Gaining Clarity: Understanding Your Loved One’s Bipolar Disorder

Bipolar disorder is most accurately described as a spectrum of related disorders with unique symptomatologies that center around particular types of mood episodes. While some people with certain types of bipolar disorder may experience perceptual disturbances, all forms of bipolar disorder are primarily or exclusively about patterns of mood, not psychotic symptoms. Most people with bipolar disorder never experience a psychotic episode.

To better understand how the bipolar spectrum functions, here is an overview of various forms of bipolar disorder:

• Bipolar I: Bipolar I is defined by the experiencing of a manic episode, which may or may not be accompanied by depressive episodes. Some people with this form of bipolar disorder experience psychotic episodes, which are typically brief in duration

• Bipolar II: People with Bipolar II experience both hypomanic and depressive episodes and rarely present with psychotic symptoms.

• Cyclothymic Disorder: Cyclothymic disorder is a form of bipolar disorder in which you experience hypomanic and mild depressive symptoms over a period of at least two years with no break in symptom presentation longer than 2 months. While symptoms never reach the severity observed in Bipolar I and II, do not meet the criteria for a major depressive episode, and do not include psychosis, they can nevertheless cause significant distress.
• Bipolar Disorder Not Otherwise Specified (NOS): People who experience symptoms of bipolar disorder but do not fit the diagnostic criteria for bipolar I, II, or cyclothymic disorder may receive a diagnosis of bipolar disorder NOS. Some people with this disorder do experience psychotic symptoms.

Bipolar disorder is often thought of as one of the most serious and severe psychiatric illnesses, more in line with schizophrenia than more common mental health disorders like depression and anxiety. While bipolar disorder can indeed be very severe, there is great variety in the way different people experience the bipolar spectrum, both within each diagnostic category and between categories. Whereas for one person the condition may be functionally crippling, for another it may present no major limitations. One cannot make assumptions regarding the how bipolar disorder impacts someone’s life based on the diagnosis alone.

It is commonly assumed that people with bipolar disorder are constantly experiencing a mood episode of some sort, whether manic, hypomanic, depressive, or mixed. However, most people with bipolar disorder experience periods of normalcy and stability in between mood episodes, some of which may extend for years at a time. In fact, some people are diagnosed with bipolar disorder based on a single manic episode that never recurs.

Many people imagine that those with bipolar disorder switch between mood states constantly, even within the course of a single day. In fact, both bipolar I and II have minimum mood episode duration criteria for diagnosis; mania must last at least one week, hypomania must last at least 4 days, depressive episodes must last at least last two weeks. For most, each mood episode lasts significantly longer than the minimum duration.

Part of the confusion about mood switching lies in the term “rapid cycling,” which many people have heard but don’t fully understand. While it may seem logical to assume that rapid cycling means quick, day-to-day changes, in reality it means that you experience four or more mood episodes within a 12-month period, which “can occur in any combination and order.” About 10-20% of people with bipolar disorder experience rapid cycling, with women making up 70-90% of that group. A much smaller proportion of people experience ultra-rapid cycling (mood switching at least once a month) or ultradian cycling (switching at least once per day). Ultradian cycling, in particular, is considered exceptionally rare, and many psychiatrists believe such mood changes may be indicative of another condition altogether. As Dr. Joseph F. Goldberg, Associate Clinical Professor at the Mount Sinai School of Medicine, writes:

Abrupt, sudden, drastic, or dramatic mood shifts from one moment to the next are nowhere to be found in the DSM-IV-TR definition of BD, and the construct of mood lability or affective instability is neither a cardinal nor defining element of BD. Although individuals with BD I or bipolar II disorder (BD II) may have periods of affective lability, rapid shifts in mood are neither necessary nor sufficient for a BD diagnosis, and may indicate other types of psychopathology when affective instability occurs in the absence of a history of discernible manic or hypomanic episodes.

One feature of bipolar disorder that many do experience, however, is mixed episodes in which both depressive and manic or depressive and hypomanic episodes present simultaneously. To the untrained eye, this may look like ultradian cycling, but it is actually a sustained state of co-occurring symptoms.

Bipolar II is sometimes referred to as ‘bipolar lite’ due to the fact that people with this form of bipolar disorder experience hypomanic episodes rather than full blown mania. While the intensity of elevated episodes and the likelihood of psychosis are indeed lower, people with bipolar II can still experience profound psychological distress. Often this distress arises from the more severe and prolonged depressive episodes that tend to accompany this condition, which may partially explain the higher suicide rate observed in those with bipolar II as opposed to bipolar I. Research also suggests that mood switching itself significantly augments suicide risk; because bipolar II requires cycling between hypomania and depression rather than experiencing only one type of mood disturbance, the condition may lend itself to more frequent suicide attempts.

Some symptoms of bipolar disorder can make come people act irrationally or against their true nature. This is not a reflection of their character, but the result of overwhelming emotional distress as they struggle to cope with their illness. However, people with bipolar disorder don’t all act any one particular way, nor are symptoms always expressed within relationships or social encounters; chances are that you have met many people with bipolar disorder without knowing it because their illness—particularly if effectively treated—does not interfere with interpersonal function. It is also important to remember that bipolar disorder doesn’t define everything a person thinks and does; they may have very legitimate reasons for disagreeing with you or being sad, angry, or frustrated, that have nothing to do with their illness.

While medication can play a vital role in the treatment of bipolar disorder, a range of non-pharmacological therapies have been found to be highly effective in supporting the psychological health of people living with the condition, regardless of whether or not they also take psychotropic medication. Psychotherapeutic interventions such as Psychodynamic and Cognitive Behavioral Therapy offer people with bipolar disorder the opportunity to explore themselves and their illness to gain greater insight into their experience while also developing the coping mechanisms needed to establish and maintain emotional stability. Dr. Edward Watkins writes in Advances in Psychiatric Treatment:

Although the use of medication has produced substantial treatment benefits, particularly in the treatment of acute episodes, a substantial proportion of patients with bipolar disorder still relapse despite the use of mood stabilisers. Poor coping strategies in response to prodromes and disruptions of sleep and social routine have been implicated in bipolar relapse. Cognitive therapy is well suited to teach patients better coping strategies to deal with prodromes and stressors and thereby to minimise their risk of relapse. Pilot studies and one large-scale randomised controlled trial have found that the addition of cognitive therapy to routine mood stabilisers significantly reduces the number of bipolar episodes over a 1-year period.

Psychotherapy and holistic therapies may also be vital to protecting the psychological health of those people who do not respond to or can’t tolerate pharmacological treatment, or who are experiencing decreased effectiveness of their psychotropic medication regimen.