(reviewed and revised 12/2010)
The "Bottom Line" -- The Main Point of
But that "something else" often does not look anything like mania. "Hypomania", which you'll learn about here, can show up as huge sleep changes, irritability, agitation/anxiety, and difficulty concentrating.Benazzi And finally, some people can have some bipolarity without any hypomania at all. Really. You'll see references to mood experts who have shown all these things as you go. Oh yes, and let's laugh a little as we go.
"Which one do you want, the mumbo-jumbo or the statistical analysis?"
(from artist and cartoonist Sidney Harris; used by permission)
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.
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.)
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 1994, the "DSM-IV". "Bipolar II" was added in this edition, although it was first described as a pattern of mood change long before that. Technically Bipolar II describes a pattern in which patients experience "hypomania" (to be discussed in detail below), alternating with episodes of severe depression.
"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. 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 recent 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-IV, using what we've learned since 1994 in the diagnostic process (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). Their recommendations are very consistent with what you'll read below.
Technically, this is literally a "little" mania the familiar symptoms but less so:
You may have noticed that "delusions" have disappeared from the list: these are by definition not found in Bipolar II. A patient who has had the above symptoms repeatedly, without having delusions, is much less likely to ever lose contact with reality (including weird experiences like auditory hallucinations, which are common in bipolar mania) than a patient who has experienced delusions.
"Bipolar II" is technically the combination of hypomanic phases with separate phases of severe depression If the depressive phases are only mild, the term "cyclothymia" is used. 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.
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 many mood specialists as two extremes on a continuum, with variations found at all points in between, as in the graph below (e.g. Ghaemi; Pies; Moller; Birmaher; Skeppar; Mackinnon; Angst and Cassano; Akiskal to name just a few important articles since 2001; and finally, my ISBD review in 2008):
On the left, the "unipolar" extreme represents straightforward depression with no complications. There are many forms of depression, of course. For an overview, see the appendix: "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 includes more people than either extreme. In other words, it might be the most common form of bipolar disorder, this middle group.Angst
Consider the following 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 dont 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 "soft sign" 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 dont, including some psychiatrists who have not adopted this new "spectrum" way of thinking about diagnosis. The DSM-IV itself 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. 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: The following represents my clinical experience taking referrals from primary care physicians. Most patients I see have been on 3 or more antidepressants before I see them. This selects very directly for "bipolar spectrum" patients. However, note that none of these descriptions are found in the DSM, nor are they widely spoken of by mood experts. This is my personal formulation based on almost 15 years of full-time selection for such patients.
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"; "Im a special representative for God"). So they think "well, I cant have that Ive never had a manic episode".
However, the new view of bipolar disorder means its time to reconsider that conclusion. Hypomania doesnt 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 pointFawcett, especially if the first depression occurred before age twenty.Geller, Rao These two features--repeated recurrence, and early onset--are also included among the bipolar "soft signs" 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.Ghaemi
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 cant handle is the anxiety: it isnt "good energy". Many say they feel as though they just have too much energy pent up inside their bodies. They cant 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 cant 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 doesnt "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(b)
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 doesnt 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 theyre "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
Finally, there are people with depression whose most noticeable symptom is severe insomnia. These people can go for days 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.
Want to see similar explanations from another source? Or more detail on the kinds of symptoms people with this illness can have? Here are another doctor's observations on the issue of "soft" bipolar variations.
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. This list 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).
There is a very radical idea buried in these 11 items, which we should look at before going on, but you should 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. "I thought bipolar disorder was distinguished from 'unipolar' depression by the presence of some degree of hypomania. 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 it 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 (their prognosis) 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. As of 2005 the Harvard-associated Mood Disorder program started using this approach to diagnosis. They call it the Bipolarity Index.
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 The concept of a bipolar "spectrum" is supported by work from a research group calling themselves the Spectrum Project.e.g. Cassano
Probably better not to raise this issue unless you have to, but if you must, cite the source. Here's that article link again.Ghaemi Dr. Ghaemi is the chairman of the committee on diagnosis for the International Society for Bipolar Disorder. One of his two co-authors 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, e.g. see Antidepressant Controversies). But he is certainly not the only such voice. If you haven't seen enough references yet, here's another similar recent one, by other international mood experts.Mitchell
Warning: leaving DSM-IV territory
The remainder of this "diagnosis" discussion cannot be found in the DSM. I will repeatedly reference mood disorder experts, but many of these views are controversial. You must evaluate for yourself the validity of what follows.
Unfortunately, "hypomania" is quite a mis-naming. There are many patients whose "hypomanic" phases are an extreme and very negative experience. 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 inability to sleep, rather than decreased need. (If you or a friend or doctor is skeptical about anxiety as a "bipolar" symptom, try that link for more details and references.)
In my experience most of these people come to treatment with a combination of agitation, anxiety and self-criticism and they cant sleep well. Is this "anxiety?" Is this some mood variation? How could you tell the difference? Is there a difference? What is really going on chemically? Unfortunately, this is still almost completely unknown. See the appendix "Whats the latest on why?", which I will try to keep updated frequently, for the latest research about the cause of this illness.
Again, my opinion: you cant easily distinguish "anxious depression" from bipolar II in a mixed state. I doubt that there is a distinction to be made, ultimately (when we know, hopefully someday relatively soon, what the chemical basis for anxiety with depression really is). For example there is nearly complete overlap between Generalized Anxiety Disorder and Bipolar II.
For now, the only way to tell is by how treatment turns out. Depression that is not bipolar can get better and stay better: with time, or counseling, or formal psychotherapy, or antidepressants. If you get better great! If you dont, you may need this new understanding of mood disorders in order to consider mood stabilizers medications, discussed in detail below, as an option.
Meanwhile, at least one experienced mood researcher warns that anxiety in someone who is depressed is associated with a high suicide risk.Fawcett(b) So although there is diagnostic confusion, there are tremendous stakes involved. Approaching this situation with an open mind seems wise, given this risk.
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 (from Smith 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 writes eloquently about bipolarity).
First, the positive phase:
Then, the negative phase of hypomania (still pretty subtle):
Officially, the answer is "four days", according to the DSM. But in real life, it's very clear that episodes can be shorter, and that's agreed 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 studyBauer 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, it's "how bipolar are you?" as affirmed in a recent editorial Smith in the British Journal of Psychiatry (one of the biggies...).
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 before they 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 these are her typical symptoms in official "Major Depression". And low energy can also be seen in Major Depression. But look at how prominent it is in this study. I think that 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. He might find it useful in that respect also.
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, another mood disorder expert has shown that bipolar disorder is overdiagnosed (Zimmerman, 2008; here is a close examination of his findings). He's certainly right, if one sticks to the DSM rules (although his paper also shows a notable underdiagnosis rate as well). And there are quite a few people getting this diagnosis who might be better understood with a different diagnostic framework, like Post-Traumatic Stress Disorder (PTSD). But in my view, one of the things that can help you figure out what's going on is to learn more about "bipolarity", as you have done here. You are an important part of the diagnostic process.
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:
As you now know (start this section on diagnosis afresh if you came from elsewhere), 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 dont 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.
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 consider treatment. Or that the diagnostic basis for that treatment should include a consideration of bipolar II. 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.
Thank you for patiently reading all the way to this point. It's a lot to swallow at once, isn't it? From here you can review, or read more about diagnosis issues in the Diagnosis Details section, or go on to Treatment.