Understanding Bipolar

What is Bipolar Disorder (BD) 

Bipolar Disorder (BD) (formally known as Manic-Depressive Illness) is a brain-based disorder that causes shifts in mood, energy and ability to function.  These shifts in mood move between feeling low or depressed and high energy states, known as mania or hypomania. 

These states are clinically different from just feeling happy or sad, they are periods of uncontrollable and pervasive mood shifts which affect a person’s ability to work and socially function. 

Mania 

Mania and hypomania are two distinct types of episodes in bipolar, but they have the same symptoms. Mania is more severe than hypomania and causes more noticeable problems at work/social activities, as well as relationship difficulties. Mania may also trigger a break from reality (psychosis) and require hospitalisation. 

Both a manic and a hypomanic episode include three or more of any of these common symptoms (the difference is in degree of severity): 

  • Abnormally upbeat, jumpy or wired 
  • Increased goal directed activity 
  • Grandiosity 
  • Increased activity, energy or agitation 
  • Exaggerated sense of well-being and self-confidence (euphoria) 
  • Decreased need for sleep 
  • Unusual talkativeness (pressured speech) 
  • Racing thoughts (jumping from one idea to another) 
  • Distractibility 
  • Poor or impulsive decision-making — going on buying sprees, taking sexual risks, unplanned travel, increased drug and alcohol use. 

 Types of Bipolar Disorder 

Bipolar Disorder is classified by the DSM V – Diagnostic and Statistical Manual of Mental Disorders (2013) into 4 distinct types: 

Bipolar I Disorder— defined by manic episodes that last at least 7 days, or by manic symptoms that are so severe that the person needs immediate hospital care or experiences psychosis (loss of touch with reality). Usually, depressive episodes occur as well, typically lasting at least 2 weeks. Episodes of depression with mixed features (having depression and manic symptoms at the same time) are also possible. 

Bipolar II Disorder— defined by a pattern of mostly recurring depressive episodes and mildly manic episodes called hypomanic episodes.  

Cyclothymic Disorder (also called cyclothymia)— defined by numerous periods of hypomanic symptoms as well numerous periods of depressive symptoms lasting for at least 2 years.  However, the symptoms are not severe enough to meet the diagnostic requirements for a hypomanic episode and a depressive episode. 

Other Specified and Unspecified Bipolar and Related Disorders— defined by bipolar disorder symptoms that do not match the three categories listed above. Refer to Bipolar Spectrum below. 

Clinicians may use the following differential diagnoses to describe Bipolar and Related Disorders:

With Anxious Distress – this is when a person feels keyed up/tense, is unusually restless, or has a feeling or fear that something awful may happen or they may lose control.

With mixed features –  A hypomanic or manic episode with mixed features would include symptoms that are typically found in a depressive episode (depressed mood, lack of interest or pleasure from activities, fatigue or loss of energy, etc.). A depressive episode with mixed features would include hypomanic or manic symptoms, such as elevated mood, inflated self-esteem, increased energy, risky behaviour, etcetera.

With rapid cycling – There have been at least four mood episodes in the previous 12-months that met the full criteria for mania, hypomania or major depressive episodes. This specifier can be used with bipolar I and II diagnoses.

With atypical features – this is when symptoms occur with mood reactivity. For example, the person’s mood brightens when good things happen, when they gain weight or have an increase in appetite, sleep more than usual, or have heavy almost paralysing feeling in their arms and legs.

With psychotic features – this is used when delusions and/or hallucinations are experienced. When the delusions and/or hallucinations are consistent with typical manic feelings such as inflated sense of self-esteem, being invulnerable, or feeling suspicious or paranoid, they are said to be mood-congruent. When they do not follow typical manic feelings, but are instead the opposite or a mixture of the two, they are known as mood-incongruent.

With peripartum onset – this is used if the onset of hypomania, mania or major depressive disorder occurs during pregnancy or in the 4 weeks following childbirth. This is just when the symptoms first appear, but they may last longer than the noted four weeks. Because 50% of ‘postpartum’ episodes begin during pregnancy, this category is now called peripartum rather than postpartum.

With catatonia – In this case, a person displays one or many unusual movements and mannerisms, including a stupor, excessive movement, mutism or posturing.  For example, a person sitting on a park bench who seems unable to stop imitating gestures and words of passers-by might be suffering from a bipolar disorder with catatonic features.

With seasonal pattern – this occurs when a person experiences mood symptoms at a particular time of year, and then feels a lifting of symptoms at other times of the year on a regular basis for the past two years.

