One of the most interesting challenges in psychiatry is trying to identify patients with bipolar disorder as early as possible. Because many patients experience major depression first, before they have an episode of hypomania or mania, they may be treated with antidepressants. Unfortunately, antidepressants may not be any help at all for bipolar depression. Worse, antidepressants sometimes make people with bipolar disorder feel worse. They can make the brain zing up to a manic episode, or a hypomanic episode, or an agitated “mixed state.”
So first we need to understand the basic varieties of bipolar disorder: Bipolar 1 and Bipolar 2. This is a very simplified discussion. For much more info, read Dr Francis Mondimore’s book called Bipolar Disorder, or my upcoming book The Essential Guide to Bipolar 2 Disorder: Master Your Moods, Create the Life You Want. I promise to put a discount code on the blog as soon as it’s ready!
Here’s the tricky part. In Major Depressive Disorder, patients have recurring episodes of major depression. In Bipolar Disorder, patients have episodes of mania or hypomania, and they have episodes of major depression. Bipolar means two poles of mood, energy, and cognitive speed: up and down. So until someone recognizes the mania or hypomania “up” part, we might misdiagnose someone with Major Depressive Disorder (sometimes called “unipolar depression”) when they are actually having a major depressive episode as part of Bipolar Disorder (“bipolar depression”).
An episode of major depression has the same symptoms whether someone has Major Depressive Disorder or Bipolar Disorder. The difference is that someone with Bipolar Disorder will also have episodes of mania (in Bipolar 1 Disorder) or hypomania (in Bipolar 2 Disorder). So how do we diagnose mania or hypomania
Patients who have manic episodes can be stable and look completely healthy and normal for years. They may have had an episode of major depression, or they might not have ever had one. Then, over days or weeks, they develop elevated energy, decreased need for sleep, and grandiosity, usually with psychotic features (delusions or hallucinations), that is way out the realm of normal behavior for anyone. Everyone notices, and it causes big problems. We diagnose Bipolar 1 Disorder.
In the DSM-5, mania is a period with these symptoms most of the time, most every day:
Abnormally and persistently elevated, expansive, or irritable mood
And persistently goal-directed behavior or energy
lasting at least a week, or any duration if hospitalization is necessary. It’s severe enough to cause “marked impairment” in school/work, social activities, or relationships; requires hospitalization to prevent harm to self or others; or there are psychotic features. Often mania causes all of these.
During mania, the person has at least three of these symptoms which are a noticeable change from usual behavior and occur “to a significant degree”:
Inflated self-esteem or grandiosity
Decreased need for sleep (like feeling rested after only three hours of sleep)
More talkative than usual, or pressure to keep talking
Flight of ideas or the subjective experience that thoughts are racing
Distractibility
Increase in goal-directed activity (socially, at work or school, or sexually) or “psychomotor agitation”
Excessive involvement activities with a high potential for painful consequences (like shopping sprees, sexual impulsivity, foolish business investments)
For example, a classic example of mania would be a philosophy graduate student who got increasingly fascinated by mathematical symbols. He began writing a new graduate thesis, unifying mathematical theorems with space travel and nanoparticles, with so many ideas and so much energy that he didn’t need to sleep for three days. He began posting long tirades on the internet regarding his belief that he was a new incarnation of Mahatma Gandhi, and then that he was the recipient of the Nobel Peace Prize for the unification of all humanity. His friends became increasingly alarmed after they realized he wasn’t just being funny, he was serious. As he got increasingly angry and agitated that no one was listening to him, he quickly shifted to a very dark mood state and became paranoid, believing that Special Forces military personnel had targeted him. Ultimately he had to be involuntarily hospitalized before he took action in “self-defense.” He was treated with lithium and an antipsychotic, and his symptoms resolved over several weeks. Eventually, the antipsychotic was tapered off. He was well for about ten years on lithium until a similar manic episode occurred after he had become a professor.
So manic episodes are dramatically out of the ordinary. When someone is manic, everyone (other than the patient, who usually lacks insight that they are ill during the manic episode) agrees that the patient is really sick, and they get identified. Bipolar 1 Disorder is fairly straightforward to diagnose. It affects about 1% of the population, and occurs equally in men and women. We have a lot of good treatments for manic episodes that can help people get stabilized, usually within a few weeks and sometimes within days.
