Bipolar Support Groups.com blog

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 havesome 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 vs 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 Jamison, Ph.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 colleagues; 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 milddepression.  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;Birmaher; Skeppar; Mackinnon; Angst and Cassano; my ISBD review 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 depression 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 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 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 account).

Some mood disorder experts consider depression that occurs repeatedly to have a high likelihood of having a manic phase at some point^Fawcett, 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 fordays 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. These factors are well accepted. (e.g. International Society for Bipolar Disorders reviews: Mitchell et al; Phelps et al).  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. 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.

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 Bipolarity 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.^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

More: The concept of a bipolar “spectrum” is supported by work from a research group calling themselves the Spectrum Project.^e.g.Cassano 

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 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. But he is certainly not the only such voice, as I hoped you’ve noticed from all the references linked so far.

Anxious depression could be “bipolar”?
Yes, in Mixed States

An international group of experts^ISBD described anxiety in bipolar disorder thus:

• General hyperarousal
• Inner tension
• Irritability /impatience
• Agitation
• “Frantically anxious”

These symptoms are not generally regarded as symptoms of bipolar disorder. Unfortunately, the very name “bi-polar” is misleading. 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 inabilityto sleep, a desperate wish to be able to sleep to get out of the agitated state.

One way to understand these states is called “mixed states”. Bipolar disorder is an unfortunate name, as it implies a North/South Pole experience.  A better picture looks like this graph:

Both manic symptoms and depressive symptoms at the same time? Sure enough. Not intuitive, if you think North/South pole. But these symptoms can vary independently or occur together (For more on that, see mixed states as waves of depression, anxiety, and normal time.)

This is not controversial. Mixed states were officially recognized in the 1994 version of the DSM, and expanded to look more like the graph above in the 2013 version.

What’s the difference between “anxious depression” and a bipolar mixed state? Not enough to easily be able to tell them apart, unfortunately. The same group of experts quoted above also said: “some but not all agitated depressed states are bipolar.”^ISBD

Worst of all, mixed states can be caused by antidepressants.^ISBD Yet antidepressants are what depressed patients commonly receive, of course.right?  But some of those depressed folks have bipolar depression. The antidepressants can take them from pure depression to agitated depression. The good news is that slowly coming off the antidepressant is one way to address anxiety.^Phelps Don’t do that on your own, of course. Here are some guidelines on stopping antidepressants in bipolar disorder.

Bottom line here: bipolar disorder is complicated, much more complex than “bipolar” (North/South) implies. Anxious depression can be bipolar. Tense, irritable agitation can be bipolar disorder. For more, see the Anxiety and Bipolar page.

What does hypomania feel like?  How short or long?

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 (fromSmith 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 wrote 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 or long can an episode be? 

For hypomania, officially the answer is “four days” (DSM). But in real life, it’s very clear that episodes can be shorter, and that’s  greed 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 study^Bauer 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, ask “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 beforethey 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 those are typical symptoms in official “Major Depression”. And low energy can also be seen in Major Depression. But look at how prominent low energy is in this study. I think this 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. You might find it useful in that respect also.

Overdiagnosis?

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, sticking to the DSM rules, you’ll hear that bipolar disorder is overdiagnosed  (the most widely cited paperalso shows a notable underdiagnosis rate as well, by the way. Here is a close examination of their findings. ) They’re right: bipolar disorder is overdiagnosed, if one sticks to the DSM rules. But psychiatry is moving beyond that rigid approach; here are more examples of that movement.

At least one thing is clear: when there’s a question, you’ll be better off if you understand more about “bipolarity”, as you have done here. You are an important part of the diagnostic process.

Is there a test for bipolar disorder?

Not exactly, but…

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
• Rapid speech
• Little need for sleep
• Racing thoughts, trouble concentrating
• Continuous high energy
• Overconfidence
• Loss of contact with reality (delusions)

As you now know, 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.^Ghaemi

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 learn more about treatment.   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.

Bottom line:  The “bipolar spectrum” view used to be regarded as radical, breaking away from the DSM.  But it’s not radical anymore. It’s practically mainstream now.  Both ways of looking at diagnosis have value. Use both.

“Spectrum” is not radical

First of all, let’s get this straight:  the Harvard-associated Bipolar program has been using a spectrum approach to diagnosis since 2004.  They say “Do you have bipolar disorder, or not?” is the wrong question. The right question is “how bipolar are you?”  Gary Sachs, M.D., of Harvard.  In their Bipolarity Index they give tremendous weight to family history and age of onset of depression. These factors are markers of bipolar disorder and yet they are not in the DSM, even the new DSM. So anyone who’s insisting the DSM is the only way to approach bipolar diagnosis is hanging on to an old system. Let me show you…

Just consider the genetics: there are 226 genes associated with bipolar disorder.^Nurnburger Imagine how many combinations are possible.  If each gene had only two variations — many have far more — that would be 35,000 different versions. Okay, say half of those are variations are not really different becaus they lead to a single common pathway.  That’s still at least 17,000 variations?

