Beyond Blue

Beyond Blue


Bipolar Disorder I, II, Maybe III: There Are All Shades

posted by Beyond Blue

John McManamy writes an exceptionally informative article on the types of Bipolar Disorder as defined by the DSM-IV (the shrink handbook). You can get to his article and others by clicking here. I have pasted it below.

There is far more to bipolar than meets the eye. Let’s start with the boring stuff:
The DSM-IV (the diagnostic Bible published by theAmerican Psychiatric Association) divides bipolar disorder into two types, rather unimaginatively labeled bipolar I and bipolar II. “Raging” and “Swinging” are far more apt:
Bipolar I
Raging bipolar (I) is characterized by at least one full-blown manic episode lasting at least one week or any duration if hospitalization is required. This may include inflated self-esteem or grandiosity, decreased need for sleep, being more talkative than usual, flight of ideas, distractibility, increase in goal-oriented activity, and excessive involvement in risky activities.
The symptoms are severe enough to disrupt the patient’s ability to work and socialize, and may require hospitalization to prevent harm to himself or others. The patient may lose touch with reality to the point of being psychotic.
The other option for raging bipolar is at least one “mixed” episode on the part of the patient. The DSM-IV is uncharacteristically vague as to what constitutes mixed, an accurate reflection of the confusion within the psychiatric profession. More tellingly, a mixed episode is almost impossible to explain to the public. One is literally “up” and “down” at the same time.


