Bipolar and related disorders

Maybe you’ve heard the term “bipolar” used flippantly to describe someone who’s moody, or who has mood swings, but the colloquial use of the term is really different from clinically diagnosed bipolar disorder. Bipolar disorder, which used to be called manic depression, is a serious mental disorder that causes a person to have dramatic shifts in emotions, mood, and energy levels: moving from extreme lows to extreme highs. But these shifts don’t happen moment to moment—they usually happen over several days or weeks. Now, bipolar and related disorders include several different conditions, but the most important ones are bipolar I disorder, bipolar II disorder, and cyclothymic disorder.

Now, let’s cover some important clinical features associated with these conditions. The first one is a major depressive episode, which is characterized by the low moods that are identical to those in a related disorder: major depressive disorder, also known as unipolar depression. During major depressive episodes, individuals can feel hopeless and discouraged, lack energy and mental focus, and can have physical symptoms like eating and sleeping too much or too little.

But along with these lows, the thing that sets bipolar disorders apart from unipolar depression is that individuals can have periods of high moods, which are called manic episodes or hypomanic episodes, depending on their level of severity.

Manic episodes are described as an abnormally elevated mood that lasts for at least one week or requires hospitalization. In a manic state, people can feel energetic, overly happy or optimistic, euphoric with really high self-esteem, or even unusually irritable.

And on the surface, these might seem like very positive characteristics, but when an individual is in a full manic episode, these symptoms can reach a dangerous extreme. A person experiencing mania might invest all of their money in a risky business venture or behave recklessly.

Individuals might talk pressured speech, where they talk constantly at a rapid-fire pace, or they might have racing thoughts and might feel “wired,” as if they don’t need sleep.

Manic episodes can also include delusions of grandeur: for example, they might believe that they are on a personal mission from god, or that they have supernatural powers. And they might make poor decisions without any regard for later consequences.

On the flip side, hypomanic episodes are described as an abnormally elevated mood that lasts for at least 4 consecutive days and doesn’t require hospitalization.

In a hypomanic state, individuals experience similar symptoms and feelings to the ones seen during manic episodes, but it's important to note that they are milder in severity. Additionally, there are no psychotic features.

Between major depressive episodes and manic or hypomanic episodes, individuals usually have a relatively stable mood, which is often described as euthymia.

One way to understand these swings is by charting them on a graph. So let’s say the y-axis is mood, with mania and depression being on the far ends of the axis, and the x-axis is time. A neurotypical person (someone without a mental health disorder) might have normal ups and downs throughout their life, and they might even have some pretty serious lows once in a while, maybe after losing a job or moving to a new place and feeling lonely.

Now, the diagnosis of bipolar I disorder includes at least one manic episode, which may be preceded or followed by hypomanic or major depressive episodes.

On the flip side, the diagnosis of bipolar II disorder includes at least one hypomanic and one major depressive episode, but no manic episodes.

Finally, the diagnosis of cyclothymic disorder is based on frequent hypomanic and depressive symptoms over a 2-year period, which are not as severe as the ones seen in bipolar I and bipolar II disorders. The symptoms must be present for at least half the time, meaning at least one year, and there shouldn’t be a period without symptoms for more than 2 months.

Now, sometimes, these conditions can be further described by additional clinical features, also known as specifiers.

For example, some individuals might have bipolar disorder with anxious distress, so they might complain of feeling restless or experiencing fear that something terrible might happen.