• The "Bottom Line"-- The Main Point of All This
• What happened to "manic-depressive" (now bipolar I)?
• What are the official (DSM-IV) definitions of the "new" bipolar variations?
• What is the "mood spectrum?", sometimes called the "bipolar spectrum"? 
• What do "bipolar variations" look like?
• "Soft signs" which suggest but do not confirm the diagnosis
• Anxious depression could be "bipolar"?!
• Can you be sure if you have it or not?

The "Bottom Line" -- The Main Point of All This

Bipolar Disorder has many variations. Bipolar II is one of them. You'll read here about those forms which do not have "mania" to make them stand out or easily recognizable. Depression is the main symptom, including especially sleeping too much, extreme fatigue, and lack of motivation. What makes bipolar depression different is the presence of something else as well. But that "something else" often does not look anything like mania: "hypomania", which you'll learn about here, can show up as huge sleep changes, irritability, agitation/anxiety, and difficulty concentrating.^Benazzi And finally, some people can have some bipolarity without any hypomania at all. Really. You'll see references to mood experts who have shown all these things as you go. Oh yes, and let's laugh a little as we go.

 "Which one do you want, the mumbo-jumbo or the statistical analysis?" 

(from artist and cartoonist Sidney Harris; used by permission)

Wait a minute: isn't there concern about overdiagnosis of bipolar disorder? Yes, we'll talk about that too, after you've learned some basics. 

What happened to "manic-depressive" (now bipolar I)?

Somewhere along the way you probably learned about manic-depressive illness: episodes of mania, and episodes of severe depression. Here are the symptoms of "mania" (not that you have these, as such; the lack of them is the main point here. Hang on.)

• Mood much better than normal
• Rapid speech
• Little need for sleep
• Racing thoughts, trouble concentrating
• Continuous high energy
• Overconfidence
• Delusions (often grandiose, but including paranoid)

What happened to "manic-depressive"? As our understanding of bipolar disorder has grown, the naming system has changed as well. Recently the concept of a "mixed state" of bipolar disorder, in which manic symptoms and depressive symptoms are found at the same time, was added. Obviously this changes the understanding of manic-depressive illness from one in which the two mood states alternate, to one in which they can co-occur! Things were getting more complicated.

Psychiatry has a diagnostic "rule book" that lists the symptoms people must have in order to meet the definition of a particular "disorder", called the Diagnostic and Statistical Manual. The most recent edition came out 5 years ago, the "DSM-IV". "Bipolar II" was added in this edition, although it was first described 20 years ago. Technically Bipolar II describes a pattern in which patients experience "hypomania" (to be discussed in detail below), alternating with episodes of severe depression.

However, one of the most experienced professionals in this field, who has bipolar disorder herself, has criticized even this advance as too limited:

"The clinical reality of manic-depressive illness is far more lethal and infinitely more complex than the current psychiatric nomenclature, bipolar disorder, would suggest. Cycles of fluctuating moods and energy levels serve as a background to constantly changing thoughts, behaviors, and feelings. 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 mental activity can occur. Behavior can be frenzied, expansive, bizarre, and seductive, or it can be seclusive, sluggish, and dangerously suicidal. Moods may swing erratically between euphoria and despair or irritability and desperation. The rapid oscillations and combinations of such extremes result in an intricately textured clinical picture." (Kay Jamison, Ph.D.)

I arrived at the same conclusion from listening to patients describe their symptoms. When I used this broader conception with patients, people who had struggled for years often got much better. When I tried to explain that to some of my colleagues, they thought I was a "bipolar wacko".  That's how this website got started, and why you'll see so many reference links:  I needed to show that these were not my ideas alone, but rather those of mood experts around the world (it also seemed like a handy way to explain all this to my patients without saying the same thing over and over!) For example, everything you will read below can be found in a recent review by two mood experts, except that their version is written in full medical jargon.

What are the official definitions of the "new" bipolar variations?

Some of you may wish to see "official" definitions, before we start getting into variations. The two crucial new concepts are mixed states and hypomania. Here they are, as indicated by DSM rules.

