# Types of Bipolar Disorder



## David Baxter PhD (Mar 16, 2009)

Types of Bipolar Disorder
_Bipolar Chick Blog_
Sunday, March 15th, 2009 

The bipolar classifications in this post are loosely paraphrased from the _DSM-IV_ (_Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition_) published by the American Psychiatric Association, research by the National Institute of Mental Health, and interviews with leading bipolar experts.

*Bipolar I*
This is the most severe type of bipolar disorder and the classic type. A diagnosis of Bipolar I requires at least one full-blown manic episode some time during a per-son?s life that doctors cannot attribute to another cause, such as a medication or substance abuse. The manic episode must last at least one week, or be serious enough to require hospitalization or cause functional impairment in some aspect of a person?s life (marriage, career, finances, etc.). Interestingly, a major depressive episode is not required to be diagnosed with this form of bipolar disorder, but it is almost always present and usually even much more common than the manic episodes.

*Bipolar II*
Most experts agree that there are versions of bipolar disorder that don?t produce full mania, yet respond very well to mood-stabilizing medications. People whose symptoms fit this category are often diagnosed with Bipolar II, sometimes called ?soft? bipolar. According to Dr. Ghaemi, the primary difference between Bipolar I and Bipolar II is that the manic symptoms of the latter are not severe enough to cause functional impairment.

?With Bipolar II, the sufferer won?t become so grandiose that he or she loses his job,? says Dr. Ghaemi. ?They will be much more active than normal, but they won?t have problems due to those activities.?

To be diagnosed with Bipolar II, a person must experience at least one major depressive episode that doctors can?t attribute to another cause and at least one episode of hypomania during his or her lifetime. People with Bipolar II never experience a full-blown manic episode. If they do, their diagnosis would likely be upgraded to Bipolar I. Again, usually there are many more depressive than hypomanic episodes.

*Cyclothymic Disorder*
Sometimes called ?bipolar lite,? this diagnosis requires multiple depressive and hypomanic episodes not extreme enough to warrant a diagnosis of Bipolar I or II. In some cases, depression and mania occur simultaneously, resulting in a state of chronic irritability. A person?s symptoms must last for at least two years with no more than two months of stable mood during that time. Some people with Cyclothymic disorder go on to develop a full-blown mixed or depressive episode, which usually leads doctors to upgrade their diagnosis to Bipolar I or II. Usually these symptoms are so mild that persons with this condition do not seek treatment. This variety can be seen as the personality manifestation of bipolar disorder in some people. If symptoms are severe enough to cause problems, then Cyclothymia usually is not the diagnosis, but rather type I or type II Bipolar Disorder.

*Bipolar NOS (Not Otherwise Specified)*
This form of bipolar requires manic or depressive episodes that doctors can?t categorize as unipolar depression. The episodes also can?t fit into any of the other bipolar categories. The Bipolar NOS label often applies in the following circumstances:


Rapid mood fluctuations intense enough to qualify as manic, hypomanic, or depressive, but that don?t meet the duration requirements for a Bipolar I, Bipolar II, or Cyclothymic disorder diagnosis
Hypomania without depression
Mania or Cyclothymic disorder that occurs simultaneously with schizophrenia, psychotic disorder NOS, or delusional disorder (a disorder characterized by psychoses, hallucinations, and delusional thinking)
Chronic depression or dysthymia (long-term, low-level depression) accompanied by hypomanic episodes.
Dr. Ghaemi suggests that this category also be used for persons with recurrent severe depression (but no clear hypomania) who also experience manic or hypomanic periods only with antidepressant use, or who have family members diagnosed with bipolar disorder.

*Rapid-Cycling*
Rapid-cycling isn?t a separate type of bipolar disorder; it is a descriptor of the course of bp. It is more common in women than in men. To qualify as rapid-cycling, a person must experience four or more episodes (depression, mania, hypomania, or mixed state) in a year. The episodes must be full-blown and, in the case of mania or mixed state, last at least one week or result in hospitalization. A depression must last at least two weeks and a person?s hypomania must last at least four days. This term does NOT mean that one?s moods fluctuate on a day by day, or hour by hour basis. Such short-term mood shifts are common in mania and mixed episodes, and are not themselves diagnostic of anything.

