How Many Types of Bipolar Disorder Are There?
Bipolar disorder is a severe psychiatric/psychological disorder that involves specific fluctuations of:
- Mood, which is the subjective emotional content that an individual personally experiences and can describe to others (e.g., “I feel very sad.”)
- Affect, which are the behaviors that a person exhibits and that are used to infer internal emotional states in someone (e.g., a person who is continually crying is considered to be very sad)
The eminent psychiatrist Emil Krapelin, who is considered the founding father of modern psychiatric diagnoses by many, first described a disorder known as manic-depression, which is the forerunner to the current conceptualization of what is now called bipolar disorder. For practical purposes, there is essentially no difference in the disorders associated with the diagnostic labels of manic depression or bipolar disorder; however, recent reconceptualizations of bipolar disorder and new knowledge have added information to this diagnostic category.
Bipolar Disorder in the DSM
For many years, bipolar disorder or manic-depression was characterized as a specific type of mood disorder that grouped depression and mania within the same diagnostic category. The term bipolar was used as a descriptive reference to an individual’s fluctuation between two different extreme poles of emotions: depression and manic behavior. Researchers investigating the causes and manifestations of bipolar disorder have indicated that this disorder may actually represent a sort of bridge or connection between depression and more severe psychiatric disorders like schizophrenia.
As a result of this research, the American Psychiatric Association (APA) placed bipolar disorder in its own category, separate from depression. Previously, these disorders were both listed in the category of “mood disorders.”
However, the actual diagnostic criteria associated with bipolar disorder and its subtypes essentially remain consistent with previous conceptualizations of the disorder.
In order for an individual to be diagnosed with bipolar disorder, they must meet the diagnostic criteria for mania or hypomania. The DSM–5 (Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition) presents extensive formal diagnostic criteria for bipolar disorder.
In general, mania and hypomania are identified by the following features:
- The person exhibits abnormally expansive, elevated, or irritable displays of mood/affect that are persistent and last for at least one week. If the person’s elevated mood is so severe that it forces them to be hospitalized, they need not display these for an entire week.
- Additional signs and symptoms must also be displayed. If the individual is primarily displaying increased levels of energy or expansive mood, they must also display three of the following symptoms, whereas if they are primarily displaying irritable mood, they must display at least four of the following symptoms:
- Inflated self-esteem or grandiosity
- Being markedly more talkative than normal
- A significant decrease in sleep or the need for sleep
- Racing thoughts (this is often assessed by rapid speech patterns)
- Extreme distractibility
- A significant increase in goal-directed behavior, such as work-related activities or cleaning the house, or in non-goal-directed behavior, such as pacing
- A significant increase in behavior that could be potentially dangerous or damaging, such as engaging in multiple sexual relationships, shopping binges, excessive investing, etc.
- Mania and hypomania are differentiated by:
- The duration of mania is at least one week where hypomania can last for four days or more.
- Mania is associated with significant impairment in daily functioning (e.g. issues at work, school, being hospitalized, having legal issues, or issues in one’s personal relationships), whereas hypomania is not.
In addition to displaying manic or hypomanic behaviors, individuals may also display corresponding periods of depression. Depression is diagnosed when an individual displays at least five of 11 potential symptoms consistently over a two-week period. These symptoms include:
- Feeling sad most of the day nearly every day
- Displaying an inability to experience pleasure nearly every day
- Sleeping excessively or not being able to sleep at all
- Feeling guilty or worthless nearly every day
- Issues with thinking nearly every day that include issues with concentration, attention, remembering things, making decisions, etc.
- Significant weight loss or gain in the absence of trying to intentionally lose or gain weight
- Feeling extremely tired or fatigued nearly every day
- Feeling restless and irritable nearly every day
- Moving as if in “slow motion” most of the day nearly every day
- Excessively thinking about death, dying, or killing or hurting oneself nearly every day
The formal diagnosis of clinical depression can only be made if at least five of the formal diagnostic symptoms are met consistently over two weeks, and one of the five symptoms is either the experience of sadness nearly every day or a loss of the ability to feel pleasure nearly every day. Typically, manic or hypomanic episodes are relatively short-lived (most often extend for a week or two without formal treatment), and depressive episodes last much longer (can extend for months at a time without treatment).
Types of Bipolar Disorder
The potential number of so-called “types” of bipolar disorder depends on how one defines a “type.”
The American Psychiatric Association depicts only two major types of bipolar disorder; however, it also recognizes a number of different presentations of bipolar disorder that many might consider to be different types of bipolar disorder. These different presentations focus on some of the predominant symptoms that occur in the individual expression of bipolar disorder and are referred to in diagnostic processes as specifiers; as special presentations of symptoms that resemble bipolar disorder, but are caused by drugs or medical conditions; or represent other clinical observations that present with bipolar-like symptoms but do not meet the formal diagnostic criteria for any type of bipolar disorder.
