Bipolar4LifeSupport

Recognizing the diversity of types and intensities of mood episodes, the DSM-IV-TR (the Diagnostic and Statistical Manual of Mental Disorders, the book that describes mental health diagnoses) has subdivided the diagnosis of bipolar disorder into four basic categories, each defined by a particular pattern of severity of spontaneous depressions, manias, hypomanias or mixed episodes. The term “Bipolar I Disorder” is applied to patients who demonstrate full-strength manic and depressive episodes. The term “Bipolar II Disorder” is applied to patients who demonstrate full-strength depression, but only hypomanic presentations rather than full-strength manias. The term “Cyclothymic Disorder” is used to describe patients who demonstrate repeated mood swings which are never quite severe enough to qualify as major depressive or manic episodes. Finally, the term “Bipolar Disorder, Not Otherwise Specified (NOS)” is used to describe all other patients with bipolar symptoms which cannot neatly be fitted into the above categories. We’ll have more to say about DSM bipolar diagnoses in our discussion below.

Periodicity of Swings

Besides the energy or intensity of mood episodes, the other important factor relating to bipolar mood swings has to do with their periodicity; how long each episode lasts, and how rapidly they fluctuate. Most of the time bipolar mood swings occur with relative slowness, over periods of weeks and months. Usually, less than four complete mood cycles occur within a given year, and each mood episode might last up to two months.

There is generally a period of relatively normal mood that occurs between mood episode extremes. However, some individuals bipolar disorder do not experience this normal inter-episode period and instead experience this interval as a point in time when their mood symptoms are milder than normal (rather than being absent). For example, a person who is clearly between episodes might still feel low on some days or slightly manic on others.

Though less common than the longer cycling forms of bipolar disorder, a rapid-cycling variation of bipolar disorder is recognized. Rapid cycling bipolar disorder occurs when complete mood cycle periods occur four or more times per year. Rapid cycling bipolar conditions are thought to occur in 20% or less of all bipolar patients.

Two additional cycling terms are now beginning to enter the literature. Ultra-rapid cycling is in use to describe cases where complete mood cycles occur in less than one month. Ultridian cycling is in use to indicate cases where complete mood cycles occur inside the space of one day (and thus might be confused with a mixed episode). It is important to note that ultra-rapid and ultridian forms of mood cycling are not yet formally recognized in the DSM and thus are not currently official terms.

Rapid cycling in any form of bipolar disorder tends to be associated with a poorer long-term prognosis, which is to say, rapid-cyclers don’t tend to hold their lives together as well as do bipolar patients who have longer cycles.

Just as the manic aspect of bipolar disorder is associated with manic episodes, the depressive aspect of bipolar disorder is likewise associated with depressive episodes. The severe form of depressive episode is known as a Major Depressive Episode.

Major depressive episodes are characterized by five or more of the following symptoms, all of which must be present in a more or less uninterrupted manner for at least a two week period:

• A pervasive depressed mood that colors and tones daily experience
• A diminished ability to take pleasure from activities that used to be pleasurable (such as sex, food, hobbies, social interaction)
• Appetite changes (either more hungry or less), which may be accompanied by weight loss or gain. (No conscious dieting is occurring)
• Sleep changes (either sleeping more or less than normal)
• Psychomotor (e.g., body) agitation or retardation; either can’t sit still, or can hardly move.
• Constant complaints of fatigue and low energy
• Thoughts of the affected person’s worthlessness, guilt or shame plague him or her
• Concentration becomes more difficult to achieve than before
• Thoughts of the desirability of death and suicide

People experiencing a major depressive episode may be lacking in energy and show slower, unmotivated movements, or they may appear irritable and agitated. They may have a hard time getting out of bed in the morning, or they may stay up all night with insomnia. Either way, they are likely to complain of constant tiredness and difficulty concentrating on tasks. They may eat very little or eat to excess so as to comfort themselves, possibly leading to rapid changes in weight. They may lose interest in doing things they previously enjoyed or spending time with other people. The low mood tone, inability to accomplish tasks, and general shut-down of the brain’s ability to think clearly and rationally can lead to exaggerated feelings of worthlessness, misery and despair. Such extreme negative feelings and self-judgments drive a substantial minority of bipolar-diagnosed people towards contemplating and (all too often) actually committing suicide.