*Major Depressive Episode*
To have a major depressive episode, a person must have five or more of the following symptoms that last for at least two weeks:


Depressed mood-feeling hopeless, sad, discouraged, or empty
Markedly diminished interest in activities previously considered pleasurable, including sex
A decrease or increase in appetite that lasts for two weeks
Sleeping too much or too little
Moving uncharacteristically slowly, both in mind and body
Fatigue
Feelings of worthlessness, excessive guilt, or inappropriate guilt
Uncharacteristic indecisiveness or diminished ability to think clearly or concentrate on a given task
Recurrent thoughts of death or suicide.
Any of the following can disqualify the episode from reaching major depression status:


Something terrible happened before a person became depressed, such as the death of a loved one, a divorce, or a job loss. (In other words, the person has a good reason to feel depressed.)
A person is dealing with substance abuse, such as heavy drinking.
The depression is a component of a mixed episode.
*Manic Episode*
A manic episode isn?t ?official? unless it lasts for at least one week or requires hospitalization. The episode also must be characterized by an ?abnormally and persistently elevated, expansive, or irritable mood.? In order to qualify as a bona fide manic episode, the mania must be severe enough to cause harm to some aspect of a person?s life, such as their interpersonal relationships, job, or physical functioning. The mania also must not be substance-induced. Three of the following symptoms must also be present during the week; four if a person?s mood is irritable rather than euphoric.


Euphoric mood, feeling ?high,? or excessively optimistic
Inflated self-importance or grandiosity
Extreme irritability, exhibiting behavior that is aggressive, provocative, or intrusive
Decreased need for sleep (feeling well-rested after just a few hours of sleep)
Extremely talkative and sociable, pressure to keep talking
Increased activity
Racing thoughts
Inability to concentrate
Easily distracted by insignificant external stimuli
Significant increase in goal-directed activity or significant speeding up of thoughts and physical movement (such as planning to remodel the kitchen in less than a week, or moving on a whim to Nashville to become a country singer)
Excessive involvement in risky, potentially self-destructive activities, including sexual indiscretions, gambling, unrestrained shopping sprees, and investments in pyramid schemes
Impaired judgment, i.e., no perception that the mood and behaviors are abnormal.
Dr. Ghaemi notes that about 25 percent of patients with manic episodes have classic impulsive sexual or spending behaviors. Thus, the absence of those behaviors does not rule out bipolar disorder. Further, only about 25 percent of patients with manic episodes have euphoric mood; the majority have depressed or irritable mood. Thus, the absence of euphoria also does not rule out mania.

*Hypomanic Episode*
Hypomania is a less-intense mania that doesn?t last as long as a full-blown mania and doesn?t cause significant problems with interpersonal relationships or one?s job. Hypomania may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. A person?s mood must be elevated above his or her normal state and display characteristics that others believe are slightly out of character for the person. The episode must last at least four days. Hypomania presents in two forms-euphoric and dysphoric-and can last for a few hours or several weeks. According to Jim Phelps, MD, an Oregon-based psychiatrist and author of _Why Am I Still Depressed? Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorder_, euphoric hypomania feels good and is sometimes productive, but dysphoric hypomania produces irritability, impulsiveness, uncontrollable temper, and impaired judgment. The hypomania frequently alternates with episodes of depression; it almost always accompanies mood instability.

*Mixed Manic Episode*
Mixed states are found in Bipolar I, Bipolar II, and Bipolar spectrum disorders. They are more common in women and are often associated with thyroid abnormalities, lack of response to lithium (the standard treatment for Bipolar I disorder), and antidepressant-induced worsening of symptoms. To qualify, an episode must simultaneously meet the requirements stipulated for a major depressive episode and a manic episode. A person?s symptoms must occur nearly every day for a week straight.

Diagnosis of mixed states is most likely to be made after a patient fails to respond to outpatient treatment, or becomes worse on antidepressant medications and is subsequently admitted to the hospital for closer observation. Misdiagnosis of these conditions is common, leading to delays in effective treatment and a higher risk of suicide. Thus, any depressed patient should be carefully assessed for manic symptoms too: they could be suffering from a mixed episode in disguise.

