Everyone’s looks a little different

By Elizabeth Forbes

Imagine a big museum filled with widely varied portraits. The shimmering figure in an ornate gold frame runs up his credit cards, cruises the bars and takes off on spontaneous trips every spring. Next to him is a monochrome image with just a splash of red—a man who mostly lives with depression but has a one-off manic episode in his past.

Over here is a woman photographed in vibrant color, reflecting the exuberant feeling of her hypomanic episodes. Facing her is a Cubist image which conveys an uncomfortable mix of twitchy energy, irritability and a kind of wired-up unhappiness. A tiny canvas represents symptoms that pass in days, while a mood that persists for weeks takes up a wall-sized tapestry.

In the Diagnostic and Statistical Manual of Mental Disorders (DSM for short), psychiatry has done its best to capture all those individual shades of experience and boil them down to a set of common criteria for bipolar disorder—or rather, bipolar disorders, because there are a handful of different diagnoses under the bipolar umbrella.

If you can’t count on that stability, it makes life extremely difficult.

At the far manic end of the spectrum sits bipolar I disorder. Next comes bipolar II: depression with a helping of hypomania. Then there’s cyclothymic disorder, which describes frequent mood shifts that never reach a full-blown episode of depression or mania, and a category previously known as “not otherwise specified,” used for conditions that don’t precisely fit the other categories.

Bipolar II is often seen as a milder or “softer” form of the illness than bipolar I. Not so, says Ellen Frank, a professor of psychiatry and psychology at the University of Pittsburgh School of Medicine and director of the Depression and Manic Depression Prevention program at the medical center’s Western Psychiatric Institute and Clinic.

In bipolar II, she says, “the depressions … can be so disabling and so long-lasting. The manias of bipolar I disorder are very dramatic and get people’s attention and yes, people can do a lot of financial and interpersonal damage during mania, but we know how to treat mania quite well. We’re not so good at treating either bipolar I or bipolar II depression.”

Cyclothymic disorder may seem milder yet, but by definition the diagnosis means that a person’s stable periods don’t last more than two months. “If you can’t really count on whether you’re going to be excessively energetic or optimistic or excessively pessimistic and not able to get anything done—if you can’t count on that stability, it makes life extremely difficult,” Frank says.

“By definition” gets back to those common criteria in the DSM, which is the standard reference clinicians use for figuring out how to label a set of symptoms—and thus how to treat the underlying illness. Unfortunately, life doesn’t always play by the book. And when your particular portrait of bipolar disorder doesn’t mesh neatly with the DSM descriptions, it can be harder to develop a treatment plan that will really help.

Revisions to the DSM take aim at that disconnect. Frank was part of a group tasked with updating the section on bipolar disorder in the DSM-IV (or fourth edition), which the American Psychiatric Association put out back in 1994. She says the new fifth edition, called DSM-5, tries to get closer to what clinicians see in actual practice.

She says the group set out to address several problems, including “the incredible time lag between first symptoms and an accurate diagnosis … individuals who have bipolar disorder often wait 7 to 10 years for a correct diagnosis. That means they often wait 7 to 10 years for appropriate treatment.”

There are some things no amount of revising can fix. If someone doesn’t seek help because of stigma or some other reason, they’re not going to be diagnosed with anything. And an initial diagnosis of depression may actually be correct in the early stage of the illness, because hypomania or mania may not emerge until a good while later.

It’s really hard to pin down changes in mood.

What DSM-5 does try to tackle is the tricky job of ferreting out signs that indicate bipolar rather than unipolar depression. Primary care physicians may be getting more familiar with recognizing depression, but limited time with their patients and lack of comprehensive screening tools mean those elusive signs tend to go undetected. Even experienced clinicians may have a hard time “unless the individual is in a flagrant episode of mania,” Frank says.

According to clinical psychologist Eric Youngstrom, PhD, “There isn’t anything in the snapshot of bipolar depression that’s any different from any other kind of depression. The only way that we’re going to recognize that is by playing lifetime mood bingo, asking about all the different types of mood episodes in the past and in the present.”

Youngstrom is acting director of the Center of Excellence for Research and Treatment of Bipolar Disorder at the University of North Carolina at Chapel Hill, where he is also a professor of psychology and psychiatry. His clinic has been working on a “roadmap to better assessment” that plugs in a lot of information beyond DSM symptoms to make diagnosis more accurate.

To diagnose a mood episode according to DSM criteria, clinicians go down a checklist of symptoms that are set up in a “one from column A, three to five from column B” format. For mania or hypomania, Column A has included just one major symptom: “abnormally elevated, expansive, or irritable mood.” If you don’t answer yes to that, it’s usually game over.