 

Tests for Bipolar Disorder

For some reliable self tests that you can take and share with your doctor I recommend these 2 below:

Take the Black Dog Institute diagnostic test here. 

Or the widely used Mood Disorder Questionnaire MQQ here. 

To book a thorough personal assessment with me today click here.

Types of Depressive Disorders 

Depressive disorders are classified into 3 categories according to the DSM V – Diagnostic and Statistical Manual of Mental Disorders (2013): 

Major Depressive Disorder (MDD) 

A major depressive episode includes depressive symptoms that are severe enough to cause noticeable difficulty in day-to-day activities, such as work, school, social activities or relationships. An episode includes five or more of these symptoms for at least 2 weeks consistently: 

  • Depressed mood, such as feeling sad, empty, hopeless or tearful (in children and teens, men – depressed mood can appear as irritability) 
  • Marked loss of interest or feeling no pleasure in all — or almost all — activities 
  • Significant weight loss (when not dieting), weight gain, or decrease or increase in appetite 
  • Either insomnia or sleeping too much 
  • Either restlessness or slowed behavior 
  • Fatigue or loss of energy 
  • Feelings of worthlessness or excessive or inappropriate guilt 
  • Decreased ability to think or concentrate, or indecisiveness 
  • Thinking about, planning or attempting suicide  

Disruptive Mood Dysregulation Disorder (DMDD) (Children)

The defining characteristic of disruptive mood dysregulation disorder (DMDD) in children is a chronic, severe, and persistent irritability. This irritability is often displayed by the child as a temper tantrum, or temper outburst, that occur frequently (3 or more times per week). When the child isn’t having a temper outburst, they appear to be in a persistently irritable or angry mood, present most of the day, nearly every day. As the DSM-5 Fact Sheet says, “Far beyond temper tantrums, DMDD is characterized by severe and recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation.” 

This disorder, which was new to the DSM-5 in 2013, was created in an effort to replace the diagnosis of childhood bipolar disorder.

Persistent Depressive Disorder (PDD) 

A continuous long-term form of milder depression symptoms previously known as Dysthymia. 

Persistent depressive disorder symptoms usually come and go over a period of years, and their intensity can change over time. But typically, symptoms don’t disappear for more than two months at a time. In addition, major depressive episodes may occur before or during persistent depressive disorder — this is sometimes called double depression. 

Symptoms of persistent depressive disorder can cause significant impairment and may include: 

  • Loss of interest in daily activities 
  • Sadness, emptiness or feeling down 
  • Hopelessness 
  • Tiredness and lack of energy 
  • Low self-esteem, self-criticism or feeling incapable 
  • Trouble concentrating and trouble making decisions 
  • Irritability or excessive anger 
  • Decreased activity, effectiveness and productivity 
  • Avoidance of social activities 
  • Feelings of guilt and worries over the past 
  • Poor appetite or overeating 
  • Sleep problems 

 

Distinguishing Bipolar Disorder (BD) from Unipolar Depression (Major Depressive Disorder) (MDD) 

The Bipolar Spectrum 

Bipolar clinicians and researchers have more recently moved towards a spectrum model of understanding, where Bipolar is no longer thought of as a discrete disorder (that is Bipolar I or II).  The spectrum now runs along a continuum which connects unipolarity and bipolarity.  This Spectrum model identifies and includes those people that may lie diagnostically between Major Depressive Disorder (MDD) and Bipolar Disorder (BD).  That is, they may not make criteria but they still experience symptoms and impairment and may better respond to mood stabilising medications rather than anti-depressants. 

A spectrum model of mood disorders as seen in the figure below better describes what we see as clinicians in patients than a yes/no or Bipolar I/II system.  Rather than asking “Does this patient have Bipolar Disorder or not?” we now start to ask “How Bipolar are they?” and to place them on the spectrum (Phelps, 2016) 

For further reading I highly recommend: 

Dr Ghaemi and colleagues in their 2002 review characterised Bipolar Spectrum Disorder as the presence of certain bipolar markers in the absence of a history of identifiable hypomania: 

These diagnostic markers for Bipolar Spectrum Disorder are (WHIPLASHED): 

W  worse or “wired” when taking an anti-depressant 

H  Hypomania, hyperthymic temperament, or mood swings by history 

I  Irritable, hostile, or showing mixed features in depression 

 Psychomotor (retardation or agitation) 

 Loaded family history of affective illness (not necessarily just bipolar disorder) 

Abrupt onset or termination of episodes 

S  Seasonal or postpartum pattern of depression 

 Hyperphagia (over eating) or hypersomnia (over sleeping) 

E  Early age of onset of depression (18-24yrs) 

 Delusions, hallucinations, or other psychotic features 

 

 

What Bipolar ISN’T

The following conditions can either mimic Bipolar or exist co-morbidly (side by side with it).

