Bipolar Disorder - A Closer Look

There is far more to bipolar than meets the eye.

by John McManamy

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.