Bipolar Spectrum Disorders: Episodes, Patterns, and Treatment

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Bipolar Spectrum Disorders: Episodes, Patterns, and Treatment

Abnormal Psychology · Chapter 12: Mood Disorders: Types, Origins, and RecoverySection 12.3 · lesson 45 of 9720 min · free with a free account

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In this lesson

Why the pole that causes least suffering is the one that decides the diagnosis.

  • Describe manic and hypomanic episodes in the course's own terms
  • Distinguish bipolar I, bipolar II, and related presentations
  • Explain why diagnostic delay of years is the norm
  • Describe the models, the differential, and management

Transcript

Everything said in the video, section by section (2,619 words). Read along, or search it.

Mood Disorders: Types, Origins, and Recovery

Bipolar Spectrum Disorders: Episodes, Patterns, and Treatment

A person is treated for depression for eight years, and never gets durably better. Then a relative describes a week that frightened them, and the diagnosis changes completely. That sequence is not unusual. It is close to typical. This section is about the bipolar conditions, and about why they are found so late. We define the manic and hypomanic episodes, which is where all the work happens. Then bipolar one and bipolar two, and a correction most people need. Then course, explanatory models, and the differential. And we finish with management, which turns on decisions made in advance.

The Grouping

Defined by One Kind of Episode

The current edition places bipolar conditions in a grouping of their own. Separate from the depressive conditions, on three grounds. The lifetime course, which involves episodes in two directions and typically begins earlier. The pattern of aggregation in families. And treatment, which is specialist-led and organized differently. The defining feature of the grouping is the occurrence of an episode of elevated mood. Everything else follows from which kind of elevated episode has occurred. A word about language, because the popular usage does real damage here. Bipolar is widely used as an adjective for changeable moods and unpredictable weather. That describes ordinary variability. These conditions involve sustained episodes, lasting days to weeks. Episodes that alter judgment, sleep, energy, and functioning. This course also does not romanticize mania, or treat a link with creativity as established. Mania involves impaired judgment, and its consequences are frequently severe. One note before we go on. This material is educational, and is not a basis for diagnosing anyone.

Mania

Two Components, Required Together

A manic episode is a distinct period of abnormally and persistently elevated mood. Elevated, expansive, or irritable. Together with abnormally and persistently increased activity or energy. Present most of the day, nearly every day. Two components are required together, and this matters. The mood change alone is not sufficient. The increase in activity is part of the core. That was made explicit in the current edition, partly because mood-only accounts were over-inclusive. Then a specified number of accompanying features, each representing a noticeable change. Inflated self-esteem or grandiosity, which may reach delusional intensity. Decreased need for sleep. More talkative than usual, or pressure to keep talking. Flight of ideas, or a subjective experience of racing thoughts. Distractibility, which is observable rather than only reported. Increased goal-directed activity, or psychomotor agitation. And excessive involvement in activities with a high potential for painful consequences. Now the duration and severity requirements. The period must last at least one week. Or any duration at all, if hospitalization is necessary. And it must be severe enough to cause marked impairment in functioning. Or to necessitate hospitalization, or to involve psychotic features. That severity requirement is what separates mania from hypomania. It is the whole of the difference.

Two Corrections

Judgment, and the Face Mania Usually Wears

Two corrections belong here, and both change how the episode is recognized. The first concerns judgment. Impaired judgment is a defining part of the picture. Not an incidental consequence of it. During a manic episode, the capacity to evaluate risk and weigh consequence is affected. Which is why decisions made during an episode can be so damaging. And why the person's own assessment of their state is unreliable at the time. That is also why treatment planning includes arrangements made in advance. A smaller correction, but a common exam error. Decreased need for sleep is not insomnia. In insomnia a person cannot sleep, and suffers for it. Here the person sleeps considerably less and does not feel tired. The second correction is larger. The popular image of mania is euphoria. Elevated, expansive, cheerful. That image misleads, and the consequence is missed diagnosis. A substantial proportion of manic episodes present with irritability rather than euphoria. Many involve both, sometimes shifting within a single day. An irritable presentation has the same increased energy and activity. The same reduced sleep need, the same accelerated speech and thought, the same impaired judgment. Only the mood registers as anger, impatience, or hostility rather than elation. Here is why it gets missed. Nobody describes an irritable, argumentative, sleepless week as a high. Not the person, and not their family. It is attributed to stress, to a difficult period, or to character. And none of those attributions leads to the mania question being asked.

