internally and/or observed by others
✔ Recurrent thoughts of death or suicide (suicide ideation), a suicide attempt, or a plan to commit suicide
These symptoms must cause significant problems in your day-to-day life and function to qualify as indicators of a major depressive episode. If they occur solely in response to use of a medication or substance, or another medical condition, then the episode has its own category, such as substance/medication-induced depressive disorder or depressive disorder due to another medical condition, and, therefore, doesn’t count toward a diagnosis of either unipolar or bipolar depression.
Most people experience mood fluctuations to some acceptable degree, but bipolar mood episodes are amplified and extend far beyond the levels of discomfort – to the point of impairing a person’s ability to function and enjoy life. Episodes associated with bipolar disorder make a person think, feel, speak, and behave in ways that are extremely uncharacteristic of the individual. And they may drag on for weeks or even months. They strain relationships, disrupt lives, and often land people in the hospital or in legal trouble. And they’re not something a person can just snap out of. Figure 1-1 illustrates the difference between normal mood fluctuations and those related to bipolar disorder.
© John Wiley & Sons, Inc.
Figure 1-1: Normal mood variation versus bipolar mood episodes.
For any mood episode to count toward a diagnosis of bipolar disorder, the mood episode can’t be better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, other specific or unspecified schizophrenia spectrum disorders, or other psychotic disorders. All these conditions have at least some period of psychosis that’s not part of a mood episode. The point is to clarify that a bipolar diagnosis can’t be decided if symptoms include disordered thinking and reality testing that aren’t part of a mood episode. (For more about psychosis, see “Presence or absence of psychosis,” later in this chapter.)
Distinguishing Types of Bipolar Disorder
Bipolar disorder wears many masks. It can be happy, sad, fearful, confident, sexy, or furious. It can seduce strangers, intimidate bank tellers, throw extravagant parties, and steal your joy late into the night. However, based on research, psychiatrists have managed to bring order to the disorder by grouping the many manifestations of bipolar into categories that include bipolar I, bipolar II, and cyclothymic disorder. In the following sections, we offer guidance for distinguishing among the many different types of bipolar disorder.
Bipolar disorder is often considered the Cadillac of brain disorders because so many famous and creative individuals – Vincent van Gogh, Abraham Lincoln, Winston Churchill, and Virginia Woolf – are thought to have struggled with it and perhaps even benefited from it. This may be small comfort when your symptoms are severe and painful, but it can give you a sense of kinship with people who made a positive impact despite this disorder. Maybe it can motivate you to find and focus on the talents that make you stand out in this world.
More good news: With advances in treatment, people with bipolar no longer have to swap creativity for good health. In fact, most people with bipolar find that they’re more consistently creative and productive with the right combination of medication, self-help, and therapy.
To earn the bipolar I label, you must experience at least one manic episode sometime during your life (see “Manic episode,” earlier in this chapter). A major depressive episode isn’t required for the bipolar I diagnosis, although many people with bipolar I have experienced one or more major depressive episodes at some point in their lives. In fact, depression is actually the phase of bipolar that causes the most problems for people with bipolar.
Bipolar II is characterized by one or more major depressive episodes with at least one hypomanic episode sometime during the person’s life. The major depressive episode must last at least two weeks, and the hypomania must last at least four days. (For more about what qualifies as hypomania, check out the earlier section “Hypomanic episode.”)
Cyclothymic disorder involves multiple episodes of hypomania and depressive symptoms that don’t meet the criteria for a manic episode or a major depressive episode in intensity or duration. Your symptoms must last for at least two years (or one year in children or adolescents) without more than two months of a stable, or euthymic, mood during that time to qualify for a cyclothymic disorder diagnosis.
The substance/medication-induced bipolar disorder diagnosis applies when someone presents with all the symptoms of bipolar disorder (elevated, expansive, or irritable mood with or without depression), but only in the context of acute substance intoxication or withdrawal or medication effects. When this diagnostic category is used correctly, the mood disorder doesn’t predate the introduction of the substance or persist long after the substance effects or withdrawal is over.
When a person’s mania or hypomania can be traced to another medical condition, such as hyperthyroidism (overactive thyroid), based on medical history, physical examination, or lab results, the person may receive a diagnosis of bipolar and related disorder due to another medical condition, and the doctor will identify that other medical condition.
Introduced in DSM-5, this diagnosis enables doctors to diagnose bipolar disorder when symptoms characteristic of bipolar disorder significantly impair normal function or cause considerable distress, but don’t quite meet the full diagnostic criteria for the other bipolar diagnostic classes. Here are some examples:
✔ Major depression with short-duration hypomanic episodes: An individual has experienced one or more major depressive episodes and two or more hypomanic episodes, but the hypomanic episodes have lasted for only a couple days (not the full four consecutive days required). In addition, the
