Tourette Syndrome Plus - Conditions - Mood Disorders- Subtypesof Bipolar Disorder

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Information Section: Conditions
Condition: Mood
Article: Subtypes of Bipolar Disorder
Source: Leslie E. Packer, PhD 2006

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PREFACE

Bipolar Disorder is a condition in which the student "swings" between different types of mood episodes: depression and mania or depression and hypomania. Bipolar Disorder used to be called "Manic-Depression."

For some individuals with Bipolar Disorder, there may be relatively long periods of wellness between the different mood cycles. Some children will cycle very rapidly, and other children or teens with Bipolar may be in a "mixed" state that has both manicky features and some depressive features.

Some Bpolar Disorder patients experience a seasonal pattern to their episodes of illness, similar to what some patients with depression experience. Some research suggests that there may be even more seasonality to Bipolar Disorder than to unipolar depression.

SUBTYPES

Bipolar Disorder is generally classified according to symptom severity as Bipolar Disorder I, Bipolar Disorder II, and Cyclothymic Disorder:

Bipolar Disorder Type I is characterized by at least one manic episode, with or without major depression. With mania, either euphoria or irritability may mark the phase, and there are significant negative effects.
Bipolar Disorder type II is characterized by at least one episode of hypomania and at least one episode of major depression. With hypomania the symptoms of mania (euphoria or irritability) appear in milder forms and are of shorter duration. They do not affect social or school functioning as dramatically. Bipolar II is a bit "softer," then, in that the individual has hypomanic episodes instead of the manic or mixed episodes that are present in Bipolar I. While research on Bipolar suggests that Bipolar I is more common than Bipolar II, given that the mood swings may not be as apparent or extreme in Bipolar II, the reported differences may represent differential under-recognition or underdiagnosis of Bipolar II. Males and females seem to be equally likely to be affected by Bipolar I; but Bipolar II seems to be more prevalent in females.
Cyclothymic Disorder is not as severe as either Bipolar Disorder II or I, but the condition is more chronic. The disorder lasts at least two years, with single episodes persisting for more than two months. Cyclothymic disorder may be a precursor to full-blown bipolar disorder in some people or it may continue as a low-grade chronic condition. Some people refer to Cyclothymic Disorder as Bipolar III. In Cyclothymic Disorder, the lows are not as "low" as in a major depressive episode and the "highs" are not as "high" as in mania.

While the DSM-IV recognizes two subtypes of Bipolar, many sources actually talk about more subtypes, where:

Bipolar III is cyclothymia
Bipolar IV represents antidepressant-induced hypomania
Bipolar V is used to describe the situation in which the individual meets the diagnostic criteria for major depression and there is a family history of Bipolar Disorder, and
Bipolar VI is used for the unusual situation in which the individual meets diagnostic criteria for manic episodes, but not any of the depressive conditions; it is rare to find this kind of unipolar ("one pole") mania.

While the DSM-IV does not include subtypes III, IV, V, and VI, it does include a diagnosis called Bipolar Disorder Not Otherwise Specified.

What is referred to as "Bipolar IV" above is often a significant concern as there are a subset of children or adults who appear to get "activated" or even "tripped into mania" when they are on an antidepressant.

WHAT ARE MANIA AND HYPOMANIA?

The prefix "hypo" means "under," so "hypomania" actually translates into "under mania," or just below the level of (full) mania. An individual who is hypomanic will be sleeping less (or may not sleep at all), will have a burst of energy, feel heightened focus or creativity, a sense of increased confidence, and may be able to accomplish a lot and tackle a number of meaningful and organized projects.

If the individual is able to control the hypomania, it is a state that may actually be very positive and pleasurable. Some of the impulsivity and increased energy may result in spending sprees or other activities that, while not bizarre, are not what the individual would normally do. While some aspects of hypomania are experienced as positive, the individual's impulsivity can pose genuine problems. Distractibility is often present, and as in mania, speech may be very rapid as the person responds to everything going on around them. All too often, hypomania progresses into full-blown mania.

While some people think of mania as the opposite of depression, i.e., as a "high," it is not really that way, although hypomania (and early stages of mania) are associated with feelings of euphoria or exuberance. The evolution of a hypomanic episode into mania might look like this:

Manic episodes generally begin with what is experienced as an improvement or upward shift in mood. This initially euphoric or elated mood, accompanied by decreased need for sleep is usually experienced as an initially increased sense of energy and confidence. This is the hypomanic state.

As the hypomania progresses into mania, thoughts begin to race and speech becomes rapid (pressured).

The euphoria is replaced by irritability, and in some cases, assaultiveness.

The individual becomes more impulsive, disinhibited, and takes more risks.

Thoughts become more disorganized, and in severe cases, delusional or psychotic.

An individual in a severely manic state is in as much danger as an individual in a major depression. Overly confident (and having grandiose thoughts), there is an excess of what are usually thought of as "approach behaviors." Anything the individual might seek out while in normal mood (such as sex, alcohol or drugs, or excitement) becomes magnified. Wild spending sprees or impulsive purchases are not uncommon, nor are impulsive marriages or major commitments. Patty Duke, the actress, in describing her manic episodes in her autobiography, "A Brilliant Madness", gives readers a clear picture of how devastating mania can be. During some of her manic episodes, Ms. Duke invited a stranger and her daughter to come live with her upon hearing that the young woman had no place to live (the woman later stole all her belongings), married a man she had met only four hours earlier, threw tantrums on the set while working on her show, abused drugs, and would impulsively decide to move and buy a different home.

As with depression, in severe mania, the individual may experience hallucinations. With or without hallucinations, however, individuals in severely manic states had a significant mortality rate until the lithium started being prescribed. In some cases, death was accidental, but related to the risk-taking or impulsive behaviors. In other cases, patients died of dehydration (they might neglect to eat and drink in their manic state) or cardiovascular collapse as the body couldn't keep up with increased psychomotor agitation and 'racing.'

MIXED EPISODE

Some individuals may experience both depression and mania at the same time, giving rise to the notion of a "mixed episode." Indeed, if the predominant symptom is irritability, it may be difficult to know whether it is from depression or mania. An individual in a mixed episode may exhibit signs of agitation, suffer from insomnia, experience changes in appetite, have some psychotic features, and experience suicidal thinking.

SUBTYPES OF MANIA

When Kraepelin first described mania, several subtypes were described, including hypomania, acute mania, delusional mania, and depressive or anxious mania. Cassidy et al. (2001) attempted to validate the different subtypes using a multivariate structural analysis. They found five subtypes with good validity, and validated the major Kraepelinian subtypes noted above, bug they also identified two other subtypes involving mixed mania presentations characterized by significant mood variability. The first of these subtypes is quite different than what we normally think of as mania, as the dominant mood was severely depressive with labile periods of pressured, irritable hostility and paranoia and the complete absence of any euphoria or humor. The second new mixed mania subtype they identified involved a mixture of affects: periods of classical manic symptoms (euphoria, elevated mood, humor, grandiosity, psychosis, and psychomotor activation), switching frequently to depressed mood accompanied by anxiety and irritability.

Information Section: Conditions
Condition: Mood
Article: Subtypes of Bipolar Disorder
Source: Leslie E. Packer, PhD 2006

Page 1 of 1

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