The “bottom line” of diagnosis

If your depressions are complicated; if you have mood swings, but not “mania”, you can still be “bipolar enough” to need a treatment that’s more like the treatments we use in more easily recognized Bipolar Disorder. You’ll read here about forms of depression  which do not have “mania” to make them stand out as different, yet are not plain depression either. For these people, Depression is  by far the main symptom, including especially sleeping too much, extreme fatigue, and lack of motivation. What makes bipolar depression different is the presence of something else as well.
But that “something else” often does not look anything like mania. “Hypomania”, which you’ll learn about here, can show up as extreme insomnia, irritability, agitation/anxiety, and difficulty concentrating.  And finally, some people can have some bipolarity without any hypomania at all. Really. You’ll see references to mood experts who have shown all these things as you go.
Wait a minute: isn’t there concern about overdiagnosis of bipolar disorder? Yes, we’ll talk about that too, after you’ve learned some basics.

What happened to “manic-depressive”? What’s “Bipolar II”?

Somewhere along the way you probably learned about manic-depressive illness: episodes of mania, and episodes of severe depression. Here are the symptoms of “mania”.  Not that you have these, as such; the lack of them is the main point here. Hang on.

• Mood much better than normal
• Rapid speech
• Little need for sleep
• Racing thoughts, trouble concentrating
• Continuous high energy
• Overconfidence
• Delusions (often grandiose, but including paranoid)

What happened to “manic-depressive”? As our understanding of bipolar disorder has grown, the naming system has changed as well. Recently the concept of a “mixed state” of bipolar disorder, in which manic symptoms and depressive symptoms are found at the same time, was added. Obviously this changes the understanding of manic-depressive illness from one in which the two mood states alternate, to one in which they can co-occur! Things are getting more complicated.
Psychiatry has a diagnostic “rule book” that lists the symptoms people must have in order to meet the definition of a particular “disorder”, called the Diagnostic and Statistical Manual. The most recent edition came out in 2013, the “DSM 5”. If much of what you read below seems to describe you well, but someone tells you “you don’t have bipolar disorder”, it could be that they are using a strict interpretation of the DSM rules. This is a highly controversial area in psychiatry. Even the validity of the DSM itself is now controversial. (For examples of this, see my page on DSM SPECTRUM DIAGNOSIS).
Technically Bipolar II describes a pattern in which patients experience “hypomania” (to be discussed in detail below), alternating with episodes of severe depression. However, one of the most experienced professionals in this field, who has bipolar disorder herself, has criticized the DSM as too limited:

“The clinical reality of manic-depressive illness is far more lethal and infinitely more complex than the current psychiatric nomenclature, bipolar disorder, would suggest. Cycles of fluctuating moods and energy levels serve as a background to constantly changing thoughts, behaviors, and feelings. The illness encompasses the extremes of human experience. Thinking can range from florid psychosis, or “madness,” to patterns of unusually clear, fast and creative associations, to retardation so profound that no meaningful mental activity can occur. Behavior can be frenzied, expansive, bizarre, and seductive, or it can be seclusive, sluggish, and dangerously suicidal. Moods may swing erratically between euphoria and despair or irritability and desperation. The rapid oscillations and combinations of such extremes result in an intricately textured clinical picture.” (Kay Jameson p.h.d.)

I arrived at the same conclusion from listening to patients describe their symptoms. When I used this broader conception to guide treatment, people who had struggled for years often got much better.
Yet when I tried to explain this to some of my colleagues, they thought I was a “bipolar wacko”. That’s how this website got started, and why you’ll see so many reference links. I needed to show that these were not my ideas alone, but rather those of mood experts around the world (it also seemed like a handy way to explain all this to my patients without saying the same thing over and over!) For example, everything you will read below can be found in a review by two mood experts, except that their version is written in full medical jargon.
Even the International Society for Bipolar Disorders has advocated a change in diagnostic procedure, moving beyond the DSM, using what we’ve learned in the last decade.  See Ghaemi and collegues; if you look closely you’ll see that my name is on the list of co-authors. I was honored to be invited to participate and write for this 2008 update on bipolar diagnosis guidelines. I was the lead author on the “Bipolar Spectrum” paper. Its content is reflected below.

What’s “Bipolar II”?