The pioneering German psychiatrist Emil Kraepelin around the turn of the twentieth century divided mania into four classes, including hypomania, acute mania, delusional or psychotic mania, and depressive or anxious mania (ie mixed). Researchers at Duke University, following a study of 327 bipolar inpatients, have refined this to five categories:
Pure Type 1 (20.5 percent of sample) resembles Kraepelin’s hypomania, with euphoric mood, humor, grandiosity, decreased sleep, psychomotor acceleration, and hypersexuality. Absent was aggression and paranoia, with low irritability.
Pure Type 2 (24.5 of sample), by contrast, is a very severe form of classic mania, similar to Kraepelin’s acute mania with prominent euphoria, irritability, volatility, sexual drive, grandiosity, and high levels of psychosis, paranoia, and aggression.
Group 3 (18 percent) had high ratings of psychosis, paranoia, delusional grandiosity and delusional lack of insight, but lower levels of psychomotor and hedonic activation than the first two types. Resembling Kraepelin’s delusional mania, patients also had low ratings of dysphoria.
Group 4 (21.4 percent) had the highest ratings of dysphoria and the lowest of hedonic activation. Corresponding with Kraepelin’s depressive or anxious mania, these patients were marked by prominent depressed mood, anxiety, suicidal ideation, and feelings of guilt, along with high levels of irritability, aggression, psychosis, and paranoid thinking.
Group 5 patients (15.6 percent) also had notable dysphoric features (though not of suicidality or guilt) as well as Type 2 euphoria. Though this category was not formalized by Kraepelin, he acknowledged that “the doctrine of mixed states is … too incomplete for a more thorough characterization …”
The study notes that while Groups 4 and 5 comprised 37 percent of all manic episodes in their sample, only 13 percent of the subjects met DSM criteria for a mixed bipolar episode, and of these, 86 percent fell into Group 4, leading the authors to conclude that the DSM criteria for a mixed episode is too restrictive.
Different manias often demand different medications. Lithium, for example, is effective for classic mania while Depakote is the treatment of choice for mixed mania.
The next DSM is likely to expand on mania. In a grand rounds lecture delivered at UCLA in March 2003, Susan McElroy MD of the University of Cincinnati outlined her four “domains” of mania, namely:
As well as the “classic” DSM-IV symptoms (eg euphoria and grandiosity), there are also “psychotic” symptoms, with “all the psychotic symptoms in schizophrenia also in mania.” Then there is “negative mood and behavior,” including depression, anxiety, irritability, violence, or suicide. Finally, there are “cognitive symptoms,” such as racing thoughts, distractibility, disorganization, and inattentiveness. Unfortunately, “if you have thought disorder problems, you get all sorts of points for schizophrenia, but not for mania unless there are racing thoughts and distractibility.”
Kay Jamison in Touched with Fire writes:
“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 activity can occur.”
The DSM-IV has given delusional or psychotic mania its own separate diagnosis as schizoaffective disorder – a sort of hybrid between bipolar disorder and schizophrenia, but this may be a completely artificial distinction. These days, psychiatrists are acknowledging psychotic features as part of the illness, and are finding the newer generation of antipsychotics such as Zyprexa effective in treating mania. As Terrance Ketter MD of Yale told the 2001 National Depressive and Manic Depressive Association Conference, it may be inappropriate to have a discrete cut between the two disorders when both may represent part of a spectrum.
At the 2003 Fifth International Conference on Bipolar Disorder, Gary Sachs MD of Harvard and principal investigator of the NIMH-funded STEP-BD reported that of the first 500 patients in the study, 52.8 percent of bipolar I patients and 46.1 percent of bipolar II patients had a co-occurring (comorbid) anxiety disorder. Dr Sachs suggested that in light of these numbers, comorbid may be a misnomer, that anxiety could actually be a manifestation of bipolar. About 60 percent of bipolar patients with a current anxiety disorder had attempted suicide as opposed to 30 percent with no anxiety. Among those with PTSD, more than 70 percent had attempted suicide.
Depression is not a necessary component of raging bipolar, though it is strongly implied what goes up must come down. The DSM-IV subdivides bipolar I into those presenting with a single manic episode with no past major depression, and those who have had a past major depression (corresponding to the DSM -IV for unipolar depression).
Bipolar II
Swinging bipolar (II) presumes at least one major depressive episode, plus at least one hypomanic episode over at least four days. The same characteristics as mania are evident, with the disturbance of mood observable by others, but the episode is not enough to disrupt normal functioning or necessitate hospitalization, and there are no psychotic features.
Those in a state of hypomania are typically the life of the party, the salesperson of the month, and more often than not the best-selling author or Fortune 500 mover and shaker, which is why so many refuse to seek treatment. But the same condition can also turn on its victim, resulting in bad decision-making, social embarrassments, wrecked relationships, and projects left unfinished.
Hypomania can also occur in those with raging bipolar, and may be the prelude to a full-blown manic episode.
While working on the American Psychiatric Association’s latest DSM version of bipolar (IV-TR), Trisha Suppes MD, PhD of the University of Texas Medical Center in Dallas carefully read its criteria for hypomania, and had an epiphany. “I said, wait,” she told a UCLA grand rounds lecture in April 2003 and webcast the same day, “where are all those patients of mine who are hypomanic and say they don’t feel good?”
Apparently, there is more to hypomania than mere mania lite. Dr Suppes had in mind a different type of patient, say one who experiences road rage and can’t sleep. Why was there no mention of that in hypomania? she wondered. A subsequent literature search yielded virtually no data.
The DSM alludes to mixed states where full-blown mania and major depression collide in a raging sound and fury, but nowhere does it account for more subtle manifestations, often the type of states many bipolar patients may spend a good deal of their lives in. The treatment implications can be enormous. Dr Suppes referred to a secondary analysis Swann of a Bowden et al study of patients with acute mania on lithium or Depakote which found that even two or three depressed symptoms in mania were a predictor of outcome.
Clinicians commonly refer to these under-the-DSM radar mixed states as dysphoric hypomania or agitated depression, often using the terms interchangeably. Dr Suppes defines the former as “an energized depression,” which she and her colleagues made the object of in a prospective study of 919 outpatients from the Stanley Bipolar Treatment Network. Of 17,648 patient visits, 6993 involved depressive symptoms, 1,294 hypomania, and 9,361 were euthymic (symptom-free). Of the hypomania visits, 60 percent (783) met her criteria for dysphoric hypomania. Females accounted for 58.3 percent of those with the condition.
Neither the pioneering TIMA Bipolar Algorithms nor the APA’s Revised Practice Guideline (with Dr Suppes a major contributor to both) offer specific recommendations for treating dysphoric hypomania, such is our lack of knowledge. Clearly the day will come when psychiatrists will probe for depressive symptoms or mere suggestions of symptoms in mania or hypomania, knowing this will guide them in the prescriptions they write, thus adding an element of science to the largely hit or miss practice that governs much of meds treatment today. But that day isn’t here yet.