Hypomania

The Same Features, and Three Differences

A hypomanic episode involves the same feature set at lower intensity. With three differences that matter. First, a shorter duration threshold. At least four consecutive days, rather than a week. Second, an observable change. The episode must represent an unequivocal change in functioning, noticeable to others. The person's own report of feeling good is not sufficient. Someone else must have observed a difference. Third, the absence of marked impairment, hospitalization, and psychotic features. If any of those is present, the episode is manic rather than hypomanic. By definition. Now the central practical difficulty of this whole subchapter. The absence of impairment is exactly what makes hypomania easy to overlook. A hypomanic episode frequently involves feeling well. Sleeping less and coping with it. Being productive, sociable, and confident. People do not seek help for that. They do not remember it as illness, and they do not report it when asked how they have been. Some describe it as the best they have ever felt. Some describe it as having recovered. So hypomania is generally identified retrospectively, by direct and specific questioning. And frequently only with collateral report from someone who observed the change. Ask a person whether they have ever had a period of abnormally elevated mood. They will very often say no, while a period meeting the description has occurred.

Compared

Three Episode Types on the Same Dimensions

Put the three episode types side by side on the same dimensions. Duration. Mania is at least one week, or any duration if hospitalization is needed. Hypomania is at least four consecutive days. A depressive episode is at least two weeks. Core requirement. Mania needs elevated mood and increased activity together. Hypomania needs the same, at lower intensity. A depressive episode needs depressed mood or loss of interest and pleasure. Severity. Mania involves marked impairment in functioning. Hypomania involves an unequivocal change observable by others, without marked impairment. Read that severity row across, because it is the point of the table. Severity is the dimension separating the first two columns. The duration difference follows from it, rather than defining it. Now the two rows students most often get wrong, because they are definitional. An episode with psychotic features is a manic episode by construction. So is one requiring hospitalization. Whatever its length. And the final row is the diagnostic consequence. One manic episode is sufficient for bipolar one, on its own.

I And II

The Poles Differ at the Top, Not at the Bottom

Bipolar one disorder is defined by the occurrence of at least one manic episode. That is the whole requirement. Depressive episodes are usual, and they are not required for the diagnosis. A single manic episode is sufficient, and a person may be diagnosed on that basis. Bipolar two disorder requires at least one hypomanic episode. And at least one major depressive episode, with no history of a manic episode. The presence of any manic episode moves the diagnosis to bipolar one permanently. Because the classification records lifetime history. Now the correction that matters most in this section. Bipolar two is not a milder condition. The reasoning is straightforward. The two differ in the intensity of the elevated pole. They do not differ in the depressive pole, and that is where the burden lies. People with bipolar two typically spend more time depressed than people with bipolar one. Their depressive episodes are as severe. And the associated impairment across a lifetime is comparable, or greater. Picture the two course charts. Only the first crosses the manic threshold. That single feature is what separates them. The second chart spends at least as much time below the line as the first. So the conditions differ at the top of the chart, and not at the bottom. Calling bipolar two, bipolar lite, is inaccurate. Told to a person receiving the diagnosis, it is misleading about what they face.