You get the point: this is not like Huntington’s Disease, another psychiatric illness, where you either have it or you don’t, because there’s just a single gene involved. This is completely different.  How many of the bipolar genes do you have, and what are they saying?How bipolar are you? 

For historical reasons we still have a diagnostic system that insists: you either have bipolar disorder, or you do not. There is no middle ground.  You can’t be “a little bipolar”. You can only have the whole thing, or none at all. That just doesn’t match the way this illness works.  Very few mood specialists would disagree.

Why hasn’t the whole diagnostic process been changed to reflect this new understanding? Because the DSM is a very political, very conservative system. (Think about the legal system, which uses it. Judges would not take kindly to “a little bipolar”.  They need a yes or no).

Nevertheless, more and more research papers are now referring to the “Bipolar Spectrum Disorder” (example ). The  NIMH bipolar research group is called the Bipolar Spectrum Division. Their director said in a recent important journal:

“categories will remain somewhat arbitrary because they will be imposed on fully continuous, smooth distributions”  [italics mine]^Liebenluft

In other words, a diagnostic system based on categories is not mapping reality. Reality is continuous — a spectrum from absent to fully present. Thus insistence on the yes/no “dichotomous” view is getting harder to justify. As one of Barcelona’s great bipolar researchers said:

“Dichotomies are useful for education, communication, simplification. Unfortunately, simplicity is useful, but untrue; whereas complexity is true, but useless.” ^Vieta

In the case of bipolar disorders,  the DSM is useful, to a point. It’s just not “true” (although people certainly act and talk and write as though it is). What’s true is complexity, “bipolarity”.

More evidence that the DSM-only view is changing

When the DSM-5 got underway, there was an effort to bring into it a “spectrum” view. But that failed almost completely. Here are interesting notes about that early process.

But since the arrival of the DSM-5, movement away from yes/no “categorical” system has continued. Here are two striking changes in that direction.  First, the chairman of the DSM-5 wrote that “unipolar” and “bipolar”

“might be better represented as an affective disorders continuum, with variable expressions of bipolarity representing dimensions of underlying pathophysiologic processes.”^Kupfer

Dimensions is the jargon term for “spectrum”.  In other words, the guy in charge of the DSM doesn’t buy the DSM’s categories anymore.

Secondly, the entire NIMH has said the DSM system is not matching well with findings from research.  For example, even though schizophrenia and bipolar disorder are, in the DSM, completely different illnesses; in reality they share a lot of symptoms. Both can cause auditory hallucinations. Both can cause delusions. And both share a lot of genes. So, maybe they really aren’t two separate conditions. Maybe they’re two extremes on a continuum. That’s what the NIMH now says. And they’ve come up with a new way of dividing mental phenomena using a “spectrum” system (the Research Domain Criteria; RDOC).

So why didn’t the DSM-5 become a spectrum-based system? The best rationale I ever heard, from colleague Jack Katzow: “maybe it’s not a good idea to completely change the entire psychiatric diagnostic system too many times in one century.”

Okay, so let’s just agree at this point to put the “spectrum” system up there alongside the DSM system. (That’s what the Harvard-associated mood clinic did 10 years ago). Each patient should be viewed through both lenses. Some people’s problems will make sense through one lens, some through the other.  Keep your eyes on the prize: is the patient getting better?  Is it time to try another strategy, based on another view?

Double depression, bipolarity-style

Here’s one more example of how a rigid division between “unipolar” (plain depression) and “bipolar” is interfering with understanding what’s really going on.

If a person has “dysthymia”, a persistent depression, and then has episodes of Major Depression on top of that, this has been called “double depression”.  The term is used informally; it’s not in the DSM. No one quibbles about the logic of these two superimposed conditions.  Double depression is recognized to be very frequent, an unfortunate consequence of a rough childhood plus adult hard life, plus a genetic dose of Major Depression on top of that.

But what if someone had that persistent dysthymia and instead had a bipolar cycling pattern as well?  That too could be called double depression. No one ever talks about this.