Bipolar Depression
Major depression is part of the DSM-IV criteria for swinging bipolar, but the next edition of the DSM may have to revisit what constitutes the downward aspect of this illness (see Bipolar Depression article). At present, the DSM-IV criteria for major unipolar depression pinch-hits for a genuine bipolar depression diagnosis. On the surface, there is little to distinguish between bipolar and unipolar depression, but certain “atypical” features may indicate different forces at work inside the brain.
According to Francis Mondimore MD, assistant professor at Johns Hopkins and author of “Bipolar Disorder: A Guide for Patients and Families”, talking to a 2002 DRADA conference, people with bipolar depression are more likely to have psychotic features and slowed-down depressions (such as sleeping too much) while those with unipolar depression are more prone to crying spells and significant anxiety (with difficulty falling asleep).
Because bipolar II patients spend far more time depressed than hypomanic (50 percent depressed vs one percent hypomanic, according to a 2002 NIMH study) misdiagnosis is common. According to S Nassir Ghaemi MD bipolar II patients 11.6 years from first contact with the mental health system to achieve a correct diagnosis.
The implications for treatment are enormous. All too often, bipolar II patients are given just an antidepressant for their depression, which may confer no clinical benefit, but which can drastically worsen the outcome of their illness, including switches into mania or hypomania and cycle acceleration. Bipolar depression calls for a far more sophisticated meds approach, which makes it absolutely essential that those with bipolar II get the right diagnosis.
This bears emphasis: The hypomanias of bipolar II – at least the ones with no mixed features – are generally easily managed or may not present a problem. But until those hypomanias are identified, a correct diagnosis may not be possible. And without that diagnosis, your depression – the real problem – will not get the right treatment, which could prolong your suffering for years.
Bipolar I vs Bipolar II
Dividing bipolar into I and II arguably has more to do with diagnostic convenience than true biology. A University of Chicago/Johns Hopkins study, however, makes a strong case for a genetic distinction. That study found a greater sharing of alleles (one of two or more alternate forms of a gene) along the chromosome 18q21in siblings with bipolar II than mere randomness would account for.
A 2003 NMIH study tracking 135 bipolar I and 71 bipolar II patients for up to 20 years found:
* Both BP I and BP II patients had similar demographics and ages of onset at first episode.
* Both had more lifetime co-occurring substance abuse than the general population.
* BP II had “significantly higher lifetime prevalence” of anxiety disorders, especially social and other phobias.
* BP Is had more severe episodes at intake.
* BP IIs had “a substantially more chronic course, with significantly more major and minor depressive episodes and shorter inter-episode well intervals.”
Nevertheless, for many people, bipolar II may be bipolar I waiting to happen.
Cyclothymia
A likely candidate for the DSM-V as bipolar III is “cyclothymia,” (see article) listed in the DSM as a separate disorder, characterized by symptoms (but not necessarily full episodes of) hypomania and mild depression. One third of those with cyclothymia are eventually diagnosed with bipolar, lending credence to the “kindling” theory of bipolar disorder, that if left untreated in its early stages the illness will break out into something far more severe later on.
Spectrum Considerations
The DSM’s one-week minimum for mania and four-day minimum for hypomania are regarded by many experts as artificial criteria. The British Association for Psychopharmacology’s 2003 Evidence-based Guidelines for Treating Bipolar Disorder, for instance, notes that when the four-day minimum was reduced to two in a sample population in Zurich, the rate of those with bipolar II jumped from 0.4 percent to 5.3 percent. The point is that diagnostic categories are arbitrary, at best. A strong case can be made that the current ones are overly inclusive of unipolar depression at the expense of bipolar disorder. (See The Mood Spectrum and related articles.)
Scientific Theories
The cause and workings of the disorder are terra incognita to science, though there are lots of theories based on encouraging genetics, imaging, and brain science studies. A sampling of what is going on is offered by way of a 2001 Newsletter report:
“Att the Fourth International Conference on Bipolar Disorder in June 2001, Paul Harrison MD, MRC Psych of Oxford reported on the Stanley Foundation’s pooled research of 60 brains and other studies:
“Among the usual suspects in the brain for bipolar are mild ventricular enlargement, smaller cingulate cortex, and an enlarged amygdala and smaller hippocampus. The classical theory of the brain is that the neurons do all the exciting stuff while the glia acts as mind glue. Now science is finding that astrocytes (a type of glia) and neurons are anatomically and functionally related, with an impact on synaptic activity. By measuring various synaptic protein genes and finding corresponding decreases in glial action, researchers have uncovered ‘perhaps more [brain] abnormalities … in bipolar disorder than would have been expected.’ These anomalies overlap with schizophrenia, but not with unipolar depression.
“Dr Harrison concluded that there is probably a structural neuropathology of bipolar disorder situated in the medial prefrontal cortex and possibly other connected brain regions.”
Conclusion
So little is actually known about the illness that the pharmaceutical industry has yet to develop a drug to treat its symptoms. Lithium, the best-known mood stabilizer, is a common salt, not a proprietary drug. Drugs used as mood stabilizers – Depakote, Neurontin, Lamictal, Topamax, and Tegretol – came on the market as antiseizure medications for treating epilepsy. Antidepressants were developed with unipolar depression in mind, and antipsychotics went into production to treat schizophrenia.
Inevitably, a “bipolar” pill will find its way to the market, and there will be an eager queue of desperate people lining up to be treated. Make no mistake, there is nothing glamorous or romantic about an illness that destroys up to one in five of those who have it, and wreaks havoc on the survivors, not to mention their families. The streets and prisons are littered with wrecked lives. Vincent Van Gogh may have created great works of art, but his death in his brother’s arms at age 37 was not a pretty picture.
The standard propaganda about bipolar is that it is the result of a chemical imbalance in the brain, a physical condition not unlike diabetes. For the purposes of gaining acceptance in society, most people with bipolar seem to go along with this blatant half-truth.
True, a chemical storm is raging in the brain, but the analogy to the one taking place in the diabetic’s pancreas is totally misleading. Unlike diabetes and other physical diseases, bipolar defines who we are, from the way we perceive colors and listen to music to how we taste our food. We don’t HAVE bipolar. We ARE bipolar, for both better and worse.
In one way, it’s akin to being God’s chosen people. As God’s chosen, we are prime candidates for God’s wrath, but even as God strikes the final blow – as the old Jewish saying goes – he provides the eventual healing. In a way that only God can understand, God has bestowed on us a great blessing. Living with this blessing is both a challenge and a terrible burden, but in the end we hope to emerge from this ordeal as better people, more compassionate toward our fellow beings and just a little bit closer to God.