There is no corollary to a hypomanic episode for depression; no short-term “hypodepressive” episode that can be diagnosed. There is a related condition known as Dysthymic Disorder or Dysthymia, which describes a long-lasting mild depression. Dysthymia cannot be diagnosed at the same time as bipolar disorder, however, because in order to qualify for a diagnosis of Dysthymia, you have to show evidence of consistently mild depressive symptoms occurring more days than not over a period of at least two years. The presence of manic or hypomanic episodes during the two year period would disqualify any dysthymic disorder diagnosis.

Mixed Episodes

While bipolar disorder most frequently manifests as a swing between manic and depressive episodes, in a minority of cases, a third type of Mixed mood episode occurs. In a mixed episode, the criteria for mania and the criteria for depression are both simultaneously met more often than not for at least a one week period duration. Just because criteria for both manic and depressive episodes are both met during a single day does not mean that both sets of symptoms are simultaneously present, however. Instead, what appears to be more the case is that there is a rapid alteration between manic and depressive states, occurring one or more times in a single day. Mixed episodes tend to be severe when they occur; psychotic symptoms such as hallucinations and delusions, and suicidal thinking are frequently present.

Not everyone who becomes manic experiences the full-blown syndrome of a manic episode. Hypomanic individuals show an expansive, energized and sometimes elated mood, with rapid thinking and pressured speaking in evidence. At a minimum (for the label hypomania to be appropriately applied), this expanded mood state must persist for at least four straight days.

As is the case with manic episodes, hypomanic episodes are also characterized by the presence of characteristic symptoms. At least three of the following must be present (for at least four days) before the diagnosis of hypomanic episode is appropriate:

• an inflated or expansive and even grandiose (but not delusional; not completely out of touch with reality) sense of self
• reduced sleep needs compared to normal
• talks more than usual
• subjective sensation of racing thoughts (often called a “flight of ideas”)
• distraction or derailment of thought occurring significantly more often than normal
• an increase in goal-directed activity, or physical agitation
• a marked increase in participation in risky but pleasurable behavior (such as unprotected sex, gambling, unrestrained shopping, etc.)

You’ll notice that these are essentially the same criteria that are applied to manic episodes. What is suggested (and what is intended) by this duplication of criteria is that what separates a hypomanic episode from a manic episode is mostly the degree of intensity (or energy) present in the behaviors the manic person emits (and not in their variety). When the observed energy level is above average but still within normal limits, you have a hypomanic state on your hands. When the energy level goes off the normal scale entirely, you have a manic episode.

People experiencing a hypomanic state are not necessarily unrelentingly sunny in disposition; they may experience irritable mood states too, as is also the case with full manic episodes. However, whatever level of irritability may be present during a hypomanic episode is by definition nowhere near as severe as what might occur during a fully manic episode.

Since hypomania is less severe than mania, people experiencing a hypomanic episode may retain sound judgment and not engage in self-destructive behavior. In fact, their sharpened intellect and ability to function with little sleep contributes to hypomanic individuals’ increased productivity compared to non-manic people. This is to say, hypomania can create a distinct advantage in the workplace, because it helps people to be maximally productive and get more things done than their peers. This positive aspect of hypomania is often seen as a benefit by people who have bipolar disorder. Hypomanic individuals are likely to be creative risk-takers, who can bring creative ideas to fruition. Numerous historical and contemporary figures, including composer Ludwig van Beethoven, pioneering physicist Issac Newton, authors Charles Dickens and Edgar Allen Poe, artist Vincent van Gogh, statesmen Abraham Lincoln, Winston Churchill and Theodore Roosevelt, and media mogul Ted Turner have been documented to have experienced severe and debilitating recurrent mood swings. Some authors (e.g., John Gartner, MD [Hypomanic Edge] have even suggested that America’s unique entrepreneurial character and spectacular economic achievements achieved over the last century are due in large part to a high incidence of hypomania among American entrepreneurs. While we can neither confirm or discard this interesting speculation, we can say that there is more to hypomania than a simple business advantage. When you are hypomanic on a regular basis, you have a mild form of what can be a disabling illness. There is no guarantee that your hypomania will stay stable as hypomania. When left untreated, the underlying causes that produce hypomania can and do sometimes worsen until full manic episodes occur.