The two major types of bipolar disorder are:
- Bipolar I: This type of bipolar disorder is diagnosed when the person is formally diagnosed with at least one full manic episode. The individual may not have displayed any clinical depression and may have experienced past episodes of hypomania; however, whenever a full manic episode is diagnosed, the individual is automatically diagnosed with this type of bipolar disorder.
- Bipolar II: This type of bipolar disorder is diagnosed when the individual has only displayed formal hypomanic episodes. They may or may not have displayed episodes of depression, but they have never displayed a full manic episode.
Other “types” of bipolar disorder are commonly designated as specifiers to the formal diagnosis of bipolar disorder. These specifiers are added to the diagnosis of bipolar disorder and allow for a more complete clinical description of the individual case and the symptoms being expressed in that case.
The major specifiers for bipolar disorder follow.
- Bipolar disorder with psychotic features is diagnosed when the individual who has bipolar disorder also presents with hallucinations (seeing or hearing things that are not really there) or delusions (fixed, irrational, and dysfunctional beliefs, such as the belief that everyone is out to harm them).
- Bipolar disorder with catatonia may be diagnosed when individuals who have bipolar disorder start remaining frozen in various poses or engage in repetitive, useless, non-goal-directed behavioral acts, such as dancing, scratching, etc. These acts are sequences of behavior that are typically relatively short in nature and repeated continually.
- Rapid cycling results when a person experiences four or more episodes of mania, hypomania, or depression within 12 months. Again, one of these episodes must have been mania or hypomania for an initial diagnosis of bipolar disorder to be made.
- Bipolar disorder with mixed features is diagnosed when the individual actually displays combinations of mania or hypomania in conjunction with depressive symptoms; these combinations occur at the same time.
- Bipolar disorder with anxious distress occurs when the individual displays the symptoms of bipolar disorder and also at least two of a total of five potential symptoms of anxiety.
- Bipolar disorder with atypical features occurs when the symptoms do not represent the typical presentation associated with the overall presentation of the disorder. For instance, most people with depression lose weight or have decreased appetite. An atypical feature of depression is weight gain or increased appetite. A person with bipolar disorder displaying these features could receive this specifier.
- Bipolar disorder with melancholic features is diagnosed when the depressive episode is primarily concerned with an inability to experience pleasure.
- Bipolar disorder with seasonal pattern is diagnosed when some of the symptoms of bipolar disorder can be consistently diagnosed during a specific time of year.
Two other potential categories of bipolar disorder relate to bipolar disorder-like symptoms that occur in response to the use of drugs or medications (substance/medication-induced bipolar and related disorder) or the symptoms result from some other medical condition (bipolar and related disorder due to another medical condition). For example, individuals who take large amounts of stimulant medications may exhibit alterations in mood that appear to represent formal manic episodes and depressive episodes, whereas individuals with certain types of head injuries or strokes may also display these symptoms.
Cyclothymic disorder is a longer and less intense manifestation of the symptoms that occur in bipolar disorder. Even though it is a separate diagnostic category, it is often considered by many to be a formal type of bipolar disorder, and it is listed by APA in the same overall category as other forms of bipolar disorder. This disorder consists of episodes of hypomania and depression that do not formally meet the criteria for bipolar disorder and continue for a period of two years or more.
APA recognizes several other types of bipolar disorder-like presentations that may be observed in clinical practice, but do not actually meet the formal diagnostic criteria for bipolar disorder:
- Short-duration hypomanic episodes and major depressive episodes involve a shorter duration of hypomania as the name suggests. Hypomania typically must last at least four days, whereas in this specific condition, the hypomania may only last 2-3 days. The depression presents as normal.
- Hypomania with insufficient symptoms and major depressive episodes occurs when the individual experiences irritability but the symptoms do not meet the full diagnostic specifications for hypomania. Depression occurs as specified.
- Hypomanic episode without major depression occurs when the individual experiences one or more hypomanic episodes but never has experienced a clinically diagnosable or significant episode of depression.
- Short-duration cyclothymia occurs when the individual meets the criteria for cyclothymia but has not met them consistently for 24 months.
Finally, in an effort to provide descriptive information to other clinicians and individuals who treat these disorders, the above diagnoses can sometimes be specified as either being mild, moderate, or severe in terms of their presentation. These designations are typically made based on the number of symptoms the individual formally presents with. Mild manifestations have fewer symptoms than moderate manifestations of bipolar disorder; moderate manifestations have fewer symptoms than severe manifestations of bipolar disorder.