Those who are living with a bipolar disorder diagnosis may experience extreme swings in their emotional state—bubbling with energy one week and navigating a deep depression the next. This often-described rollercoaster of emotions is a hallmark of Bipolar Disorder that 2.3 million Americans are navigating, but many times this diagnosis may go misdiagnosed, so the number of people navigating the symptoms is likely much more. It’s essential to understand the nuances between the classifications of the disorder, including Bipolar I Disorder (BPI), Bipolar II Disorder (BPII), and Cyclothymia. It is crucial for proper diagnosis and an effective treatment plan. In this blog, we will discuss the conditions themselves, how to identify and differ between the diagnoses, and what it looks like living with them.
What Is Bipolar Disorder?
Bipolar disorder is a mental health diagnosis classified as a mood disorder by the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), which causes atypical changes in a person’s mood, energy levels, and concentration, significantly impacting activities of daily living. The condition typically surfaces in the adolescent and early adulthood developmental stages but can also develop at any stage of life. To be considered for a diagnosis, there needs to be the presence in some capacity of a depressive episode and a manic or hypomanic episode.
A manic episode is defined by the DSM-V as a specific period of abnormally elevated, expansive, or irritable mood and increased energy lasting for at least seven days, for most of the day, every day. The elevation is severe enough to sufficiently impact all aspects of life, including professional and interpersonal commitments. They often lead to hospitalization to prevent the risk of injury to self and others. The symptoms of the elevation or irritability may present in many ways. Some things to look out for are a grandiose presentation of self-esteem, lack of need for sleep (maybe only 3 hours a day), pressured or desire to talk, racing thoughts and flight of ideas, inability to stay attentive, hyperfiction on goal-oriented activities, and an increase in risky behavior including but not limited, intense spending, sexual behaviors, impulsivity, and violence.
These symptoms may present differently depending on the situation. Still, some examples would be that someone may suddenly put all their attention to a new business idea, sometimes presenting in a hostile way, to see that goal achieved. People may think they are God-like and above laws, rules, and regulations. This level of invincibility may cause them to engage in risky behavior and put their desire to achieve goals above all other reality. Often, there is a detachment from reality, which may result in a psychotic episode. During this period, mannerisms, speech, and eye contact may change and become more pointed and exact/directed.
A hypomanic episode follows the diagnostics for a manic episode similarly, including a noticeable change in elevated or irritable behavior that would be observable by others lasting at least four consecutive days for a majority of the day. The severity of the symptoms experienced in hypomania is less than that of a manic episode as they are still severe but not to a point where there is no need for hospitalization for a risk of danger to self and others.
A major depressive episode is characterized by a depressed mood or loss of interest in pleasure for at least two weeks of consecutive symptoms appearing for the majority of the day every day. In addition to an observable decrease in mood and lack of interest in pleasurable activities, the diagnosis may also present with a decrease in appetite and significant weight loss, changes in sleeping patterns, including sleeping all day or an inability to fall asleep, restlessness visible by others, lack of energy in general, feelings of worthlessness and hopelessness, trouble thinking or paying attention to tasks at hand, and thoughts of death including suicidal ideation in a passive or active sense. These symptoms are severe enough to impact responsibilities in the person’s interpersonal and professional lives.
Identifying and Differentiating Between Bipolar Classifications
As stated above, the pairing of manic, hypomanic, and depressive episodes can change the diagnosis and classification of the mood disorder. This blog will focus on the differentials between BPI, BPII, and cyclothymia. In all cases, it’s essential to identify that a common presentation of all of these diagnoses is an observable cycling of moods between an elevated state and a depressed state. What may shift depending on the disorder is the location of the baseline where the judgment of elevation and depression are assessed. Someone who is exhibiting symptoms of any of these diagnoses can be profoundly impacted, leading to challenges with interpersonal relationships, employment, increased risk of substance use and other maladaptive behaviors, as well as suicidality. It’s important to be able to diagnose these disorders clearly for proper intervention.
To meet the criteria for a bipolar I diagnosis, a classification of a manic episode must have occurred at least one time in the person’s life, as indicated by the diagnostics and symptoms above. The symptoms of mania outlined may present as someone feeling like they can feel the energy coursing through their veins and coming out of their fingertips. Someone may also describe feeling a heightened observance of their senses and a feeling that they can accomplish anything and everything. There may be a strong draw toward impulsive anti-social behavior, including gambling, spending, risky sexual behavior, and hostility when questioned. There may also be a heightened sense of invincibility, which can pose them with physical risk, a break from reality, or psychosis, which can contribute to intense behavior, often leading to a need for hospitalization. The manic episode may follow a hypomania or major depressive episode.
To meet the classification for a bipolar II diagnosis, an individual must cycle from a major depressive episode to a hypomanic state. Since the hypomanic state never reaches mania, there may not be a reason for hospitalization in the elevated state, but this does not make this diagnosis any less severe than a bipolar I diagnosis. With bipolar II, the depressive episodes that precede or follow the hypomanic episodes come frequently and deeply and feel unbearable. It is common for many maladaptive behaviors to be exhibited to cope with the feelings associated with a major depressive episode. It may include, but is not limited to, binge eating, self-harm, and suicidal ideation. In contrast to bipolar I disorder, where a major depressive episode does not need to be present, someone with bipolar II disorder may be navigating the extreme lows of a major depressive episode for lengthy periods.
Cyclothymia can often go undiagnosed as a person may rapidly cycle through depressive episodes or any hypomanic episodes without meeting a complete classification for hypomanic/manic or major depression. One crucial aspect of cyclothymia is the persistent or rapid cycling between states that persist for at least two years. If an individual has been symptom-free for at least two months in that period, they do not meet the criteria for the diagnosis. Even though the duration and intensity do not qualify their diagnosis, the impact of the changes can be extreme and present significant instability for an individual’s baseline.
Summary
Between these three classifications of bipolar disorders, it is imperative to assess and take into consideration the various severity of each elevated or depressed state and how the individual cycles between them. For a bipolar I diagnosis, the main concern would be the severity when the individual is in a manic state. For a bipolar II diagnosis, there tends to be a focus on the deeper depression of a major depressive episode that can pose a significant risk to the individual’s safety. Cyclothymia is a persistent up-and-down cycling of ups and downs for a prolonged period. These diagnoses should be addressed as a medication-first intervention, as stabilization is the most important aspect of treatment. It will require contact with a psychiatrist to explore what is the best combination of medication, which may include mood stabilizers, anti-depressants, and antipsychotics. Once stabilized, working with a mental health professional using Cognitive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy (DBT) is important. It will be helpful to partner with a therapist to track moods, identify triggers, and recognize when a mood shift is oncoming to intervene appropriately.