Mixed States

The combined presence of full manic and full depressive symptoms — at the same time — is Bipolar Mixed State. At the same time? How can that be? Most people have always thought of the two "poles" of "bipolar" to mean something like the North and South Poles:

Bipolar experts have recognized that this illness is much more complicated . Dr. Susan McElroy of the University of Cincinnati says that two "poles" of "bipolar" disorder are like axes of a graph:

and that any point on the graph is possible in the "mixed states" of bipolar disorder.

What does this look like, in real people? Several variations are described in the next section. For now, imagine someone with manic symptoms of rapid thoughts and speech, who instead of feeling euphoric, feels terrible: depressed; with negative thoughts, especially about her/himself; full of negative energy, and possibly even delusional (e.g persecutory or paranoid delusions, or delusions of terrible guilt and responsibility). This combined state occurs very commonly in mania, unfortunately.

Technically the DSM-IV recognizes only the upper right hand point on the above graph as "mixed state". However, most bipolar experts agree^{Fawcett, Angst, Akiskal and Pinto, Perugi et al, Akiskal, Jamison, Ketter (b)} that any combination of manic symptoms and depressive symptoms is possible, thus the "nearly infinite" variations described by Dr. Jamison. For more on how these many variations can be produced from simple changes in mood, energy and thought speed, see my page on Mixed States and Rapid Cycling. 

Hypomania

Technically, this is literally "little" mania — the familiar symptoms but less so:

• Mood much better than normal
• Rapid speech
• Little need for sleep
• Racing thoughts, trouble concentrating
• Continuous high energy
• Overconfidence

You may have noticed that "delusions" have disappeared from the list: these are by definition not found in Bipolar II. A patient who has had the above symptoms repeatedly, without having delusions, is much less likely to lose contact with reality (including abnormal perceptions such as auditory hallucinations, which are common in bipolar mania) than a patient who has experienced delusions.

"Bipolar II" is technically the combination of hypomanic phases with separate phases of severe depression If the depressive phases are only mild, the term "cyclothymia" is used. Getting confused? I certainly was, until I began to think of these variations as points on a continuous spectrum. I hope the following discussion will impress you as simpler.

What is the "mood spectrum?" (references updated 4/2008)

Until very recently, depression and "manic-depressive illness" were understood as completely independent: a patient either had one or the other. Now the two are seen by many mood specialists  as two extremes on a continuum, with variations found at all points in between, as in the graph below :(e.g. Ghaemi; Pies; Moller; Birmaher; Skeppar; Mackinnon; Angst and Cassano; Akiskal to name just a few important articles since 2001)

On the left, the "unipolar" extreme represents straightforward depression with no complications. There are many forms of depression, of course. For an overview, see the appendix: "What kinds of depression are there?". The depressions discussed further here are of a more genetic, or "chemical" nature; as opposed to those of a more environmental, or situational type. The latter may respond well to time or therapy and not require "bipolar" thinking.

On the right, the "manic-depressive" extreme is defined by the presence of manic episodes, just the kind that most people have seen or heard of: full delusional mania. But in between these extremes is a large area which some mood experts think includes more people than either extreme. In other words, it might be the most common form of bipolar disorder, this middle group.^{e.g. Judd, Benazzi, Sharma}

Consider the following points A and B on this spectrum:

Point A on the continuum describes people who have a complex depression but who still respond well to antidepressant medication or psychotherapy. Around point B, however, there is some sort of threshold where these approaches are no longer completely or continuously effective: either they don’t work at all, offer only partial relief, or help for a while then "stop working" (which may account for some or much of "Prozac poop-out", now regarded as a "soft sign" of bipolar disorder, described below).  

Until 1994 and the publication of the DSM-IV, there was no official name for all the variations between B and the "manic-depressive" extreme. It was as though these variations did not exist. In the minds of a few, they still don’t, including some psychiatrists who have not adopted this new "spectrum" way of thinking about diagnosis. The DSM-IV itself does not describe this "spectrum" concept. In it, the entire span between B and "manic-depressive" is just "bipolar II". 