*Psychosis*
This can accompany depression or mania, but is not required to receive a bipolar diagnosis. Psychosis is marked by delusional thinking, paranoia, and visual or auditory hallucinations. It can accompany either an extremely high or extremely low mood episode. The extremes of depression and, more often, mania can shock the mind to such a degree that it begins to experience self-destructive or grandiose beliefs, becomes obsessed with fears that have no basis in reality, or sees or hears things that are not real. Although psychosis sounds dramatic and easily identifiable, it can be subtle and blended with enough reality to make ?psychotic? seem more like ?unusually perceptive.? It can include:


A person thinks he or she has special powers.
They hear voices that other people can?t.
They believe that people can read their mind.
They think that the television or radio is sending them special messages.
They believe people are following them or trying to harm them when they?re not.
They believe that they can accomplish things that they can?t.
They believe they are someone they are not-like God or a famous person in history.
*Suicide*
Some people with bipolar disorder become suicidal. Risk for suicide appears to be higher earlier in the course of the illness. Therefore, recognizing bipolar disorder early and learning how best to manage it may decrease the risk of death by suicide. Signs and symptoms that may accompany suicidal feelings include:


Talking about feeling suicidal or wanting to die
Feeling hopeless, believing that nothing will ever change or get better
Feeling helpless, believing that nothing one does makes any difference
Feeling like a burden to family and friends
Abusing alcohol or drugs
Putting affairs in order (such as organizing finances or giving away possessions to prepare for one?s death)
Writing a suicide note
Putting oneself in harm?s way, or in situations where there is a danger of being killed.
Suicide risk is highest with mixed episodes, followed by major depressive episodes, but suicide is relatively uncommon in pure manic episodes. Lithium has been shown to prevent suicide based on relatively strong evidence, according to Dr. Ghaemi, a major benefit that has not been consistently shown for any other psychotropic medication (in particular antidepressants).


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## Atlantean (Mar 16, 2009)

This has actually been helpful in understanding why I have been continually labelled bipolar, though I have constantly believed this not to be the case. 

I dont suffer the depressive episodes and just experience primarily hypomanic states of being, but I dont get the bouts of depression that accompany it.

I think its a grave misnomer to call someone whos always hypomanic "bipolar" because there is no bipolar opposite or extreme mood swing, and I think this definition needs serious revision. I suppose the ADHD doesnt help.  '-)

Additionally, I have never responded to bipolar meds.


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## stargazer (Mar 18, 2009)

Symptoms of ADHD can be very similar to those of bipolar.  You might want to seek a second-opinion diagnosis, Atlantean, especially if you're not responding to bipolar meds.  Just a thought - not from a professional, but from a fellow bipolar (or a bipolar fellow, or something like that).  :jiggy:


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## Atlantean (Mar 18, 2009)

Hi, StarGazer.

  I actually have been diagnosed with both ADHD and Bipolar, so who knows where the one ends and the other begins.


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## stargazer (Mar 18, 2009)

I had gathered you were given both diagnoses, but your saying that you don't respond to bipolar meds is what got me to thinking you might not be bipolar, but only ADHD - especially if you *never* experience the depressive cycle of a bipolar mood swing.  That's why I suggested your seeking a second doctor's opinion, being as perhaps it might be construed that you are only ADHD.  I'm also curious - do you respond to ADHD meds?  

Again, I need to disclaim that (as you know) I am not a doctor.  But these seem to me to be logical questions.  For the record, my most recent primary care physician was more-or-less forced by the system into the position of prescribing me bipolar meds, as my insurance was unable to cover a pscyhiatrist in that County, for complex reasons.  At our first meeting, she told me - without my so much as even proffering any of the above information - that she suspected I was actually ADHD and not bipolar.  

Meds for bipolar might differ radically from those for ADHD, so this has been a concern of mine, especially seeing as a good friend of mine has been diagnosed with both by two different doctors.  He was responding well to ADHD meds, then went for a second opinion where a new doctor diagnosed him bipolar.  After being given lithium by the second doctor, he began to make extremely erratic decisions, both personally and professionally.

Anyway, I just think it's something to consider.  For the record, I think my primary care physician was wrong, since I definitely have depressive phases (more lately than usual, I've noticed), although my usual mood-state might be characterized more frequently as hypomanic.


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## Jazzey (Mar 18, 2009)

I've never heard of Major Depressive Episodes being placed in the bipolar disorder category.  Is it typical for it to be placed here?


