Categorizing Bipolar Disorder

Bipolar disorder explained

/ Author:  / Reviewed by: Robert Carlson, M.D

Everyone goes through phases of highs and lows.

You get a new job and feel particularly up for a month - you go through a break up and feel down for a while. However, for those with bipolar disorder the normal swings between highs and lows become severe and extremely disruptive to normal life functions and relationships.

How these up and down phases occur and the symptoms associated with them determine the type of bipolar disorder at play.

Understanding the differences between the subsets can lead to more effective treatment for patients and better coping for all involved, including friends and family.

Understanding Bipolar Disorder

Bipolar disorder, or manic-depressive illness, often develops in the early twenties or late teenage years. Its severe symptoms cause abnormal and extreme changes in energy, mood, sleep, behavior and activity levels, often resulting in problems for the sufferer at work or school and in relationships.

These changes occur in periods called “mood episodes.” These mood episodes are intense and separate phases - either of overexcitement in a manic episode or extreme hopelessness in a depressive episode. (A “mixed state” can occur when a mood episode includes symptoms from both extremes.)

During a manic period, the patient might be overly “up” or outgoing, coupled with feeling agitated and jumpy. They often jump quickly from idea to idea and are restless and sleep little. Patients in a manic state might have an inflated view of their own abilities and take on new projects rapidly. They behave impulsively and are in high pursuit of pleasure - which according to the National Institute of Mental Health (NIMH) can often result in high-risk behaviors like drug use, impulsive sex, risky investments or shopping sprees.

During a depressive period on the other hand, the patient can feel completely empty or lost for a long period of time. They might lose interest in normally enjoyable activities and feel tired often. They can have trouble making decisions or concentrating. A change in eating or sleeping habits is often a sign of a depressive episode, and patients might think of death or suicide during these periods.

Regardless of what type of mood episode the patient is experiencing, they are typically irritable and explosive during these times. At first, the symptoms might seem like separate issues, often making it difficult to identify bipolar disorder initially.

Though the basic symptoms are generalized for all patients, the Diagnostic and Statistical Manual of Mental Disorders (DSM) separates the disorder into four types, each with different time frames and distinctions.

Bipolar I Disorder
For people with Bipolar I Disorder, manic or mixed mood episodes that last a minimum of seven days and sometimes depressive episodes lasting a minimum of two weeks typically occur.

According to the National Alliance on Mental Illness (NAMI), though depression is common for a Bipolar I diagnosis, a few patients with this type will only experience mania.

The symptoms mark a severe change from the patient’s usual behavior, and the mania often requires immediate hospitalization.

Bipolar II Disorder
When Bipolar II Disorder is at play, the patient goes back and forth between depressive episodes and slightly manic (“hypomanic”) episodes, but does not experience mixed mood episodes or full-blown mania.

The main distinction between bipolar I and II is that a bipolar I diagnosis requires at least one manic episode while those with a bipolar II diagnosis may have only experienced hypomanic episodes.

Cyclothymic Disorder
In Cyclothymic Disorder, or Cyclothymia, patients cycle between periods of hypomania and slight depression for at least two years (or one year for children and adolescents). In this mild form of the disorder, the patient displays symptoms, but they do not meet the criteria for any other type.

NAMI refers to this type as a “more chronic unstable mood state.” During this time, the  patient’s moods are abnormally high or abnormally low for at least half of the days. Hypomania will be present, but no full manic or depressive periods will occur.

Bipolar Disorder Not Otherwise Specified
Patients can be diagnosed with Bipolar Disorder Not Otherwise Specified (BP-NOS) when they experience bipolar symptoms, but don’t meet the requirements to be considered bipolar I, bipolar II or cyclothymia. This may be because only a few symptoms occur or they last for a short amount of time, but symptoms are present that are clearly not a part of the person’s normal behavior.

An example would be a patient who displays some symptoms of hypomania followed by a depressive episode. NAMI explains it as follows: “Because the symptoms of hypomania never lasted that long, the person would not qualify for a diagnosis of bipolar II, since he or she did not have a full-blown hypomanic episode, but he or she would qualify for a diagnosis of bipolar NOS.”

Treating the Disorder

According to NIMH, Bipolar Disorder is generally treated with medications and psychotherapy.

Mood stabilizing medications, including Lithium or Valproic acid (an anticonvulsant), are usually the first option when treating bipolar disorder. Atypical antipsychotic medications (called such to distinguish them from older, earlier drugs) are often also used along with other prescriptions.

Antidepressant medications can be used to treat depressive episodes in bipolar patients, many times in conjunction with mood stabilizers. All three of these drug treatment options are commonly prescribed in combination in order to find the right treatment for each patient.

Many people with bipolar disorder also turn to psychotherapy to treat the disease. Cognitive behavioral therapy (CBT) aims to help patients change their negative patterns, both in terms of behavior and thought.

Some involve loved ones in Family-focused therapy, which works to improve communication and support as a group. Interpersonal and social rhythm therapy also focuses on relationships, highlighting the importance of routine in stabilizing bipolar patients.

A fourth type of psychotherapy commonly administered is Psychoeducation, which aims to lessen symptoms through patient education on the disorder. By fully understanding their issues, patients and loved ones can be proactive at spotting symptoms in hopes of preventing full-blown episodes.

Type-Specific Treatment

Mayo Clinic psychiatrist Daniel K. Hall-Flavin, M.D., highlighted the differences in treatment, both based on patient’s individuality and the type of bipolar disorder they suffer from.

According to Dr. Hall-Flavin, patients with both bipolar I or II will likely take mood-stabilizing drugs, since these medications are effective at treating the manic episodes common to both types. (Though less marked than the mania in bipolar I, the hypomania associated with bipolar II can also be lessened through use of this drug.)

Dr. Hall-Flavin also noted that inpatient hospital treatment and/or outpatient programs tend to be a more common treatment for those suffering from bipolar I, due to its often severe nature and tendency to require urgent care.

According to NIMH, though there is no known completely cure for bipolar disorder, individualized, continuous treatment has proven effective for patients. NIMH reports that “Treatment may be more effective when people work closely with a doctor and talk openly about their concerns and choices. Keeping track of mood changes and symptoms with a daily life chart can help a doctor assess a person's response to treatments.”

Careful monitoring of symptoms and developments, along with a dedicated support system and an understanding of the disorder can help bipolar patients live a happy, healthy and balanced life.

Review Date: 
May 24, 2012