In Bipolar 2 Disorder, patients do not ever have a manic episode. However, they have episodes of hypomania. “Hypo” means “less than,” so hypomania is less than mania but has higher than normal mood, energy level, and cognitive speed. The duration may only last four days, and there are no psychotic features. The other symptoms like grandiosity, distractibility, and excessive goal-directed activity are the same as in mania, but they are not severe enough to cause “marked impairment” in social or school/work functioning, and hospitalization is not necessary. The real problem in Bipolar 2 Disorder is usually long episodes of major depression.
For example, I think of a patient who worked part-time as a doctor and had two young kids. She came to see me after feeling burned out and depressed for almost a year. She felt exhausted all the time, and she had a really hard time getting up in the morning to get her kids ready for the day even if she went to bed early. Sometimes she was late for work even though she was a very conscientious person, which made her feel guilty and like she was failing as a mom and as a doctor. It was harder to concentrate at work than it used to be. In fact, it was harder to do everything, even shop for groceries or do the laundry. She was starting to think she should just give up medicine, but she had no confidence that she could do a good job as a stay-at-home mom. She was more irritable with her husband and got easily frustrated with normal toddler behavior and sometimes yelled at her kids, which also made her feel guilty. She was nervous about taking medication, but felt so bad that she was willing to try an antidepressant.
What really frustrated her was that she used to feel great. Not just good, but great. She won honors in college for a senior thesis she wrote in five days. It just flowed, and she kept writing and didn’t even need to sleep much those days because everything just seemed clear and made sense. When she was in medical school, she aced rotations that other people struggled with, like surgery – she did fine even though she had to get up by 430am to get to the hospital almost every day. She liked the fast pace and the pressure to make decisions fast. That’s what got her into emergency medicine. But now? It was like moving through molasses. No energy, no spark, no flow.
For most people, hypomania feels great. People can often think faster, better, and more creatively. They might start new projects and make new social or professional connections. Energy and libido go up, need for sleep goes down, but they can still work well. One of my patients was a businessman who could tell he was hypomanic because he’d walk into a complicated business negotiation and be able to see exactly how to manage everyone – and he was right!
But as a hypomania progresses often patients start to get impatient. Why can’t everyone else keep up with them? Sometimes they get really irritable or hostile when people aren’t willing to go along with their brilliant ideas or risks. Then there’s often a fast crash down into a bad depression lasts a long time. Many Bipolar 2 patients first seek treatment during depression, and they may not remember feeling amazing for a few days, a few months before. Or they may not even recognize their hypomania as an abnormal mood state – they just know that sometimes they finally feel good after months of feeling depressed.
But when I can get an accurate history, or when I see the hypomania myself, I can diagnose Bipolar 2 Disorder. This affects 2-5% of the population. Women are affected about twice as often as men (just like Major Depressive Disorder). Unfortunately, we have fewer good treatments for bipolar depression than for mania. Our best options are starting a mood stabilizer like lithium or lamotrigine for long-term stability, and often an atypical antipsychotic medication (even though the patient is not psychotic) that has been FDA-approved for bipolar depression.
Other clues that someone with long depressions may actually have Bipolar 2? Many have a family history of bipolar 1 or 2 disorder. Many have what we call “reverse vegetative symptoms” – unlike a classic melancholic depression where someone loses their appetite and can’t sleep, many bipolar depressions cause patients to eat more than normal and need more sleep than normal. Earlier age of first depression may be a sign of bipolar disorder. And if someone who has taken several antidepressants and they haven’t helped, or if they caused severe irritability, agitation, or insomnia, I’m going to worry about the possibility of bipolar 2 disorder.
My goal is to get patients into remission, meaning they no longer meet criteria for a manic/hypomanic episode or a major depressive episode. They still have Bipolar Disorder, but it’s not currently impairing their function at school or work, and they can have good relationships with people and enjoy their lives. Sometimes it takes a lot of trial and error to find the right combination of medications and to help patients develop healthy strategies for sleep, activity, and not using drugs or overusing alcohol. That’s what my book will describe in a lot more detail. Coming soon!
Any patients described are composites of true patients with all identifying details changed, so that privacy is protected. I’m so excited to share with you the fascinating, never boring world of adult psychiatry. Please share the blog with others, and feel free to follow me on Twitter @LeslieWalkerMD.