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## Atlantean (Mar 18, 2009)

stargazer said:


> I had gathered you were given both diagnoses, but your saying that you don't respond to bipolar meds is what got me to thinking you might not be bipolar, but only ADHD - especially if you *never* experience the depressive cycle of a bipolar mood swing.  That's why I suggested your seeking a second doctor's opinion, being as perhaps it might be construed that you are only ADHD.  I'm also curious - do you respond to ADHD meds?  <snip>



I havent been on ADHD meds since I was ten, but at the time I was on 50mg of Ritalin a day, and it made no impact one way or the other. Its use wasnt counter-indicated by an increase in energy, but it never was therapeutic, either. My last counselor thought about recommending possible meds for the ADHD, but it never got past that.

I am going to have to have a talk with my psychistrist though, because since I cant take my full dose of sleep meds at night (or I wont wake up when the baby wakes up), I havent been sleeping well and my thoughts and everything related to my brain seems to be cycling at faster speeds, part of which I also think is caused by the increase in stress since my husband left.

 Im concerned he will take me off the thorazine altogether which really scares me, but I am hoping we find find something to supplement the lower dosage with. Ambien doesnt work on me, I either just lay there or experience mild hallucinations, but I think I might try asking about Lunesta, which is either similar to or related to the Imovane which was what Dr. Baxter recommended.


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## David Baxter PhD (Mar 18, 2009)

stargazer said:


> I had gathered you were given both diagnoses, but your saying that you don't respond to bipolar meds is what got me to thinking you might not be bipolar, but only ADHD - especially if you *never* experience the depressive cycle of a bipolar mood swing.  That's why I suggested your seeking a second doctor's opinion, being as perhaps it might be construed that you are only ADHD.  I'm also curious - do you respond to ADHD meds?
> 
> Again, I need to disclaim that (as you know) I am not a doctor.  But these seem to me to be logical questions.  For the record, my most recent primary care physician was more-or-less forced by the system into the position of prescribing me bipolar meds, as my insurance was unable to cover a pscyhiatrist in that County, for complex reasons.  At our first meeting, she told me - without my so much as even proffering any of the above information - that she suspected I was actually ADHD and not bipolar.
> 
> ...



Frankly, from what I've seen, I don't think there is any doubt whatsoever that both of you meet the criteria for bipolar disorder. You may or may not meet the criteria for ADHD as well.


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## Atlantean (Mar 18, 2009)

LOL, OMG, is it that obvious?  :noidea:


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## Into The Light (Mar 18, 2009)

Jazzey said:


> I've never heard of Major Depressive Episodes being placed in the bipolar disorder category.  Is it typical for it to be placed here?



i think they are saying depression is part of the bipolar disorder - or am i misunderstanding your question?


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## Jazzey (Mar 18, 2009)

That was my question   I've never understood that it was part of bipolar disorder.


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## Atlantean (Mar 18, 2009)

yes, depressive episodes are frequently experienced with most types of bipolar disorder.


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## Jazzey (Mar 18, 2009)

Thanks Atlantean...I guess I thought it was part of a distinct diagnosis - "depression"   Given my family history, it shouldn't be such a shocker.  Just a little surprised because none of my medical health providers have quite put it under this umbrella before...


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## Into The Light (Mar 18, 2009)

people who do not have bipolar disorder but who do suffer from major depression are sometimes said to suffer from "unipolar depression":

About Depression - Information and Support for Depression


> The term unipolar depression is used to distinguish it from depression which occurs within the context of bipolar disorder, a disorder in which a person experiences alternating periods of depression and mania.



so yes, bipolar disorder often involves both the extreme highs (mania) and the extreme lows (depression), which is why it is called bipolar (two polars).


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## Atlantean (Mar 18, 2009)

Regarding 'unipolar depression', I was once also diagnosed with unipolar hypomania.


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## Jazzey (Mar 18, 2009)

Thanks Atlantean.  I really find all of this interesting only because I didn't realize just how little I knew or understood about my own diagnosis. 

I'll be very honest, I've often wondered if I'm not bipolar.  But that's just a personal impression based on how I feel - and this is not a diagnosis I've ever received from medical professionals.  

I have been diagnosed with major depression.  I guess tonight's conversation just means more questions for my psychologist during my next session.


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## Atlantean (Mar 18, 2009)

No problem. Personally I think as a non-psychiatric professional bipolar is the hardest "disorder" to understand. it comes as including mood swings and bouts of hypomania and depression, as depression alone, and hypomania alone. I dont get how it can be "bipolar" if only one end of the extreme is being experienced, it seems to directly conflict with the label of "bipolar" which directly indicates opposite extremes or polarity.


