We’ve all experienced the highs and lows of life, from the occasional blue mood to the euphoria that comes with a big accomplishment or happy experience. Yet many people spend a large portion of their lives in a middle ground zone, where stable mood and predictable behaviors are the status quo.
But for some people, especially those with bipolar disorder, finding and staying in that middle ground, can be very difficult. Dr. Ernest Rasyidi, a psychiatrist with St. Joseph Hospital in Orange County, California, says that bipolar disorder — which is classified into two categories, bipolar 1 and bipolar 2 — are defined by how patients move from one extreme end, or pole, of mood to the other.
“In both conditions, a patient may experience episodes of major depression,” but they also “have mood states on the other end of the pole. If depression is considered ‘down,’ they have periods that are considered ‘up’ relative to normal mood.”
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The Distinction Between Bipolar 1 and Bipolar 2
While both disorders have these swings in mood as a primary feature of the disorder, the distinction between them rests in the “severity or intensity of the up phases,” Rasyidi says.
“In bipolar 1, the ups are more intense and extreme and may even include hallucinations or loss of touch with reality. Psychiatrists diagnose this as mania. These episodes can be quite dramatic, and patients can get into a lot of trouble during these phases either through shopping sprees or extremely impulsive and reckless behaviors, which can often lead to interactions with law enforcement.”
This is often the image that comes to mind when someone uses the term bipolar. “Bipolar 1 disorder is what used to be called classic manic-depressive illness,” says Dr. Anthony Rothschild, a professor of psychiatry at the University of Massachusetts Medical School in Worcester.
People with bipolar 1 disorder often exhibit “a very euphoric mood, although occasionally it can be an irritable mood,” during this high-energy, high-activity period, Rothschild says.
Delusions can also be part of the mix. “They can think they’re Jesus Christ or they have to talk to the Pope or the president immediately. That kind of manic episode almost always leads to hospitalization,” he adds.
A manic episode lasts seven or more days, and symptoms may include:
— Feeling “high” or elated.
— An exaggerated sense of well-being or euphoria.
— Increased energy and agitation.
— Inflated self-esteem.
— Racing thoughts or ideas.
— Getting very little sleep.
— Becoming excessively involved in lots of activities.
— Making poor, impulsive or risky choices.
— Talking faster than normal.
— Jumping from one idea to the next.
— Excessive sexual desire, hypersexuality or engaging in risky sexual behaviors.
— A false belief of superiority.
To be diagnosed with bipolar 1 disorder, a person only needs to have experienced one manic episode. An episode of depression is not required for a diagnosis, but many people have experienced at least one depressive episode by the time they’re diagnosed.
Mania causes dysfunction that can lead to serious consequences, such as interpersonal or professional problems at home or work. And it can include engaging in risky behavior, like reckless driving, shopping sprees or sexual indiscretions that can damage an existing relationship.
In addition to manic episodes, bipolar 1 disorder also brings periods of depression, or low mood, which typically last at least two weeks. During these periods, an individual with bipolar 1 may not be able to “think straight, they’re sad, they have no motivation, they can be feeling suicidal,” Rothschild says.
People with bipolar 1 disorder will experience frequent episodes of depression, hypomania — an elevated mood somewhat milder than mania — and mania, says Dr. Samar McCutcheon, a psychiatrist in the department of psychiatry and behavioral health at the Ohio State University Wexner Medical Center in Columbus.
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Hypomania in Bipolar 2
In bipolar 2, the episodes of elevated mood are somewhat milder and labeled as hypomania. “Patients may actually feel abnormally good and not view these episodes as a problem in themselves,” Rasyidi says.
“The primary differences between bipolar 1 and bipolar 2 relate to the intensity of the manic experience,” explains Dr. Melvin McInnis, a professor of psychiatry and director of the Heinz C. Prechter Bipolar Research Program at the University of Michigan.
With classic bipolar 1 disorder, the manic episode tends to be incapacitating, so that a person isn’t able to perform day-to-day duties or function at home and work. This type of mania tends to be very noticeable. “The manifestations of this pathologic energy is typically visible to the person on the street or the person interacting with them,” McInnis says.
But the hypomania that defines bipolar 2 disorder can be less obvious and may not last as long, says Dr. Keming Gao, a professor of psychiatry and co-director of the Bipolar Disorder Research Center at Case Western Reserve University School of Medicine in Cleveland.
Symptoms of hypomania need only last four days and may include:
— Somewhat elevated mood.
— Increased irritability.
— Exaggerated self-confidence.
— Increased energy.
— Frenzied speaking.
— Moving quickly from one idea or task to another.
To be diagnosed with bipolar 2 disorder, you need to have at least one major depressive episode and one hypomanic episode, the American Psychiatric Association notes.
Although it’s not always clear if symptoms are due to mania or hypomania, a person with bipolar 2 who is experiencing hypomania can still generally function. “It’s not the full-blown manic episode. It’s a period of increased energy, increased productivity, decreased need for sleep (and) good mood,” Rothschild says.
The person with hypomania “may be a little annoying to people at work or their spouse” he adds, but this person isn’t likely to experience the kind of significant problems and dysfunction that someone with bipolar 1 does. “No one with bipolar type 2 comes to the doctor complaining of hypomania,” Rothschild says. Instead, he says individuals routinely come in complaining of depression.
That said, even hypomania can lead to intrapersonal difficulties or issues in other areas of life, when an agitated state or grandiose ideas meet reality. Loved ones and coworkers of the person may be most likely to take notice of the problem, and the person with the disorder may be unaware of their erratic behavior.
McInnis notes that “often these individuals will run into problems. They will run into relationship problems; they will run into personal issues — either in the home or with others.”
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Getting the Right Diagnosis
Past research shows that the majority of people with bipolar disorder are misdiagnosed — and this still seems to be the case, Gao says.