However, mood symptoms tend to be an unreliable marker in clinical practice. For one thing, many people experience hypomania simply as better-than-usual life, a period of brilliant ideas, abundant energy and feeling great—so what’s the problem? This is known as “lack of insight.”

“We talk about onion and garlic symptoms,” says Youngstrom, using a metaphor he credits to the late Dennis Cantwell, MD. “Onion symptoms would bug us when we’re having them and garlic symptoms bug everyone else around us first. Depression is a bunch of onion symptoms. Hypomania is a bunch of garlic symptoms.”

From the perspective of people who are hypomanic, “They’re not talking too much, they’ve just got really exciting stuff that’s more interesting than anything anyone else is trying to say,” he says.

That goes double for mania—and the effect seems to linger even after an episode has passed.

In general, Frank says, “It’s really hard to pin down changes in mood. But when you ask someone, ‘Did your level of energy change or your level of activity change?’ generally retrospective memory is better.”

So the DSM-5 moves questions about changes in energy and activity level up from the “other” column to the top-priority section, in hopes of making it easier to identify people who belong on the bipolar spectrum.

According to Youngstrom, “it tends to be more culturally accurate as well. Thinking about bipolar as a mood issue tends to be a white, middle-class American way of thinking about the problem. Thinking about changes in behavior and activity level seems to work better across cultures.”

In another attempt to improve diagnosis, the former “mixed episode” is no more. Frank says very few people actually met the full criteria for a manic and major depressive episode at the same time, which was the requirement for a diagnosis of mixed episode, so the term was almost useless. DSM-5 substitutes “with mixed features” as a description (or specifier) that can be attached to the other types of mood episodes.

The clinician now has a way to indicate “depression mixed with a little bit of hypomania or mania mixed with some depression,” Frank says. Not only is that far truer to reality, but it’s another opportunity to shorten the time to a bipolar diagnosis—even if it’s that amorphous “not otherwise specified” (now dubbed “other specified” in DSM-5 for bookkeeping reasons.)

Beyond that, the new mixed-features specifier “has implications for prognosis, in that we know that this episode is going to be more difficult to treat,” Frank explains.

That’s really the end goal of the naming game: matching medications and psychotherapeutic approaches to the situation at hand. Of course, there’s no way a rigid set of criteria can account for the many facets of experience. A thorough psychiatric evaluation will look at much more, such as an individual’s work and home life, risk factors such as family history, and relevant medical conditions.

Individuals…often wait 7 to 10 years for a correct diagnosis.

“The DSM doesn’t cover all the possibilities, all the pictures that clinicians see as we’re working with people,” Youngstrom notes. On the other hand, “it gives us a language and a set of descriptions to use.”

When someone seems to fit the definition for bipolar II, for example, “it tells us that their depression is not going to respond the same way to antidepressants or to other treatments, so we would want to manage the depression differently.”

To make it easier for you to join the conversation, here’s a rundown of the various bipolar diagnoses.

Bipolar I

Although depression is the prevailing mood state for many people who have a bipolar diagnosis, it’s the manic symptoms that dictate which particular diagnosis is given. Even one full-blown manic episode during a person’s lifetime—regardless of history of depression—equals bipolar I. However, there is an exception in each category for mood episodes caused by a medical condition or drug, legal or otherwise. Manic episodes are hard for observers to miss (although the person in mania may not see it), so that a diagnosis of bipolar I often occurs when someone has been hospitalized or has a brush with the law, or relatives insist on getting help.

Bipolar II

This diagnosis calls for at least one lifetime episode of major depression plus at least one hypomanic episode. It can be challenging for clinicians to distinguish bipolar II from major depressive disorder because people may not even recognize hypomania. “They’ve got more energy than usual, they’re more creative than usual, but they’re not experiencing it as a problem,” Youngstrom says. And when he’s asking about past history, “people will remember if they’ve been hospitalized or gotten arrested, but anything less severe than that doesn’t seem as important once time has passed.”

Cyclothymic Disorder

This diagnosis indicates “there’ve been mood issues that haven’t gotten all the way to a depression, haven’t gotten all the way to mania, but they’ve lasted a long time,” Youngstrom says. Specifically, periods of manic symptoms and periods of depressive symptoms occur frequently over the span of at least two years, causing significant distress but never qualifying as a diagnosable mood episode. Moreover, the individual doesn’t stay symptom-free for more than two months at a time.