Depression for sure. Depression far more than anything else. And then there’s this other little part.  The technical name is misleading, and causes all sorts of trouble, so careful, don’t get thrown off by it.  We’re talking about a very small amount (sometimes larger) of manic-side symptoms:

• Mood better than normal
• Rapid speech
• Dramatically reduced sleep
• Racing thoughts, trouble concentrating
• Continuous high energy
• Overconfidence

People with Bipolar II don’t have mania. They don’t have “psychosis” (loss of contact with reality). They don’t have extreme behaviors that people think are “crazy”.  They do have phases that their family and friends recognize as “not your usual self”:  something unusual along the lines of the bullets above.  Notice that “delusions” are gone from the earlier list.
Another variation less severe than Bipolar II is the combination of hypomanic phases with separate phases of mild depression.  This is called “cyclothymia”. 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?”

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 most mood specialists as two extremes on a continuum, with variations found at all points in between, even though only some points have names (e.g. Ghaemi; Pies; Moller; BirMaer; SKeppar; Mackinnon; Angst  Cassano; my ISBD in 2008; and 2014 updates.)

On the left, the “unipolar” extreme represents straightforward depression with no complications. There are many forms of depression, of course (see  “What kinds of Depressions are there“). The depressions discussed further below are of a more genetic, or “chemical” nature; versus those of a more situational type, like losing a loved one. Situational depressions may respond well to time or therapy and not require “bipolar” thinking.
On the right, the “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 might be the most common form of bipolar disorder: the green zone below.Angst

Got all that?  It gets trickier yet.  Consider the points A and B on this spectrum:
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 non-manic marker of bipolar disorder, described below).
Until 1994 and the publication of the DSM-IV, there was no official name for all the variations betweenB 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 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 (or in the DSM5: BP-NEC, Not Elsewhere Classified). 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: this is controversional territory. Ironically, your diagnosis could be determined more by the professional whom you see than the symptoms you have. Really. Read that again. This happens all the time. If your therapist or nurse practitioner or doctor uses a DSM framework, and you don’t meet criterial for bipolar disorder, then you just don’t have bipolar disorder at all. Period.
On the other hand, if your therapist/NP/etc thinks in terms of a “spectrum” of bipolarity, then you could get a bipolar label that someone else might think was “overdiagnosis”. Starts to sound kind of ridiculous, doesn’t it?  But a lot of energy becomes focused here. “Bipolar” carries more stigma than “depression”. Many believe that antidepressants are less risky than mood stabilizers (that’s not so clear either, in my view). So the “yes-or-no” view is still very powerful. You could easily be told “you don’t have bipolar disorder” when someone else has said you do.  The solution is to learn more. Read on.
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, a spectrum view of mood disorders  invites you to reconsider. 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 count).
Some mood disorder experts consider depression that occurs repeatedly to have a high likelihood of having a manic phase at some point Fawcet, especially if the first depression occurred before age twenty. Geller, Rao These two features–repeated recurrence, and early onset–are also included among the non-manic markers 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).
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
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.

Non-manic markers of bipolarity? Even with no hypomania at all?

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. The particular list below 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.
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[*]The patient has had repeated episodes of major depression (four or more; seasonal shifts in mood are also common).

[*]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).

[*]A first-degree relative (mother/father, brother/sister, daughter/son) has a diagnosis of bipolar disorder.

[*]When not depressed, mood and energy are a bit higher than average, all the time (“hyperthymicpersonality”).

[*]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.

[*]Episodes of major depression are brief, e.g. less than 3 months.

[*]The patient has had psychosis (loss of contact with reality) during an episode of depression.

[*]The patient has had severe depression after giving birth to a child (“postpartum depression“).

[*]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”).

[*]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.

[*]Three or more antidepressants have been tried, and none worked.

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Bipolarity with no hypomania at all? (!)

There is a very radical idea buried in the above 11 items, which we should look at before going on. But 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. “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 their depression 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 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.
Here’s some ammunition for you (nice soft paper bullets…) . As of 2005 the Harvard-associated Mood Disorder program started using this approach to diagnosis. They call it the Bipolar Index.
More:  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.Odegaard (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
More: The concept of a bipolar “spectrum” is supported by work from a research group calling themselves the Spectrum Project.

More?  Consider the sources.  Dr. Ghaemi was the chairman of the Committee on Diagnosis for the International Society for Bipolar Disorder. His co-author 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 onevidence 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. But he is certainly not the only such voice, as I hoped you’ve noticed from all the references linked so far.