bipolar disorderMental health clinicians and researchers in the fields of human behavior differentiate between the terms mood and affect in order to distinguish descriptive sources or observations on how an individual experiences or displays their emotions.

The term mood is used when someone describes their own particular emotions or feelings, whereas the term affect is used when some outside observer infers another person’s feelings by their behavior or presentation.

The difference may seem trivial to individuals who are not involved in diagnosing mental health disorders or researching them; however, it does represent a qualitative difference in understanding how emotions are experienced, displayed, and used in diagnostic and research venues. Psychological/psychiatric disorders that present with alterations in mood as their major diagnostic feature are assessed by both trying to understand the person’s mood and descriptions of their affect.

Bipolar disorder has been a disorder that has been described early in the history of psychiatry as presenting as alterations in extremes of mood and affect. It was one of the first formal diagnostic categories pronounced.

Bipolar Disorder Basics

Bipolar disorder was originally described as manic-depression, and despite some confusion regarding these terms in lay circles, they refer to the same disorder. The term bipolar was used to describe the severe transitions that these individuals display between two different endpoints or poles of mood and affect (mania on the one endpoint, and depression on the other).

Until recently, bipolar disorder was described as a specific type of mood disorder – psychiatric/psychological disorders where the primary presentation was based on disturbances of mood (and affect). However, recent research is indicated that bipolar disorder may actually represent a type of bridge between depression and psychotic disorders such as schizophrenia. Thus, the current diagnostic classification system used by the American Psychiatric Association now lists bipolar disorder in a separate category interspaced between the psychotic disorders and the depressive disorders.

Despite this rearrangement of categories, the diagnostic criteria for bipolar disorder remain relatively unchanged and for the most part consistent with the presentation described in the late 1800s and early 1900s by the eminent psychiatrist Emile Krapelin.

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Symptoms of Bipolar Disorder

Bipolar disorder is diagnosed when individuals present with alterations in mood and affect that range from extremely active, irritable, and manic type behavior and presentations consistent with the notions of major depressive disorder (e.g., depression). The American Psychiatric Association lists separate diagnostic criteria for presentations associated with mania or hypomania and the presentations associated with depression. Is important to understand  that when a clinician makes a diagnosis of bipolar disorder, it is done so by observing the individual’s affect as well as gathering subjective descriptions of their mood state, even though the formal diagnostic criteria appear to represent descriptions of affect only.

The formal diagnostic criteria for mania/hypomania and depression will not be presented here. The general signs and symptoms of manic episodes include:

A period of at least one week where the person experiences abnormally elevated or irritable mood states that include at least three or more of the following:

  • Increased energy
  • Grandiose behavior or inflated self-esteem
  • Extreme talkativeness
  • A flight of ideas or racing thoughts
  • Extreme distractibility
  • An increase in activity (this can be goal-directed activity, such as housecleaning or work-related activities, or non-goal-directed activity, such as pacing, purposes repetitive physical acts, etc.)
  • A markedly decreased need for sleep
  • Excessive involvement in activities that can be potentially dangerous or harmful, such as engaging in sex with numerous partners, gambling sprees, shopping sprees, etc.
  • This presentation cannot be better explained by the use of drugs/medications or by some other medical condition, and must result in impairment in the individual’s functioning.

Hypomania is a less intense presentation of manic symptoms. It is characterized by the same type of symptoms except that the duration of hypomania is four days or more, and the symptoms are not quite as intense. Typically, mania is characterized by extreme energetic and animated behaviors that include feelings of enhanced self-esteem, whereas hypomania is characterized by feelings of irritability.

The depressive aspect of bipolar disorder essentially mimics the same symptoms of major depressive disorder. There are a total of nine overall symptoms that can be used to diagnose major depressive disorder. The individual must present with five or more of these nine potential systems in the same two-week period and at least one symptom must be either depressed mood or an inability to experience pleasure (or a loss of significant interests).

Other symptoms of depression include:

  • Issues with sleeping, such as sleeping too much (hypersomnia) or sleeping too little (insomnia)
  • Significant loss of appetite and/or weight loss or significant increase in appetite and/or weight gain when the individual is not intentionally trying to lose or gain weight
  • Extreme fatigue or energy loss, or extreme periods of restlessness and irritability
  • Issues with thinking that include problems with attention, memory, and judgment
  • Presenting as if moving in slow motion or extremely indecisive
  • Feelings of guilt, worthlessness, and even feelings of self-harm, including suicidal feelings

The individual will typically experience manic or hypomanic episodes for a period of four days to two weeks, whereas depressive episodes are much longer and may last for months at a time.

The Types of Bipolar Disorder

Technically, there are only two types of bipolar disorder recognized by the American Psychiatric Association and other diagnostic entities:

  • Bipolar I disorder: The person has experienced at least one manic episode. They may or may not have experienced depression or hypomania, but when the individual has experienced one formal manic episode, they are diagnosed with bipolar I.
  • Bipolar II disorder: This diagnosis is made when the individual experiences episodes of hypomania, and may or may not experience episodes of depression. No manic episodes have ever been diagnosed.