Update 4/2008: although disagreement was common when I wrote this website in 2001, the spectrum concept pictured above is now quite widely accepted.  Indeed, an international bipolar specialty group, the International Society for Bipolar Disorders, just published "Diagnostic Guidelines" including a paper on the Spectrum concept. These guidelines are intended as a sort of update on the DSM, while we await the next revision in 2012 or so.  The new guidelines touch on seven different aspects of bipolar diagnosis which have been controversial over the last decade.  I was honored to be able to participate in this project, serving as the main author on the "spectrum" paper.  In general I think it is fair to say that the spectrum concept featured prominently in most of the seven summary/recommendations.  Here is a summary of those 2008 ISBD Diagnostic Guidelines.

What do "bipolar variations" look like?

Warning: The following represents my clinical experience taking referrals from primary care physicians. Most patients I see have been on 3 or more antidepressants before I see them. This selects very directly for "bipolar spectrum" patients. However, note that none of these descriptions are found in the DSM, nor are they widely spoken of by mood experts. This is my personal formulation based on 5 years of full-time selection for such patients.

Roller coaster depression

Many people have forms of depression in which their symptoms vary a lot with time: "crash" into depression, then up into doing fine for a while, then "crash" again — sometimes for a reason, but often for no clear reason at all. They feel like they are on some sort of mood "roller coaster". They wonder if they have "manic-depression". But, most people know someone or have heard of someone who had a "manic" episode: decreased need for sleep, high energy, risky behaviors, or even grandiose delusions (‘I can make millions with my ideas"; "I have a mission in space"; "I’m God"). So they think "well, I can’t have that — I’ve never had a manic episode".

However, the new view of bipolar disorder means it’s time to reconsider that conclusion. Hypomania doesn’t look or feel at all like full delusional mania in some patients. Sometimes there is just a clear sense of something cyclic going on. (For a striking version of this, read a patient's account). Some mood disorder experts consider depression that occurs repeatedly to have a high likelihood of having a manic phase at some point^Fawcett, especially if the first depression occurred before age twenty.^{Geller, Rao} These two features--repeated recurrence, and early onset--are also included among the bipolar "soft signs" below:  not enough to make a diagnosis, but suggestive, especially if they occur with several other such signs--even if "hypomania" is not detectable at all!^Ghaemi 

Depression with profound anxiety

Many people live with anxiety so severe, their depression is not the main problem. They seem to handle the periods of low energy, as miserable as they are. Often they sleep for 10, 12, even 14 hours a day during those times. But the part they can’t handle is the anxiety: it isn’t "good energy". Many say they feel as though they just have too much energy pent up inside their bodies. They can’t sit still. They pace. And worst of all, their minds "race" with thoughts that go over and over the same thing to no purpose. Or they fly from one idea to the next so fast their thoughts become "unglued", and they can’t think their way from A to C let alone A to Z. When this is severe, people who enjoy books can find themselves completely unable to read: they just go over and over the same paragraph and it doesn’t "sink in". They will get some negative idea in their head and go around and around with it until it completely dominates their experience of the world. Usually these "high negative energy" phases come along with severely disturbed sleep (see Depression with Severe Insomnia, below). Thoughts about suicide are extremely common and the risk may be high.^Fawcett(b)

Depressive episodes with irritable episodes

Many people with depression go through phases in which even they can recognize that their anger is completely out of proportion to the circumstance that started it. They "blow up" over something trivial. Those close to them are very well aware of the problem, of course. Many women can experience this as part of "PMS". As their mood problems become more severe, they find themselves having this kind of irritability during more and more of their cycle. Similarly, when they get better with treatment, often the premenstrual symptoms are the "last to go". Others can have this kind of cyclic irritability without any relationship to hormonal cycles. Many men with bipolar variations say they have problems with anger or rage.

Depression that doesn’t respond to antidepressants (or gets worse, or "poops out")

Many people have repeated episodes of depression. Sometimes the first several episodes respond fairly well to antidepressant medication, but after a while the medications seem to "stop working". For others, no antidepressant ever seems to work. And others find that some antidepressants seem to make them feel terrible:  not just mild side effects, but severe reactions, especially severe agitation. These people feel like they’re "going crazy". Usually at this time they also have very poor sleep. Many people have the odd experience of feeling the depression actually improve with antidepressants, yet overall —perhaps even months later —they somehow feel worse overall.  In most cases this "worse" is due to agitation, irritability, and insomnia. 