  • Larry Parker

    I wish the dimestore theology in the last paragraph had been laid out more. If it was, I might not oppose it, but I certainly do as written.
    That said, this is a valuable article — particularly in its documentation that bipolar II is NOT “better” than bipolar I. (Or worse, either.) Both are equally (potentially, if not in good control) crippling diseases in different ways.

  • Seashell Nancy

    I am one of the people who had a very adverse reaction to Zoloft and to Paxil. I have had suicidal thoughts since childhood…lost my only sibling to carbon monoxide poisoning. I learned, over time, to deal with the thoughts fairly well…until I began taking a lot of meds
    about ten years ago. It has been a rollercoaster ride. I kept telling my docs the meds were making me worse…they apparently didn’t believe me. Only recently has it become known that many of the meds I was given may increase suicidality. Not just that the SSRI’s may
    cause mania, which was known years ago. I just received a message this morning about a possible relationship beween Singulair and
    suicidality. I will be seeing a doc in a few weeks regarding a calcium channel blocker I’ve been given for hypertension. I was doing very well on a thryoid regime…until the CaCB was increased.
    I AM NOT ANTI MEDS. I am praying that very soon many more health care providers will learn to better diagnose the illnesses their patients
    present with…and learn to more appropriately prescribe meds to help them.
    Bipolar disorder is hell to live with.

  • Giliana

    I perceive the article to be helpful, indeed, thank you. However, I agree with Larry about the ending, which makes me irate. I have begun to understand that far too many people profess *everyone* to be “special” which is absolutely impossible! I think a far more realistic representation would be to report people as being *different,* which has a far truer ring. I don’t at all consider that my illness has brought me closer to God, but it has definitely brought me closer to myself, as well as closer to reality. No matter how I cut it, I can’t put a romantic or religious spin on my personal experience with mental illness.

  • Bill Ellis

    Please let me make this short. There are 2 things I’d like to say:
    1. BP (or any kind of depressive disorder) is a disease, disorder, or “special case out-of-the-mainstream” condition that is associated with the EMOTIONAL (or, as the Zen-Buddhists say, “Astral plane”). It is NOT a physical disease, yet it DOES affect the physical body.
    2. In the “Chemical Storm” (next-to-the-last paragraph), a really strong point is mentioned (although I’m not taking sides on either perspective). However, in Matthew 5:3 (NIV), He states “Blessed are the poor in spirit, for theirs is the kingdom of heaven…” Maybe some scholars would like to give insight on the meaning of “poor in spirit” mentioned here wrt depressive disorders.