Technically, those are the only types of bipolar disorder; however, many individuals consider certain presentations of bipolar disorder as different “types.” Technically, this is not correct. These different presentations are termed diagnostic specifiers, which are used to describe the most current symptoms associated with the person’s bipolar disorder. These symptoms/specifiers are presentations that stand out in the overall presentation of the individual’s bipolar disorder. This designation allows for clinicians to better treat the specific presentation of bipolar disorder and communicate to other clinicians the specifics of the individual’s case.

These specifiers include bipolar disorder with:

  • Anxious distress, where the presentation is primarily one of anxiety
  • Mixed features, presenting with mania/hypomania concurrently with depressive features
  • Rapid cycling, presenting with four or more episodes of mania, hypomania, or depression in a 12-month period
  • Melancholia, where the depression is primary loss of interest or pleasure
  • Atypical features, when depression presents with unusual features, such as weight gain or hypersomnia
  • Psychotic features, presenting with hallucinations or delusions that can be consistent with one’s mood (mood congruent) or inconsistent with one’s mood (mood incongruent)
  • Seasonal pattern, when the features reliably occur during different seasons
  • Catatonia, when the individual appears frozen in various poses during depression or repeatedly engages in stereotypic non-goal-directed behavior, such as hand flapping during mania
  • With peripartum onset, when symptoms occur during pregnancy or within four weeks of giving birth

Again, these presentations do not represent different “types” of bipolar disorder but different presentations of the same disorder. The use of different specifiers in diagnostic categories allows for targeted treatment aimed at individual presentations of specific disorders. Again, it is important to understand that these are not different “types” of bipolar disorder.

Cyclothymic Disorder

Cyclothymia represents a chronic, less intense presentation of hypomania and depressive episodes that do not fully meet the criteria for bipolar II. This chronic presentation must occur for at least two years. It is a separate disorder that is included in the category of bipolar disorder and related conditions. While many may view it as a “type” of bipolar disorder, it is not one; it is a separate disorder.

Bipolar Disorder due to a Medical Condition

This diagnosis is made when individuals present with the features of bipolar disorder, but these are due to a known medical condition, such as a thyroid condition, stroke, head injury, or other medical condition. These are not technically “types” of bipolar disorder as the symptoms are the result of some other medical condition.

Substance- or Medication-Induced Bipolar Disorder

Taking certain medications or drugs can produce symptoms of bipolar disorder. This category is offered for clinicians when it is known that the individual’s presentation is due to the effects of drugs or alcohol. This is not a type of bipolar disorder, but allows for the diagnosis of bipolar-like symptoms when the individual is known to abuse certain medications or drugs.

Sometimes, individuals will continue to display bipolar disorder-like symptoms after the detoxification period for the specific drug has passed. In these cases, clinicians would reassess the individual.

Others

substance induced bipolar disorder The diagnostic criteria for bipolar disorder are sometimes not always observed in the initial assessments of individuals, but conditions may be suspicious that the individual may be developing bipolar disorder, and there are alternatives to the diagnosis in these cases. The American Psychiatric Association offers a category: other specified bipolar and related disorder with four alternatives to allow clinicians to communicate with one another regarding the presentation of individuals who have bipolar-like symptoms but did not meet the full diagnostic criteria. These are not types of bipolar disorder, but represent conditions that may actually really be cases of bipolar disorder that are either not developed or the symptoms of bipolar disorder have not been observed.

In addition, individuals diagnosed with major depressive disorder often experience waxing and waning of their depression. In these presentations, individuals who were severely depressed may suddenly experience bursts of energy and feelings of wellbeing that are inconsistent with their former presentation. It can be tempting to diagnose these individuals with bipolar disorder; however, these presentations simply represent the well-known fluctuations of clinical depression.

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Bipolar Disorder and Substance Abuse

substance abuse As mentioned above, bipolar disorder-like symptoms can result from the use of medications or illicit drugs. Manic symptoms most often result from the use of stimulant medications, such as amphetamine, methylphenidate (e.g., Ritalin), and cocaine products, whereas depressive symptoms will often be associated with the use of central nervous system depressant drugs, such as narcotics and benzodiazepines. However, atypical reactions to drugs can present as bipolar-like symptoms, such as individuals becoming very irritable and agitated when they use marijuana, or individuals coming down from the use of stimulants, such as cocaine, presenting with severe apathy and depression.

All mental health disorders are often noted to be comorbid with substance use disorders and bipolar disorder is no exception. The most commonly abused substance in individuals with bipolar disorder is alcohol; however, individuals with bipolar disorder also have high rates of abuse of drugs like marijuana and central nervous system depressants. Individuals during depressive episodes may abuse stimulant medications.

Conclusions

Technically, there are only two types of bipolar disorder: bipolar I disorder and bipolar II disorder. However, there are a number of different presentations of bipolar disorder and a number of different conditions that can cause symptoms that mimic bipolar disorder. Because the diagnosis of these different conditions and disorders is complicated, only licensed mental health care clinicians can definitively diagnose bipolar disorder.

Often, understanding the origin of symptoms that mimic bipolar disorder and diagnosing bipolar disorder present significant quandaries even for experienced clinicians. Thus, it is not unusual for individuals to be diagnosed with depression, a personality disorder, or even a psychotic disorder before finally being diagnosed with bipolar disorders