Types of Bipolar

It can take most people 10 years to get an accurate diagnosis of Bipolar and therefore put the right treatment plan in place. Understanding the type of Bipolar you have is the first step.

Ghaemi et al (2000)

Types of Bipolar Affective Disorder

There are several types of Bipolar disorder – the main ones being Bipolar 1 and Bipolar 2¹. Diagnosing Bipolar disorders is difficult, partly because the symptoms are experienced so differently – for instance ‘manic’ episodes can range from feeling hugely energised and motivated or feeling hugely irritable and angry. With depressive episodes, some people will find they need to sleep a great deal and others not at all. There is no one size fits all.

Bipolar 1 Disorder

The defining feature of Bipolar disorders is the occurrence of severe mood swings — moving between episodes of feeling elated to feeling low in mood which may including clinical depression.

Manic Episodes

The essential feature of Bipolar I is that the person experiences a full manic episode, which is defined as:

a “distinct period of abnormally and persistently elevated, expansive, or irritable mood” associated with increased energy or activity and lasting at least one week.

Apart from the elated mood, the criteria of a manic episode includes experiencing at least three of the following symptoms:

• high self-esteem or grandiosity
• not needing to sleep much
• increased rate of speech (talking fast)
• racing thoughts and ‘flight of ideas’
• getting easily distracted: attention is easily drawn to irrelevant items
• increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (pacing a room, foot tapping etc)
• excessive involvement in activities that have a high potential for painful or negative consequences (e.g. compulsive spending sprees, sexual indiscretions or making risky business investments)

In severe cases, manic episodes can be accompanied by psychotic symptoms e.g. delusions of grandeur, paranoid feelings and hearing things that aren’t there.

¹ DSM-5

Depressive episodes

Besides manic conditions, people with Bipolar I could have major (i.e. severe) depressive episodes.

The DSM-5 outlines the following criteria to make a diagnosis of major depression. At least one of the symptoms should be either:

(1) depressed mood or

(2) loss of interest or pleasure.

In addition, the individual must be experiencing four or more symptoms from the list below during the same 2 week period:

• Significant weight loss when not dieting or, alternatively, weight gain
• Slowing down of thoughts and a reduction of physical movement or feeling agitated /restless. These should be observable by others – not just thoughts by the person who is experiencing the symptoms of Bipolar
• Fatigue or loss of energy
• Feelings of worthlessness or excessive or inappropriate guilt
• Diminished ability to think or concentrate, or indecisiveness
• Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
• Insomnia or hypersomnia (sleeping a lot)

Bipolar 2 Disorder

Bipolar II can often be difficult to diagnose and can be confused with recurrent depression because the sufferer experiences major depressive episodes alternating with hypomania which is a milder form of mania.

Hypomanic episodes last on average 4 days, which is shorter than the manic periods with Bipolar 1. Hypomania symptoms are also not severe enough to cause serious impairment in functioning, and will not be accompanied by psychotic symptoms during this episode.

What is the difference between Bipolar 1 and Bipolar 2?

There are many similarities between Bipolar 1 and Bipolar 2; they both share episodes of ‘manic’ behaviour and episodes of depression.

The main difference between Bipolar I and Bipolar II is the experience of the manic period – in Bipolar I the mania is extreme and would be considered abnormal within the general population. In Bipolar II, the manic period is less severe and is known as hypomania – the symptoms might be highly unusual for the individual but might not be considered completely abnormal within the general population.
Dr Surguladze MR

Cyclothymia

Cyclothymia is a milder form of Bipolar. It is commonly misdiagnosed because the symptoms aren’t as extreme. The depressive periods may be seen as feeling lower in mood than normal – the ‘manic’ periods may be experienced as being more energised than normal.

To diagnose cyclothymia, the following symptoms have to have been experienced for at least 2 years which is another reason why the illness is often misdiagnosed – 2 years is a long time and not many people will be able to accurately recall their moods across this time.

• Numerous periods of ‘mild’ mania / hypomania
• Numerous periods of depression (not severe)
• Periods of normal mood that last less than 2 months
• The symptoms are severe enough to cause distress, but not so severe they would be better explained by Bipolar 1 or Bipolar 2.

Cyclothymia can often go undiagnosed because the symptoms are milder, but if undiagnosed there is an increased risk of developing full-blown Bipolar disorder at a later stage.

What are the signs (apart from mild fluctuations of mood) that should alert us of potential cyclothymia? We need to check out whether or not the symptoms disrupt everyday functioning, or cause problems with personal and work relationships. If this is the case – one would certainly need to see a psychiatrist.
Dr Surguladze MR

Substance/medication induced Bipolar disorder

Recent evidence has shown that some people treated with antidepressants may develop manic or hypomanic states. These episodes emerge during antidepressant treatment, such as taking medication or electroconvulsive therapy, but persist beyond the physiological effect of the treatment.

Taking illicit drugs e.g. cocaine or amphetamines can also cause medication induced Bipolar disorder – signs this is occurring may include mood elevation that clearly outlasts the clearance of the provoking drug.

Substance and medication induced Bipolar disorder is complex and needs careful diagnosis by a Psychiatrist who is an expert in the field of Bipolar. If you are experiencing adverse reactions whilst taking medication it is important to seek help as early as possible.

Rapid Cycling Bipolar

Rapid cycling Bipolar is where there are four or more episodes of mania, hypomania or depression within a twelve month period. Episodes or phases are separated either by switches to an opposite mood or by ‘remissions’ lasting 8 or more weeks.

Rapid cycling Bipolar affects a significant proportion of Bipolar patients and is more likely in those who:

• Have had Bipolar for a long time
• Developed Bipolar at a young age
• Have used illegal drugs / alcohol heavily
• Have a history of repeated suicide attempts / thoughts

The origins of rapid cycling remain unclear, although there is some discussion about the role of antidepressants usage, and hypothyroidism is also considered to be a risk to developing the illness.

Rapid cycling Bipolar is particularly difficult for the patient and their family as things can feel very much like a rollercoaster and be incredibly distressing.

Dr Simon Surguladze

MD, PhD, DSc

Consultant Psychiatrist

London

Dr Surguladze is a psychiatrist with over 30 years of clinical and academic experience in various areas of mental health.