  • Larry Parker

    Bill:
    If you’re trying to rehear the depression vs. “dark night of the soul” argument, you’re not going to win, I promise you …

  • Zana

    I have to agree with those of us who look at what we have as anything but a blessing, especially when thinking about the havoc wrecked on our relationships–friends and family, co-workers. The info in this article was interesting, but I’m disappointed in the “propaganda” paragraph. I’m having a hard time buying the idea that we cannot define BP as a physical condition and that it is not the manifestation of chemicals gone haywire. EVERYTHING that happens in our bodies is the result of chemistry. Many reactions manifest themselves in what is viewed as “normal” , others result in displays that could be sent to the “abbynormal” line. One of the frustrations I have about wanting to accept that I have BP disorder is because I know myself to be so much more than my illness. And I want other people to accept who I know myself to be at the deepest part of myself instead of looking at me as if I’m someone to fear and keep at bay. On days that my moods are not managed well, my interactions with others and my outlook are perceivably different. I’m learning to recognize when the ugliness is lurking and have some tools to nudge (or yank) my behavior toward opposite actions than I feel, but a rose is a rose, my favorite songs are still my favorite songs and banana cream pie is still yummy! We are still looking for scientific explanation and effective treatment (a cure woud be even better). 100 years ago women were considered less intelligent than men because their brains are smaller. Now we realize size does not matter (at least in this department). Epileptics were deemed insane and institutionalized because they were considered dangerous to society. Then effective medications blew that theory out of the water. Our time is coming. What I wouldn’t give to be able to talk openly about what I know now about what I Have without feeling like I’m wearing a giant BP embroidered on my head. Those aren’t my initials, they are the label used to describe one of the ways my body works differently from the majority. As Gilliana says “a far truer ring”.

  • Cosima

    I was given Lamotrigin as a mood balancer, it’s also a drug developed for seizures, the other drug is Clonazepam, that I still take in order to sleep, not every night. Half a pill helps me calm down what I describe as agitation I feel in my chest.
    It’s the same feeling I get when I’m excited, happy or animated.
    I’ve heard far too many people, including those who believe to be authorities in any mental illness ’cause they rustled a PhD. in Psychology, that a Bipolar diagnosis is a “Convenient diagnosis”…
    I think I’m the poster child for BPII, what I used to call my ‘animated’ state, laughing, joking, dancing around, reacting to music, food, etc. was/is nothing but my manic state.
    Though sometimes I wonder.
    I’ve southern Spanish ancestry on my father’s side, and when I was lucky to visit Andalucia, Spain, I found out that the people there act as I do when I’m manic.
    My husband also noticed this.
    That’s the culture there, so it can’t be that they’re all manic. People who at the smallest provocation stop in the street and sing a duet with complete stranger that’s also been ‘struck’ by the same bolt of ‘lightening’, people who do a few dance steps when they hear that incredible gypsy music, etc.
    That’s me when not depressed, I’m also very quick witted, though when depressed that ‘wit’ is biting.

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Seven Ways to Get Over an Infatuation
“Bewitched, bothered, and bewildered am I” wrote US songwriter Lorenz Hart about the feeling of infatuation. It’s blissful and euphoric, as we all know. But it’s also addicting, messy and blinding. Without careful monitoring, its wild wind can rage through your life leaving you much like the

posted 12:46:43pm Feb. 19, 2014 | read full post »

When Faith Turns Neurotic
When does reciting scripture become a symptom of neurosis? Or praying the rosary an unhealthy compulsion? Not until I had the Book of Psalms practically memorized as a young girl did I learn that words and acts of faith can morph into desperate measures to control a mood disorder, that faithfulness

posted 10:37:13am Jan. 14, 2014 | read full post »

How to Handle Negative People
One of my mom’s best pieces of advice: “Hang with the winners.” This holds true in support groups (stick with the people who have the most sobriety), in college (find the peeps with good study habits), and in your workplace (stay away from the drama queen at the water cooler). Why? Because we

posted 10:32:10am Jan. 14, 2014 | read full post »

8 Coping Strategies for the Holidays
For people prone to depression and anxiety – i.e. human beings – the holidays invite countless possibility to get sucked into negative and catastrophic thinking. You take the basic stressed-out individual and you increase her to-do list by a third, stuff her full of refined sugar and processed f

posted 9:30:12am Nov. 21, 2013 | read full post »

Can I Say I’m a Son or Daughter of Christ and Suffer From Depression?
In 1 Thessalonians 5:16-18, we read: “Rejoice always, pray without ceasing, give thanks in all circumstances; for this is the will of God in Christ Jesus for you.” What if we aren’t glad, we aren’t capable of rejoicing, and even prayer is difficult? What if, instead, everything looks dark,

posted 10:56:04am Oct. 29, 2013 | read full post »




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