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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.

Unfortunately, “hypomania” is quite a mis-naming. There are many patients whose “hypomanic” phases are an extreme and very negative experience. As noted above by Dr. Jamison, mania can be negative as often as it is positive. The “racing thoughts” can have a very negative focus, especially self-criticism. The high energy can be experienced as a severe agitation, to the point where people feel they must pace the floor for hours at a time. Sleep problems can show up as insomnia: an inability to sleep, rather than decreased need. (If you or a friend or doctor is skeptical about anxiety as a “bipolar” symptom, try that link for more details and references.)

In my experience most of these people come to treatment with a combination of agitation, anxiety and self-criticism — and they can’t sleep well. Is this “anxiety?” Is this some mood variation? How could you tell the difference? Is there a difference? What is really going on chemically? Unfortunately, this is still almost completely unknown. See the appendix “What’s the latest on why?”, which I will try to keep updated frequently, for the latest research about the cause of this illness.

Again, my opinion: you can’t easily distinguish “anxious depression” from bipolar II in a mixed state. I doubt that there is a distinction to be made, ultimately (when we know, hopefully someday relatively soon, what the chemical basis for anxiety with depression really is). For example there is nearly complete overlap between Generalized Anxiety Disorder and Bipolar II.

For now, the only way to tell is by how treatment turns out. Depression that is not bipolar can get better and stay better: with time, or counseling, or formal psychotherapy, or antidepressants. If you get better — great! 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.

What does Hypomania actually feel like?
(revised 3/2010)

It’s true that hypomania is a milder version of mania — just how mild, you’ll see in a moment. Mind you,

Bipolar II is not a milder version of Bipolar I, though it is very often described that way, to my utter dismay. The suicide rate in Bipolar II is the same or higher than the rate for Bipolar I, for example.Dunner So the BP II version is definitely not a “mild” illness. The depression phases are as bad as in BP I, and often more common (that is, they occur more frequently and represent a more dominant part of the person’s life).

Nevertheless, hypomania can indeed by subtle, certainly by comparison with full mania, as shown in this graph (from Smith and Ghaemi). Here are the symptoms which people with clear-cut hypomania actually experience — and how often. For example, at the bottom of the graph you see that nearly 100% of people with hypomania will have an increase in their activity. By comparison, optimism is prominent only about 70% of the time in hypomania.

02_dia1.jpg

As you can see, these “symptoms” are not clearly abnormal. Everyone experiences these feelings from time to time. When they are extreme; and when they show up over and over again in cycles of mood/energy change; when they are accompanied by other signs of bipolarity, such as phases of depression; that’s when we should think of this as “abnormal”, or at least as warranting caution if someone wants to treat those depressed phases with an antidepressant.

However, hypomania is not always positive. Just as manic phases can be very negative (so-called “dysphoric mania”), hypomania also can be very unpleasant. Here is an example of how hypomania can change from a positive experience to a very negative one (from a blogger who writes eloquently about bipolarity).

First, the positive phase:

Increased energy. A extraordinary feeling of happiness with myself and the world. A very loving feeling towards the people I care about. An uncommon ability to get things done. A huge burst of energy from the moment I awaken until I go to bed. An expanded ability to multi-task. An organizational acuity that is second to none. A willingness to engage with people. A desire to spend more time with people I care about–and even those I don’t.

Then, the negative phase of hypomania (still pretty subtle):

I start feeling burned out. While I still have a lot of energy, I don’t have that “I love the world” feeling. If I’ve been playing my Autoharp at my mother’s assisted living facility, and jumping up and down to help all the participants turn the pages and stay with me, I suddenly feel that the staff should be more helpful in doing this.

… things don’t just slide off my back. While I try not to “snap” back at people, I am not always successful. I am certainly less willing to ignore things that days or weeks earlier wouldn’t have bothered me at all.

I become far less happy, joyful, and kind. I dislike being criticized in any which way.