Course

Where the Time Actually Goes

Onset is typically in adolescence or early adulthood. Earlier on average than for major depressive disorder. That is one of the reasons the two groupings were separated. The most clinically important fact about the course is the distribution of time. Across the lifespan, people with bipolar conditions spend far more time depressed than elevated. That is true of bipolar one, and it is more pronounced in bipolar two. It has two consequences worth carrying. Most of the burden of these conditions is depressive burden. And most contact with services occurs during depression, not during elevated episodes. Inter-episode functioning varies considerably, and both halves should be stated. Many people recover substantially between episodes and function well. Others experience residual symptoms and continuing difficulty with concentration, energy, or confidence. Neither, people return completely to normal, nor, functioning deteriorates permanently, is accurate generally. Two specifiers belong here. Mixed features records features of the opposite pole during an episode. Depressive features during an elevated episode, or elevated features during a depressive one. They are harder to recognize, because they match neither prototype. They are associated with poorer outcome than either pole alone. Rapid cycling records four or more mood episodes within a twelve-month period. Separated by remission, or by a switch to the opposite pole. It is a course pattern rather than a permanent feature. People move in and out of it. Finally, the diagnostic delay, which follows directly from everything above. People seek help during depression, because depression is what causes suffering. They do not report past hypomania, because it was experienced as feeling well. Unless the clinician asks specifically, this is a depressive episode and is treated as one.

The Question

Not One of These Uses the Word Mania

The clinical rule is simple. Every depressive presentation gets the elevated-mood history. Every time, and asked in specific terms rather than by name. Now look at how the questions are actually worded. For a first depressive episode in a young adult, ask about sleep. Has there ever been a period of several days of needing much less sleep, and not feeling tired? For recurrent depression with early onset, ask about what others noticed. Have people ever commented that you seemed unusually energetic, or unlike yourself, for a period? Hypomania is defined partly by being observable, so an observer is the right source. For depression that has not responded to several treatment attempts, ask a different question. Has there been any period, even brief, of feeling markedly better than usual? Rather than simply well. Those two are not the same thing. Apparent treatment resistance is a recognized reason to revisit the diagnosis. For a depressive episode with agitation and racing thoughts, ask about energy within it. That raises mixed features, which changes management and needs specialist assessment. And where the family includes a bipolar condition, ask the same questions with more care. Now notice something about that middle column. Not one of those questions uses the word manic, or the word high. The diagnostic terms produce denials, because they do not describe how the experience felt.

Explanation

Five Contributions, Stated at Their Own Strength

Five contributions, and each should be stated at its own strength. Heritability. Bipolar conditions show one of the stronger heritable contributions in this course. Two cautions apply in full. Heritability is a population statistic, and says nothing about an individual. And a strong heritable contribution does not mean a single gene or a determined outcome. Most people with a family history do not develop the condition. Neurobiological findings are stated as association rather than mechanism. Differences in neurotransmitter signaling have been reported in group comparisons. So have differences in circuits involved in emotion regulation and reward. None is diagnostic, none identifies an individual, and none establishes direction of causation. Circadian and sleep disruption occupies an unusual position. It is both trigger and symptom. Reduced sleep is a feature of elevated episodes. And disruption of sleep and daily rhythm is associated with episode onset. Travel across time zones, shift work, a new baby, an irregular schedule. That two-way relationship is the rationale for the rhythm-focused approaches in management. The goal-dysregulation account proposes that reward-approach systems are unusually responsive. So goal attainment and the pursuit of reward can escalate into an elevated episode. And life events, in a diathesis-stress pattern. Two findings are worth noting. Events involving goal attainment and success are associated with elevated episodes. And events disrupting daily routine carry particular significance, for the reasons just given.