In some cases, an antidepressant works extremely well at first, then "poops out".^Byrne  The benefits usually last several weeks, often months, and occasionally even years before this occurs.  When this occurs repeatedly with different antidepressants, that may mark a "bipolar" disorder even when little else suggests the diagnosis.^Sharma

Depression with periods of severe insomnia

Finally, there are people with depression whose most noticeable symptom is severe insomnia. These people can go for days with 2-3 hours of sleep per night. Usually they fall asleep without much delay, but wake up 2-4 hours later and the rest of the night, if they get any more sleep at all, is broken into 15-60 minute segments of very restless, almost "waking" sleep. Dreams can be vivid, almost real. They finally get up feeling completely unrested. Note that this is not "decreased need for sleep" (the Bipolar I pattern). These people want desperately to sleep better and are very frustrated.

Want to see similar explanations from another source?  Or more detail on the kinds of symptoms people with this illness can have? Here are another doctor's observations on the issue of "soft" bipolar variations. 

"Soft Signs" of Bipolar Disorder (updated Feb 2007)

You have probably figured it out by now:  making a diagnosis of bipolar disorder can be pretty tricky sometimes!  You're about to read a list of eleven more factors that have been associated with bipolar disorder.  None of these factors "clinches" the diagnosis.  They are suggestive of bipolarity, but not sufficient to establish it.  They are best regarded as markers which suggest considering bipolar disorder as a possible explanation for symptoms.  They are not a scoring system, where you might think "the more I have of these, the more likely it is that I have bipolar disorder."  That way of thinking about these factors has not been tested.  

Here's the list of items which are found with bipolar disorder more often than you would expect by chance alone.  This list is adapted from a landmark article by Drs. Ghaemi and Goodwin and Ko.  (Drs. Goodwin and Ghaemi are among the most respected authorities on bipolar diagnosis in the world. This important article is online).  

1. The patient has had repeated episodes of major depression (four or more; seasonal shifts in mood are also common).
2. The first episode of major depression occurred before age 25 (some experts say before age 20, a few before age 18; most likely, the younger you were at the first episode, the more it is that bipolar disorder, not "unipolar", was the basis for that episode).
3. A first-degree relative (mother/father, brother/sister, daughter/son) has a diagnosis of bipolar disorder.
4. When not depressed, mood and energy are a bit higher than average, all the time ("hyperthymic personality").
5. When depressed, symptoms are "atypical":  extremely low energy and activity; excessive sleep (e.g. more than 10 hours a day); mood is highly reactive to the actions and actions of others; and (the weakest such sign) appetite is more likely to be increased than decreased.  Some experts think that carbohydrate craving and night eating are variants of this appetite effect. 
6. Episodes of major depression are brief, e.g. less than 3 months.
7. The patient has had psychosis (loss of contact with reality) during an episode of depression.
8. The patient has had severe depression after giving birth to a child ("postpartum depression").
9. The patient has had hypomania or mania while taking an antidepressant (remember, severe irritability, difficulty sleeping, and agitation may -- but do not always -- qualify for "hypomania").
10. The patient has had loss of response to an antidepressant (sometimes called "Prozac Poop-out"):  it worked well for a while then the depression symptoms came back, usually within a few months. 
11. Three or more antidepressants have been tried, and none worked.

There is a very radical idea buried in these 11 items, which we should look at before going on, but you should be aware that this idea is unusual; uncommon even among bipolar experts; and likely to be dismissed with a "hmmmph" by many if not nearly all practicing psychiatrists.  The idea is this:  Dr. Ghaemi and colleagues propose in this paper that there might be a version of "bipolar disorder" that does not have any mania at all, not even hypomania.  They call it "bipolar spectrum disorder".  

This is strange, you are saying to yourself.  "I thought bipolar disorder was distinguished from 'unipolar' depression by the presence of some degree of hypomania; don't you have to have some hypomania in order to be bipolar?  How could it be 'bi' - polar if there is no other pole!?"