Yet watch what happens when you apply this logic. First, take a typical diagram of Bipolar II cycling:

Then, lower the baseline mood from an average of 5 to 3, representing an unfortunate persistent depression:

And now superimpose the same Bipolar II cycling pattern:

Oh, that’s interesting:  it doesn’t look “bipolar” anymore, does it? Now it just looks like recurrent severe depressions, right? But that’s not called bipolar disorder. That’s called Major Depression, Recurrent.  Do you see how the DSM diagnoses could be confusing everyone?

Perhaps what matters is “cyclicity, not polarity” (to quote Fred Goodwin, former head of the U.S. National Institutes of Mental Health and co-author of the bipolar bible) .

Conclusion

If we can’t entirely abandon the DSM approach (and there are some good reasons not to), at least we should add a spectrum-based approach and use both at the same time to better map the problems we’re trying to understand.

Weight gain is one of the main reasons that people diagnosed with depression and other mood disorders stop taking their medication. Some people gain as much as seven percent of their body weight — or more — from psychiatric meds. In a study funded by the National Institute of Mental Health that was published in July 2006 in the Archives of General Psychiatry, researchers reported that nearly one in four cases of obesity is associated with a mood or anxiety disorder. But following a strict treatment plan that involves meds doesn’t have to mean shopping for a larger pants size. There are effective ways to manage your weight on psychiatric meds. Here are some strategies that you might find helpful:

1. Control Food Portions

Skip the diet. Just limit your portions. Restaurants today tend to serve two to three times the amount of a healthy portion. We’ve added 570 calories A DAY to our diets since the late ’70s, and half of those calories can be attributed to large portions, according to research from the University of North Carolina in Chapel hill. In aFitness magazine article, Lisa R. Young, PhD, RD, says, “Even though today’s serving sizes can be more than triple what the USDA recommends, they’ve become our new normal, and anything smaller can seem puny by comparison.”

I try to carve out an acceptable portion before I dig in, since it’s difficult to determine how much you’ve consumed otherwise. Sometimes I’ll use a smaller utensil to remind myself to savor the food and take small bites.

2. Eat Slowly and Chew Your Food

You’ve most likely at some point wolfed down a massive meal and felt fantastic until 15 minutes later, at which time you secure a few plastic bags because you’re convinced that you’ll explode on your kitchen floor. It takes an average of 20 minutes for your brain to recognize that your stomach is full — a definite waiting period between the time that the fork delivers its bite to the mouth and the bite’s arrival to the stomach. Getting in sync with this digestive schedule can not only save you from discomfort, but can also trim your waistline. If you take your time to savor the food, you’ll feel more satisfied by eating less.

RELATED: Your 10 Biggest Antidepressant Problems, Solved

This is one of the reasons that French people don’t get fat, according to a study from Cornell University in Ithaca, New York. They can better gauge when they’re full by using internal cues to know when to stop eating, unlike Americans who stuff their faces while watching TV or graze all day long, never sitting down for an official meal. The French may eat baguettes and brie, croissants and butter, and all the other forbidden foods, but they enjoy them at a table with friends or family.

3. Keep a Food Journal

Taking notes keeps you accountable for everything you put in your mouth. It’s all there on paper for you to read as many times as you want. Knowing that you’ll record everything as you’re stuffing your face with a pastry can be the difference between eating one chocolate croissant and four. You’ll also keep your momentum when you’re in a groove because you’ll see your progress as recorded in your journal. Finally, you can pick up on patterns of eating behavior during the month and connect binge eating to various stressors or other events.

4. Get Support

Just as it’s difficult to stop smoking if you live with a smoker, it’s much more challenging to lose pounds when you’re surrounded by junk food addicts. You’ll be less tempted to snack on Twinkies if they’re not in your house. Obviously, you can’t put the people in your household on a diet with you, but there’s a level of support you can ask from them. You might also try an online or local weight loss support group to discuss weight loss challenges and frustrations.

5. Set Realistic Goals

It can be tempting to set a goal of losing five pounds every week — or some other unrealistic goals for weight loss — much like we set New Year’s resolutions that never stick. It’s better to be conservative and realistic. The safest rate of weight lossis between 0.5 to 2 pounds a week. Typically, if you lose weight at a slower, consistent pace, you tend to keep it off.

It’s helpful to break down your goals into incremental steps. For example, you might want to start walking for 10 minutes a day for two weeks, bumping it up by five minutes every week. You could also try to adopt a healthy diet in stages. For example, you might start limiting sweets for a few weeks before you attempt to cut out white bread.

6. Start an Exercise Program

You don’t need to run a marathon to get a good workout. Walking up to 30 minutes, three to four days a week is often enough to get your heart rate up and your pounds off. Choose an activity that’s convenient for you to do on a regular basis, and make it part of your day. It’s best to set a consistent time and stick to it.