Differential

What Else Produces an Elevated Picture

Five things to distinguish an elevated picture from. Substance-induced states. Several substances produce elevated mood and reduced sleep need. Also increased activity, and impaired judgment. The distinguishing feature is the temporal relationship. A substance-induced state begins with use or withdrawal, and resolves with it. Establishing that needs a careful history, and where possible observation across a period without use. The two also co-occur substantially, which complicates the picture rather than resolving it. Medical causes. Some conditions and some prescribed treatments produce elevated or agitated states. Medical assessment belongs in the workup, particularly where onset is late or atypical. Attention-deficit presentations. The overlap is real. Distractibility, restlessness, talkativeness, and difficulty sustaining attention appear in both. The distinction is episodic structure. An attention-deficit presentation is a stable trait pattern, present from childhood and continuously. A manic or hypomanic episode is a distinct period, representing a change from baseline. So ask what the person is like between the described periods. Borderline personality presentations. This one is frequently got wrong in both directions. The differences are timescale and trigger. Bipolar mood shifts persist for days, and are not typically tied to interpersonal events. The instability seen in personality disorders shifts within hours, and is characteristically reactive. The two also co-occur, and neither diagnosis excludes the other. And where psychotic features occur, ask whether they occur only during mood episodes.

Management

Decisions Made in Advance, While Judgment Is Intact

Treatment of bipolar conditions is specialist-led, and medication is described by class only. Mood-stabilizing agents form the foundation, for acute episodes and for longer-term prevention. Antipsychotic agents are used in several roles, including acute elevated episodes and maintenance. Antidepressant classes occupy a genuinely contested position. Their use in bipolar depression is a clinical decision requiring care. Because of concerns about switching into an elevated state, and about effects on cycling. That is a live clinical question rather than something resolved here. Psychoeducation is a core component, and one of the better-evidenced psychological interventions here. The person, and usually those close to them, learn the condition and its early warning signs. Its effect on relapse rates is among the more consistent findings in this area. Family-focused approaches work with the household rather than the individual alone. The rationale is direct. People around a person frequently notice a change before the person does. Rhythm-focused approaches target regularity of daily routine and sleep. Stabilizing rhythm removes one identified trigger. Then relapse prevention, which has a particular logic. Early warning signs are individual, and they repeat within a person. For one it is sleeping less; for another, a particular kind of spending. Sleep is the most consistently useful single indicator. Then a written plan, made while the person is well, recording what follows if warning signs appear. Here is the whole logic of it. Judgment is impaired during an episode. So the decisions are made in advance, by the person, while it is not. Note the ethical shape of that. An agreement made in advance, with consent, is not others acting on someone without it. Finally, adherence, stated honestly. Feeling well raises the question of whether treatment is still needed. Side effects are experienced continuously, while the benefit is the absence of something. And some people miss hypomanic states, which were energetic and enjoyable. Treatment removes them, and that is a real loss. Describing it as such is more useful than treating discontinuation as non-compliance.

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Questions students ask us

About Bipolar Spectrum Disorders: Episodes, Patterns, and Treatment

What is the difference between mania and hypomania?
The key difference between mania and hypomania is severity. Mania causes marked impairment in functioning, requires hospitalization, or involves psychotic features, and lasts at least one week or any length if hospitalization is needed. Hypomania lasts at least four consecutive days and is an unequivocal change that others can observe, but without marked impairment, hospitalization or psychosis. Both require elevated or irritable mood together with increased activity or energy.
What is the difference between bipolar I and bipolar II disorder?
Bipolar I disorder requires at least one manic episode, and a single manic episode is enough for the diagnosis even without depression. Bipolar II disorder requires at least one hypomanic episode and at least one major depressive episode, with no history of mania. Because diagnosis records lifetime history, any manic episode moves a person's diagnosis to bipolar I permanently.
Is bipolar II disorder a milder form of bipolar I?
No, bipolar II disorder is not a milder condition. The two differ in the intensity of the elevated pole, not the depressive pole, which is where most of the burden lies. People with bipolar II typically spend more time depressed than people with bipolar I, their depressive episodes are as severe, and lifetime impairment is comparable or greater. Calling it bipolar lite misleads people about what they face.
Why does bipolar disorder often take years to diagnose?
Bipolar disorder often takes years to diagnose because people seek help during depression, which causes the suffering, and rarely report past hypomania, which felt like being well or productive. Irritable mania is also often blamed on stress or character. Unless a clinician asks specifically, the presentation is treated as depression. Asking about periods of needing much less sleep, or what others noticed, works better than asking about being manic or high.

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