But Dr. Ghaemi and colleagues assert that there are versions of depression that end up acting more like bipolar disorder, even though there is no hypomania at all that we can detect (or, as in item #9, only when an antidepressant has been used).   These conditions do not respond well, in the long run, to antidepressant medications (which "poop out" or actually start making things worse).  They respond better to the medications we routinely rely on in bipolar disorder, the "mood stabilizers" you'll be introduced to in the Treatment section of this website.  And these patients have other folks in their family with bipolar disorder or something that looks rather more like that (e.g. dramatic "mood swings", even if the person never really gets ill enough to need treatment).  

In Dr. Ghaemi's description, then, there are people whose depression looks so "unipolar" that even a "fine-toothed comb" approach to looking for hypomania will not identify it as part of the "bipolar spectrum".  According to Ghaemi and colleagues, these people should be regarded as "bipolar", in a sense, because of the way they will end up responding to treatment.  In other words, there is something in these people which doesn't look like our old idea of bipolar disorder, or even our newer idea of bipolar disorder (bipolar II, etc.), but will still better describe their future (their prognosis) and the medications that are most likely to help them.  Remember that this is the very purpose of "diagnosis", to describe the likely outcomes with and without treatment, and to identify effective treatments.  So, on that basis, it seems reasonable to include these patients on the "bipolar spectrum", like this: 

The idea that someone can "have" bipolar disorder and yet not have any hypomania at all is not widely understood.  You probably would get blank looks from most psychiatrists if you mention it, and frank disbelief from nearly all primary care doctors, who don't have time to read the literature on the diagnosis of bipolar disorder.  So, if you mention this idea to anyone, be prepared for some serious resistance.  Update 5/2005:  the Harvard bipolar program's new approach to diagnosis, the "Bipolarity Index", uses a spectrum-based system

Other researchers are also beginning to use the same framework of thought.  For example, one research group just reported that patients with migraine headaches are much more likely to have these bipolar spectrum traits.^Oedgaard (Migraines are much more common in patients with unipolar and Bipolar II  than in Bipolar I, interestingly.^Fasmer) One recent summary article for primary care doctors, about bipolar disorder, discusses these "soft signs" in considerable detail.^Swann The concept of a bipolar "spectrum" is supported by work from a research group calling themselves the Spectrum Project.^{e.g. Cassano} 

Probably better not to raise this issue unless you have to, at this point (December 2004), but if you must, cite the source.  Here's that article link again.^Ghaemi   Dr. Ghaemi is the chairman of the committee on diagnosis for the International Society for Bipolar Disorder.  One of his two co-authors is Dr. Frederick Goodwin, who wrote the "bible" of bipolar disorder for our lifetime (Manic-Depressive Illness, with Dr. Kay Jamison).  These are highly respected researchers amongst mood experts.  Dr. Ghaemi emphasizes the need to rely on evidence in all his papers on diagnosis and treatment and is very frequently cited by other authors on this topic (you'll see quite a few references to him on this website, e.g. see Antidepressant Controversies).  

Anxious depression could be "bipolar"?!

Warning: leaving DSM-IV territory

The remainder of this "diagnosis" discussion cannot be found in the DSM. I will repeatedly reference mood disorder experts, but many of these views are controversial. You must evaluate for yourself the validity of what follows.

Unfortunately, "hypomania" is quite a mis-naming. There are many patients whose "hypomanic" phases are an extreme and very negative experience. As noted above by Dr. Jamison, mania can be negative as often as it is positive. The "racing thoughts" can have a very negative focus, especially self-criticism. The high energy can be experienced as a severe agitation, to the point where people feel they must pace the floor for hours at a time. Sleep problems can show up as insomnia: an inability to sleep, rather than decreased need.  (If you or a friend or doctor is skeptical about anxiety as a "bipolar" symptom, try that link for more details and references.)  

In my experience most of these people come to treatment with a combination of agitation, anxiety and self-criticism — and they can’t sleep well. Is this "anxiety?" Is this some mood variation? How could you tell the difference? Is there a difference? What is really going on chemically? Unfortunately, this is still almost completely unknown. See the appendix "What’s the latest on why?", which I will try to keep updated frequently, for the latest research about the cause of this illness.

Again, my opinion: you can’t easily distinguish "anxious depression" from bipolar II in a mixed state. I doubt that there is a distinction to be made, ultimately (when we know, hopefully someday relatively soon, what the chemical basis for anxiety with depression really is). For example there is nearly complete overlap between Generalized Anxiety Disorder and Bipolar II.

