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:
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 Bipolarity 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.
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?
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.
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.
How short can an episode of hypomania be?
Officially, the answer is “four days”, according to the DSM. But in real life, it’s very clear that episodes can be shorter, and that’s agreed upon by nearly all mood experts I’ve ever heard. They might disagree whether we should shorten the required duration in the DSM, as that would “admit” a lot more people into the bipolar camp which is already a controversial issue. But no one really seems to think that a hypomanic episode lasting only 3 days instead of four is anything other than hypomania; it just doesn’t “meet criteria”, that’s all.
Indeed, a recent studyBauer showed that episodes lasting as little as one day are common. So don’t get hung up on length of episodes as an issue if you’re trying to figure out if you “have bipolar disorder” or not. Remember, that’s the wrong question anyway… Instead, it’s “how bipolar are you?” as affirmed in a recent editorial Smith in the British Journal of Psychiatry (one of the biggies…).
What does bipolar depression actually feel like?
Theoretically, bipolar depression is exactly the same as “unipolar” or straight Major Depression. Theoretically, you can’t distinguish between the two, so you can’t tell if someone has bipolar disorder just by looking at their depressions.
But I think there is a different quality to the depressions that people with bipolar disorder experience, because before they start feeling sad and having difficulty experiencing pleasure from their usual activities, they very often have problems with energy. To emphasize this I’d just like you to look at this list of symptoms which people with bipolar disorder said they have when they’re just starting to get depressed.
If you think “that’s me!”, careful: this does not mean you have bipolar depressions. But it might help to see what people with bipolar disorder have said about their experience. I don’t hear about these symptoms so much when people have a more purely “unipolar” — not bipolar — depression.
(from Lobban and colleagues, 2011)
Granted, people in this study also endorsed “loss of interest in activities” and “feeling sad, wanting to cry” but these are her typical symptoms in official “Major Depression”. And low energy can also be seen in Major Depression. But look at how prominent it is in this study. I think that might be telling us something about the nature of bipolar depression. Certainly matches what I hear from patients.
Finally, the original intent of this list was to help people identify symptoms that mark the beginning of another episode of depression. He might find it useful in that respect also.
I hope it may now make sense to you to think of mood symptoms as falling on a continuum between plain depression and “depression plus”, the far end of which is Bipolar I, with many variations falling in between.
If you are wondering whether what you’ve just read is “mainstream” or “fringe” (that’s a good thing to wonder), you’ll find the same “spectrum” concept coming from the head of the Harvard Bipolar Clinic, in this 2005 interview: Sachs.
By contrast, another mood disorder expert has shown that bipolar disorder is overdiagnosed (Zimmerman, 2008; here is a close examination of his findings). He’s certainly right, if one sticks to the DSM rules (although his paper also shows a notable underdiagnosis rate as well). And there are quite a few people getting this diagnosis who might be better understood with a different diagnostic framework, like Post-Traumatic Stress Disorder (PTSD). But in my view, one of the things that can help you figure out what’s going on is to learn more about “bipolarity”, as you have done here. You are an important part of the diagnostic process.
Is there a test for bipolar disorder? Can you be sure if you have it or not?
This used to be simple. When “manic” only meant one thing (classic mania) one could ask “have you ever had a manic episode?” and many people knew what was being asked:
•Mood much better than normal
•Little need for sleep
•Racing thoughts, trouble concentrating
•Continuous high energy
•Loss of contact with reality (delusions)
As you now know (start this section on diagnosis afresh if you came from elsewhere), this list looks for obvious mania. It misses all the complexity we have just discussed. What you might be wanting is a “no way!” bipolar test. Something to provide a clear statement, like: “no, you don’t have it, or anything like it”. Or you might be looking for the opposite: “you definitely have bipolar II”. Sorry, that is not possible, but please read on.
On other websites you’ll find a test called the Mood Disorders Questionnaire (MDQ) which is supposed to give you a “yes or no” answer. But another test came along after the MDQ which is better suited to looking for subtle versions of bipolar II.
Think about it: if by this point on this website you’re saying to yourself “that’s me!”, which some people do, then you really don’t need some test to tell you that you should go ahead and consider treatment. Or that the diagnostic basis for that treatment should include a consideration of bipolar II. On the other hand, if someone else thinks you might have it, but you don’t think you do, is a test result going to make a difference to you? If so, go ahead and take one of these tests.
Family or friends could “take the test”, answering as if they were you, on the basis of what they’ve seen you do or heard you say. And then they could gently wonder out loud if perhaps the test might mean something, who knows, no one can tell for sure, but darn it sure seems like your life is a struggle sometimes, wow, what if there was a tool out there that would make life a bit smoother sometimes, not even necessarily a medication treatment, oh well, just thinking about this, of course you’d want to decide for yourself, not for me to say of course, etc. etc.
The people who are in a position to benefit from taking one of these diagnostic tests are those who are wondering if a “bipolar” variation might be worth considering to explain their symptoms. Here’s the test I’d recommend for you, called the Bipolar Spectrum Diagnostic Scale. It won’t give you a yes-or-no answer. I hope by this point you understand why that’s a good thing. If after all that you still want to use a “fine-toothed comb” to look for hypomanic/manic symptoms, as I sometimes do when people are still wondering about the diagnosis after learning all this, here is a 32-item checklist of such symptoms.
Thank you for patiently reading all the way to this point. It’s a lot to swallow at once, isn’t it? From here you can review, or read more about diagnosis issues in the Diagnosis Details section, or go on to Treatment.