  • Endocrine problems (such as hyperthyroidism)
  • Neurological problems (such as brain tumours)
  • Autoimmune disorders (such as lupus)
  • Other psychiatric mood disorders (such as borderline personality disorder or schizophrenia)
  • Chronic and/or clinical depression (the most common misdiagnosis in bipolar)
  • Reactions to certain medications
  • Attention deficit hyperactivity disorder (ADHD), especially in young children
  • Conduct Disorder, especially in young children
  • Substance abuse

Basically the best diagnoses are made by those experts who are noted for treating bipolar disorders. They can see past the co-exisiting anxiety disorders, the depressive state, and the many overlapping symptoms of this illness.  Although there are several diagnostic questionnaires that can accurately determine mood disorders and/or depression, tests for determining the more subtle symptoms of bipolar disorder, including hypomania and Bipolar II, are scarce.  In an attempt to prevent bipolar from being misdiagnosed, several of the pioneers in bipolar disorder research devised a tool that could detect subtle hypomania and untreated bipolar disorder.  Called the HCL-32 (or Hypomanic Checklist), it was found to distinguish major depression from bipolar disorder in 51-81 percent of patients first tested.  Take the HCL-32 Test Here

What Is The Best Way for Me to Think About The Diagnosis?

Bipolar disorder is not a life sentence. Having bipolar disorder doesn’t mean you have to give up your identity, hopes, and aspirations. Try to think about bipolar in the same way you would think of diabetes or high blood pressure. That is, you have a chronic illness that requires you to take medication regularly and make appropriate lifestyle choices. Taking medication over the long term markedly reduces the changes that your illness will interfere with your life. Whilst there are some changes to lifestyle, none of these changes require that you give up your life goals, including having a successful career, maintaining good friendships and family relationships, having romance, or getting married and having children.

Many Creative, productive people have lived with this illness. Bipolar is one of a very small set of illnesses that may have an upside to it: people who have it are often highly productive and creative. Some of the most influential people in art, literature, business, and politics have had the disorder including Einstein, Van Gogh, Hemingway and Isaac Newton.

Try to maintain a healthy sense of who you are and think about how your personality strengths can be drawn on in dealing with the illness. Use your personality strengths to help you deal with your illness and treatment. For example if you are assertive, sociable, and intellectual use these inclinations to ensure you get proper medical treatment and learn as much as you can about your illness. Doing so may generate a feeling of continuity between who you used to be and who you are now.

The way you feel right now is not necessarily the way you will feel in three months, six months, or a year. In all likelihood with proper treatment you will return to a state that is close to where you used to be, or at least that is more manageable. In the same way that someone who has had a bad viral flu has to stay in bed for another few days after the worst symptoms have cleared, you may need a period of convalescence before you can get back to your ordinary routines and functioning.

Although bipolar disorder is a lifelong and sometimes chronic condition, you can manage your mood swings and other symptoms by following a treatment plan devised along with a knowledgeable psychologist or health professional that includes medication and lifestyle accommodations. Prevention of episodes is essential for positive lifetime outcomes so please seek help today.

Navigating the world of mood disorders and symptoms is difficult to understand and determine.  Many people wait for over 10 years to receive a correct diagnosis and up to 40% receive a wrong diagnosis!  The correct diagnosis and prevention of episodes is essential to stop the progressive nature of this disorder so please seek help today.
Let me help you understand – book a consultation today.

 

 

 

References

Diagnostic criteria sourced from the Mayo Clinic: https://www.mayoclinic.org/

Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. http://www.psychiatryonline.org.

Phelps, James (2016) Spectrum Approach to Mood Disorders – Not fully Bipolar But Not Unipolar – Practical Management. W.W. Norton & Company

Ghaemi SN, Ko JY, Goodwin FK. “Cade’s Disease” and beyond: misdiagnosis, antidepressant use, and a proposed definition for bipolar spectrum disorder. Can J Psychiatry. 2002 Mar; 47 (2):125-34.

Specifiers for Bipolar and Related Disorder, Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D., edited by Kathryn Patricelli, MA