For now, the only way to tell is by how treatment turns out. Depression that is not bipolar can get better and stay better: with time, or counseling, or formal psychotherapy, or antidepressants. If you get better — great! If you don’t, you may need this new understanding of mood disorders in order to consider mood stabilizers medications, discussed in detail below, as an option.

Meanwhile, at least one experienced mood researcher warns that anxiety in someone who is depressed is associated with a high suicide risk.^Fawcett(b) So although there is diagnostic confusion, there are tremendous stakes involved. Approaching this situation with an open mind seems wise, given this risk.

Diagnosis: Summary

I hope it may now make sense to you to think of mood symptoms as falling on a continuum between plain depression and "depression plus", the far end of which is Bipolar I, with many variations falling in between. If you would like to read some descriptions of symptoms by people with bipolar disorder, try this site, but caution, there are no clear distinctions being drawn about bipolar I, or II.

If you are wondering  whether what you've just read is "mainstream" or "fringe" (that's a good thing, to wonder thus), you'll find the same "spectrum" concept coming from the head of the Harvard Bipolar Clinic, in this 2005 interview: Sachs.  

By contrast, another mood disorder expert has shown bipolar disorder is overdiagnosed (Zimmerman, 2008; here is a close examination of his findings). He's certainly right, if one sticks to the DSM rules. And there are quite a few people getting this diagnosis who might be better understood with a different diagnostic framework, like Post-Traumatic Stress Disorder (PTSD). But in my view, the trick is for you to learn more about "bipolarity", as you have done here. You are an important part of the diagnostic process. 

Is there a test for bipolar disorder? Can you be sure if you have it or not? (revised 6/2003)

This used to be simple. When "manic" only meant one thing (classic mania) one could ask "have you ever had a manic episode?" and many people knew what was being asked:

• Mood much better than normal
• Rapid speech
• Little need for sleep
• Racing thoughts, trouble concentrating
• Continuous high energy
• Overconfidence
• Loss of contact with reality (delusions)

As you now know (start this section on diagnosis afresh if you came from elsewhere), this list looks for obvious mania.  It misses all the complexity we have just discussed. What you might be wanting is a "no way!" bipolar test.  Something to provide a clear statement, like: "no you don’t have it, or anything like it".  Or you might be looking for the opposite: "you definitely have bipolar II".  Sorry, that is not possible, but please read on.  

On other websites you'll find a test called the Mood Disorders Questionnaire (MDQ) which is supposed to give you a "yes or no" answer.   But another test came along after the MDQ which is better suited to looking for subtle versions of bipolar II.  

Think about it:  if by this point on this website you're saying to yourself "that's me!", which some people do, then you really don't need some test to tell you that you should go ahead and try to get treatment.  Or that the diagnostic basis for that treatment should include a consideration of bipolar II.  On the other hand, if someone else thinks you might have it, but you don't think you do, is a test result going to make a difference to you?  If so, go ahead and take one of these tests.  

Family or friends could "take the test", answering as if they were you, on the basis of what they've seen you do or heard you say.  And then they could gently wonder out loud if perhaps the test might mean something, who knows, no one can tell for sure, but darn it sure seems like your life is a struggle sometimes, wow, what if there was a tool out there that would make life a bit smoother sometimes, not even necessarily a medication treatment, oh well, just thinking about this, of course you'd want to decide for yourself, not for me to say of course, etc. etc. (there's a technique like this called Motivational Interviewing, if you're interested).  

The people who are in a position to benefit from taking one of these diagnostic tests are those who are wondering if a "bipolar" variation might be worth considering to explain their symptoms.  Here's the test I'd recommend for you, called the  Bipolar Spectrum Diagnostic Scale.  It won't give you a yes-or-no answer.  I hope by this point you understand why that's a good thing.  If after all that you still want to use a "fine-toothed comb" to look for hypomanic/manic symptoms, as I sometimes do when people are still wondering about the diagnosis after learning all this, here is a 32-item checklist of such symptoms. 

Thank you for patiently reading all the way to this point.  It's a lot to swallow at once, isn't it?  From here you can review, or read more about diagnosis issues in the Diagnosis Details section, or go on to Treatment.