7. Tap Into Your Emotions

Often, eating isn’t about hunger. It’s about soothing some emotional wound. Food can be a powerful source of comfort to relieve stress, sadness, anxiety, loneliness, or boredom. But there are more effective ways to soothe uncomfortable feelings, like calling a friend, walking, or engaging in a support group. By recognizing the behavioral and emotional cues, you can better direct your angst.

By Therese Borchard

A substantial amount of research points to the benefits of faith to mitigate symptoms of depression. In one study, for example, researchers at McLean Hospital in Belmont, Massachusetts, found that belief in God was associated with better treatment outcomes. They followed 159 individuals over the course of a year to examine the relationship between a person’s level of belief in God, expectations for treatment, and actual treatment outcomes. Individuals with no belief — or only a slight belief — in God were twice as likely to not respond to treatment than people with stronger beliefs.

Of all my sanity tools, my faith is what has kept me alive during severe depressive episodes. When I’m convinced that no one else could comprehend the intense suffering I’m experiencing, I cling to my belief in a God who created me for a reason, who knows my pain more intimately than any other human being, and who will see me through to the other side.

Faith Provides Hope

I was just 11 years old when I learned of faith’s power to strengthen someone in the midst of a deep depression. In the year of my parent’s separation, my mother, devastated by the loss, prayed a novena to Saint Thérèse of Lisieux. On the fifth day of five consecutive days of prayer — when tradition holds that the person will receive a shower of roses — our neighbor Mr. Miller, who kept an impeccable garden, was pruning his rose bushes. He gave six dozen flowers in stunning shades to my sister to surprise my mother. I’ll never ever forget the tears of hope she cried when, on the fifth day of her novena, she walked into a kitchen that looked and smelled like a rose garden. Through the intercession of St. Thérèse, she knew her prayer had been answered and God would give her the resolve she needed to get through her depression.

For a nonbeliever, I know it may appear lame to depend on such “signs” from God — superstitious attempts to make sense out of nothing. But these “signs” have provided me immense comfort during critical times in my mental health journey; they’re consolation that God is with me. They’ve even saved my life at times, reminding me that although I can’t always feel God’s love, He is with me.

Faith Changes Your Brain

One reason that faith protects against depression could be that religious practice actually changes the brain. According to research conducted by Lisa Miller, professor of clinical psychology at Columbia University’s Teachers College, a thickening of the brain cortex is associated with spiritual and religious activities. This study links the protective benefit of spirituality or religion to previous studies that identified large expanses of cortical thinning in specific regions of the brains of adult offspring of families at high risk for major depression. A previous study by Miller and her team published in September 2011 in The American Journal of Psychiatry showed a 76 percent decrease in major depression in adults who said they highly valued spirituality or religiosity, and whose parents suffered from the disease.

Faith Assigns Meaning to Suffering

All religious traditions, especially the Jewish and Christian faiths, offer plenty of examples of how some very bad situations (think Job) were redeemed in the end, and all the suffering actually had a purpose — some greater good came out of it. The Christian story is a powerful provider of redemption and hope in Jesus’s life, death, and resurrection. Pope John Paul II explains in his encyclical on suffering,Salvifici Doloris, that because of the Cross, all suffering has a purpose and is even a vocation. I, for one, find immense consolation in that concept: that my tears and angst have a greater purpose and can be used for goodness. The Psalms are full of verses of inspiration for those caught in depression’s hold, saying that God is there in our trials and will carry us through the valley of despair.

Faith Provides a Support System

AMorccording to research conducted at the University of Colorado in Boulder, regular churchgoers live longer than people who never go to worship services. One reason associated with the longevity is the social support gained by a church community. One consistent key to happiness is weaving a network of support for yourself: We all need a security net. If you go to church regularly — and especially if you get involved in your parish or church community — that social support is provided. Also, regular churchgoers are more likely to GIVE support to others, and this act of generosity, or any altruistic activity, really, promotes better health.

Faith Provides Heroes and Inspiration

We do better navigating the dark night when we know people have walked the same steps before us and arrived at the light. Different faith traditions offer us plenty of heroes we can turn to for inspiration. Like my mom, I have always maintained a strong devotion to St. Thérèse of Lisieux, my patron saint. In my deepest depressions, I would read her Story of a Soul over and over again, trying to imitate her faithfulness and little ways despite her despair at the end of her life. So many of the saints have known profound anguish and depression, which is why they can be helpful guides to anyone with inner pain.

Have Faith

Give More

Expect Less

Be true To You….JmaC