Other Specified Bipolar

Formerly called Bipolar Disorder Not Otherwise Specified, this is a kind of stopgap when symptoms don’t clearly indicate one of the other bipolar diagnoses. For example, hypomanic periods recur without any depressive interludes, or there are near-hypomanic episodes that don’t last four days or don’t have the right number of symptoms. DSM-5 gives more specifics on the various options for “other specified” and pushes for more documentation on “why the person doesn’t meet the full criteria for bipolar I or bipolar II,” Frank says. “It gives us more clinical information about how to treat, about prognosis, and so on.” (The name change makes DSM-5 consistent with the International Statistical Classification of Disease and Related Health Problems, a listing compiled by the World Health Organization.)

Rapid cycling

This is not actually a diagnostic category. Rather, it’s a “specifier” that is added to the diagnosis to indicate that four or more separate mood episodes of any stripe occurred within a single year. It’s also a widely misunderstood term, often used to describe symptoms that fluctuate by the day or even the hour. Youngstrom prefers “rapid relapsing” or “rapid episoding” to indicate the pattern of distinct but recurring mood shifts. “What that tells us is that even if we get you back to where we want you, we have to be on guard for relapse because this has jumped you already four different times in the past year,” he explains.

With psychotic features

This specifier can be applied to either a manic or depressive episode to indicate a break with reality, such as hallucinations (seeing or hearing things which aren’t there) and delusions (believing things that aren’t true). Hearing voices, receiving special messages, taking on a different identity (often that of a religious or famous figure), and being convinced of a special mission (again, often religious) are common psychotic symptoms. Paranoia and disordered thinking (not making sense) are other hallmarks of psychosis. Catatonia (paralysis of movement and speech) can occur during severe depression.

With mixed features

This new specifier takes the place of “mixed episode” and can be applied when depressive features are present during an episode of mania or hypomania—Youngstrom uses the metaphor of vanilla ice cream with fudge swirled through—or features of mania or hypomania are present during an episode of major depression, which would be chocolate ice cream with marshmallow swirls.

With anxious distress

This specifier was added to indicate symptoms of anxiety that don’t meet the full criteria for panic disorder, generalized anxiety disorder or one of the other anxiety disorders. “This is an attempt to recognize the fact that even anxiety that doesn’t meet the full criteria for a disorder is something important to note and has implications for treatment,” Frank says.

Manic episode

Several elements must be present to diagnose a manic episode. First, there must be a distinct period during which there are marked changes in mood—abnormally elevated (on top of the world), expansive (flamboyant, filters off), or irritable—and goal-directed activity or energy level. Next, the uncharacteristic behavior or mood must last at least a week, or require hospitalization. Third, there must be at least three other symptoms (or four if the abnormal mood is irritability) from the following checklist:

• inflated self-esteem or grandiosity
• decreased need for sleep (for example, feeling rested after just a few hours’ sleep)
• more talkative or sociable than usual, or pressure to keep talking
• flight of ideas or the feeling that thoughts are racing
• easily distracted by unimportant or irrelevant things
• Increase in activity levels, either goal-directed (such as taking on new projects or socializing more) or a restless busyness
• plunging into reckless activities like buying sprees, promiscuity or high-risk business deals

Furthermore, symptoms must significantly affect the ability to manage at work or school, pursue usual social activities, or maintain relationships.

Hypomanic episode

If manic symptoms last at least four days but less than a week, the episode is deemed hypomanic. Symptoms don’t interfere too much with work, relationships and usual pursuits—in fact, hypomania often brings a sense of feeling energized and able to accomplish more—but changes in sleep and behavior mark a distinct departure from the norm and are noticeable to others. Judgment may be shaky. Hypomania is often a border state leading into or out of mania, and sometimes alternates with depression. For some people, hypomania can induce irritability and agitation (dysphoria) rather than a productive high (euphoria).

Major depressive episode

Diagnosis relies on five or more symptoms co-occurring nearly every day, for most of the day, during a two-week period. One of the symptoms has to be either low mood (feeling sad or empty, crying frequently) or significant loss of interest or pleasure in usual activities. Other possible symptoms include:
• weight gain or weight loss (when not dieting), or an increase or decrease in appetite
• inability to sleep or sleeping too much
• observable restlessness or moving uncharacteristically slowly
• fatigue or loss of energy
• feelings of worthlessness, excessive guilt or inappropriate guilt
• diminished ability to think, concentrate, or make decisions
• recurring thoughts of death or suicide

In addition, the symptoms must cause significant distress or impairment in everyday life.