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Information
Section: Conditions
Condition:
Mood
Article:
Subtypes
of Bipolar
Disorder
Source: Leslie E. Packer,
PhD 2006
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Page 1 of 1
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PREFACE
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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.
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SUBTYPES
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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.
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WHAT ARE MANIA AND HYPOMANIA?
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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.'
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MIXED EPISODE
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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.
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SUBTYPES OF MANIA
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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.
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Information
Section: Conditions
Condition:
Mood
Article:
Subtypes
of Bipolar
Disorder
Source: Leslie E. Packer,
PhD 2006
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Page 1 of 1
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Tourette
Syndrome "Plus" © Copyright 1998 - 2006 Leslie
E. Packer, PhD. except as noted.
All rights reserved
This page last updated Feb. 4, 2006.
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