been used). These conditions often do not respond well, in the long run, to antidepressant medications (which “poop out” or actually start making things worse). They respond better to the medications we routinely rely on in bipolar disorder, the “mood stabilizers” you’ll be introduced to in the

Treatment section of this website (including several non-medication approaches). And these patients have other folks in their family with bipolar disorder or something that looks rather more like that (e.g. dramatic “mood swings”, even if the person never really gets ill enough to need treatment).

In Dr. Ghaemi’s description, then, there are people whose depression looks so “unipolar” that even a “fine-toothed comb” approach to looking for hypomania will not identify it as part of the “bipolar spectrum”. According to Ghaemi and colleagues, these people should be regarded as “bipolar”, in a sense, because of the way they will end up responding to treatment. In other words, there is something in these people which doesn’t look like our old idea of bipolar disorder, or even our newer idea of bipolar disorder (bipolar II, etc.), but will still better describe their future (their prognosis) and the medications that are most likely to help them. Remember that this is the very purpose of “diagnosis”, to describe the likely outcomes with and without treatment, and to identify effective treatments. So, on that basis, it seems reasonable to include these patients on the “bipolar spectrum”, like this:

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The idea that someone can “have” bipolar disorder and yet not have any hypomania at all is not widely understood. You probably would get blank looks from most psychiatrists if you mention it, and frank disbelief from nearly all primary care doctors, who don’t have time to read the literature on the diagnosis of bipolar disorder. So, if you mention this idea to anyone, be prepared for some serious resistance. As of 2005 the Harvard-associated Mood Disorder program started using this approach to diagnosis. They call it the Bipolar Index.

Other researchers are also beginning to use the same framework of thought. For example, one research group just reported that patients with migraine headaches are much more likely to have these bipolar spectrum traits.Oedgaard (Migraines are much more common in patients with unipolar and Bipolar II than in Bipolar I, interestingly.Fasmer) One recent summary article for primary care doctors, about bipolar disorder, discusses these “soft signs” in considerable detail.Swann The concept of a bipolar “spectrum” is supported by work from a research group calling themselves the Spectrum Project.e.g. Cassano

Probably better not to raise this issue unless you have to, but if you must, cite the source. Here’s that article link again.Ghaemi Dr. Ghaemi is the chairman of the committee on diagnosis for the International Society for Bipolar Disorder.

One of his two co-authors is Dr. Frederick Goodwin, who wrote the “bible” of bipolar disorder for our lifetime (Manic-Depressive Illness, with Dr. Kay Jamison). These are highly respected researchers amongst mood experts. Dr. Ghaemi emphasizes the need to rely on evidence in all his papers on diagnosis and treatment and is very frequently cited by other authors on this topic (you’ll see quite a few references to him on this website, e.g. see Antidepressant Controversies). But he is certainly not the only such voice. If you haven’t seen enough references yet, here’s another similar recent one, by other international mood experts.Mitchell

Anxious depression could be “bipolar”?!

Warning: leaving DSM-IV territory

The remainder of this “diagnosis” discussion cannot be found in the DSM. I will repeatedly reference mood disorder experts, but many of these views are controversial. You must evaluate for yourself the validity of what follows.

If you don’t, you may need this new understanding of mood disorders in order to consider mood stabilizers medications, discussed in detail below, as an option.

Meanwhile, at least one experienced mood researcher warns that anxiety in someone who is depressed is associated with a high suicide risk.Fawcett(B) So although there is diagnostic confusion, there are tremendous stakes involved. Approaching this situation with an open mind seems wise, given this risk.