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## stargazer (Mar 18, 2009)

David Baxter said:


> Frankly, from what I've seen, I don't think there is any doubt whatsoever that both of you meet the criteria for bipolar disorder. You may or may not meet the criteria for ADHD as well.



I don't doubt that *I'm* bipolar, but the reason why I wonder about Atlantean is that she is reporting the following:

(1) she never experiences the depressive end of the cycle

(2) she doesn't respond to bipolar meds.

That's why I wonder how she got that diagnoses.  Was it from an initial manic episode?


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## Atlantean (Mar 18, 2009)

stargazer said:


> I don't doubt that *I'm* bipolar, but the reason why I wonder about Atlantean is that she is reporting the following:
> 
> (1) she never experiences the depressive end of the cycle
> 
> ...



Thats why I doubt it, as well. I dont even experience the typical behavior problems associated with manic episodes (Like excessive spending, poor impulsive decisions, etc..) I just seem to function in a generally hypomanic state. But, according to the article that Dr. Baxter posted, there is a bipolar classification that allows for that, though it makes absolutely no sense to me.


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## Always Changing (Jul 3, 2009)

I think this thread may help answer your question Atlantean

Bipolar Disorder Q&A: Can someone have bipolar without depression?


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## stargazer (Jul 20, 2009)

stargazer said:


> For the record, I think my primary care physician was wrong, since I definitely have depressive phases (more lately than usual, I've noticed), although my usual mood-state might be characterized more frequently as hypomanic.



It's been quite a while since I posted the above, and I am now trying to make sense of it.  I don't remember how, in my mind, I was relating the fact that I experience depression to the idea that I must not be ADHD.

For the record, I read about bipolar disorder all the time, but I haven't really read very much on ADHD, and maybe I should.  Other people besides that doctor have told me they thought I might be ADHD as well.

The doctor, however, did seem to make the observation somewhat casually, in a very brief meeting that took place primarily for the purpose of her prescribing some meds that I had been unable to receive through the County.  I still wonder what it was I was saying, or how I was acting, that led her to believe I might be ADHD.

Also for the record, I wasn't on meds when I saw her (which is why I needed to see her), and I wasn't on meds when I was making the earlier statements in this thread.  I'm on meds now, though.


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## Sara-Bella (Oct 28, 2009)

What if someone used to be periodically depressed as a child, often excitable as a tween, but people believed they were just extremely strange or 'maniacal' and it was their personality, but sometimes experienced crippling depression. And used to also have panic attacks. Often due to feeling trapped, and coincidentally has claustrophobia. Anyway, what if now they are rapidly switching between excitability and agitated depression, with the normal periods becoming shorter and shorter?


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## Banned (Oct 28, 2009)

I would say that their best bet to find out what, if anything is "wrong", is to a) get a full physical checkup including blood work and b) get a referral to a competent mental health professional who can properly assess them.


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## Sara-Bella (Oct 28, 2009)

They already had bloodwork done a few years back, and is getting an assessment in five weeks . . . but what if they can't pull through until then?


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## Banned (Oct 28, 2009)

They should specifically get their thyroid checked.  A cycling thyroid can mimic bipolar disorder.  

If they can't hang on til then, they need to make an app't with their doctor for sooner.  They need to find a strategy to hang on.  Do they have a therapist?


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## Sara-Bella (Oct 28, 2009)

The thyroid theory has already been ruled out long ago, but it is rapid cycling, between mild depression, elation and agitated depression, usually, with normal periods in between. It's all clear right now, but who knows how long that will last. And no, there is no therapist. I'm assuming that's what the assessment is for.


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## Sara-Bella (Nov 20, 2009)

I started taking Prozac exactly a week ago, and since a few days ago, I have been BOUNCING OF THE WALLS! All the symptoms of mania, and my parents are 'freaked out' by my behaviour. All I know is that I feel really, REALLY good. I heard that sometimes anti-depressants, specifically SSRIs can induce mania. Is this true? (All the staff at the hospital are confused by me right now)


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## Daniel (Nov 20, 2009)

> I heard that sometimes anti-depressants, specifically SSRIs can induce mania. Is this true?



Yes, at least in people with bipolar disorder.


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## David Baxter PhD (Nov 20, 2009)

Daniel is correct. Make sure that your doctor(s) know about this.


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