Frequently, a person with a bipolar disorder may show up at the primary care doctor’s office feeling depressed. And — especially where time for probing questions is limited, and in the case of bipolar 2, hypomanic symptoms are more nuanced — a person can be misdiagnosed with classic, or unipolar, depression and given an antidepressant, Gao says.
Sometimes people refrain from disclosing if they have symptoms potentially associated with mania or hypomania, or try to hide these — even from clinicians, Gao says, thinking it’s stigmatizing. “As a society, I think people feel more comfortable talking about depression now,” he says. But many still feel uncomfortable talking about manic or hypomanic episodes.
Nevertheless, getting the right diagnosis is critical because the treatments for these mental health conditions differ. Despite there being a clear distinction in what the two conditions are, diagnosis isn’t always easy, says Dr. Roger McIntyre, professor of psychiatry and pharmacology at the University of Toronto, Canada, and director of the Depression and Bipolar Support Alliance in Chicago.
“Mother Nature did not read the DSM-5,” the diagnostic manual that defines mental health disorders. “The greatest unmet need in bipolar disorder today is timely and accurate diagnosis. That’s because hypomania and mania don’t always present in clinical practice the way they’re described in the textbooks.”
With some patients, it’s relatively easy to make the determination. In others, the line is blurry or difficult to discern. Getting to that accurate diagnosis — which includes the best course of treatment — “remains a terrible problem,” McIntyre says.
Another compounding factor is that bipolar disorder can evolve. “The way our current diagnostic system works, once a person has had a clearly documented manic episode, their diagnosis will be bipolar 1 and never convert to bipolar 2,” Rasyidi explains. That’s because once you’ve had a full manic episode, there’s always a risk of another.
However, if a person has bipolar 2 with episodes of hypomania, there’s the possibility that at some point in the future they may have a full manic episode, “at which point their diagnosis would change to bipolar 1,” he explains.
Often, he says, people will be diagnosed with bipolar 2 in their late teens or early 20s, and at the time, the diagnosis is accurate as they’ve only had hypomanic episodes so far.
“However, at some point in their mid- or late-20s, they may experience a full manic episode and have their diagnosis changed to bipolar type 1,” which may be related to the fact that the brain is still developing, and as it grows, the disorder develops “into a more final form.”
Treating Bipolar 1
Bipolar disorders aren’t curable, but they are manageable and good treatment protocols exist for both types. The bipolar treatment options your health care provider offers will depend on which type you have and the specific symptoms you’re experiencing.
According to the National Institute of Mental Health, an effective bipolar 1 treatment plan usually includes some combination of medication and psychotherapy (or talk therapy) — like cognitive behavioral therapy — to improve control of mood swings and address other symptoms.
“Mood stabilizers are used to prevent or treat manic episodes,” says Dr. Douglas Misquitta, medical director at the Ohio State University Wexner Medical Center‘s Harding Hospital in Columbus. These include:
— Lithium carbonate (Eskalith, Lithobid).
— Depakote (sodium valproate).
— Lamictal (lamotrigine).
“Antipsychotic medication, such as Seroquel (quetiapine), can also be used to stabilize mood,” Misquitta says. “These medications are meant to keep patients’ moods from becoming too elevated or high, and also to prevent serious lows or depression. In other words, they’re meant to keep a person’s emotions in a good middle ground, neither too high nor too low.”
When it comes to treating the depressed feelings that people with bipolar experience, antidepressants may be used, but they have to be deployed very carefully, Misquitta says. “Antidepressants aren’t used alone, as they can shift someone into mania.” If they’re used, it’s usually alongside a mood stabilizer.
Rothschild says clinicians are often reluctant to use antidepressants in people with bipolar 1. “You can, but it’s usually down the line if you’re having difficulty getting people out of a depressive episode.”
Treating Bipolar 2
While the symptoms of bipolar 2 disorder are “less severe with shorter duration and less intense symptoms of mania,” Misquitta says, the treatment can be a little more complicated.
McIntyre says that bipolar 1 disorder “affects about 1% of the population. Bipolar 2 disorder has been variably reported in its prevalence, but most studies converge at an estimate around 1% to 2%. So, it’s as common, maybe even twice as common, as bipolar 1 disorder.”
Bipolar 1 affects men and women equally, he adds, but “bipolar 2 disorder affects women twice as commonly as men.”
Still, bipolar 1 has been the focus of the majority of the research into bipolar disorders. Bipolar 2 disorder “has received significantly less research,” especially in terms of how best to treat it. This means “we don’t have as much evidence-based guidance to inform treatment selection,” and there’s often a bit of trial and error that occurs when someone is initially being treated for bipolar 2.
“Clinicians often extrapolate the evidence from bipolar 1 to bipolar 2,” McIntyre says, which means that often, the initial treatment protocol is similar to what would be offered for bipolar 1 — an imperfect state of affairs at best.
Treating the disorder depends on a variety of factors including:
— How often the hypomania has occurred.
— How bad the hypomania was.
— How certain the clinician is of the diagnosis.
“The medication options overlap, but treatment guidelines may include trying the medications in a different order based on the underlying diagnosis,” McCutcheon says.
A key area of nuance is whether to use an antidepressant alongside an antipsychotic or mood stabilizer. “A patient with bipolar 1 is less likely to receive an antidepressant without a mood stabilizer if screened properly because full manic episodes are usually pretty clear-cut,” Rasyidi says.
“The challenge is that in bipolar 2, even when a trained clinician is screening, the patients may not actually realize that those hypomanic episodes were abnormal because to them, they just felt great at the time and thought that’s what it’s like to be doing well.”
Dosing is also a complex consideration. For example, Gao says if he prescribes a mood stabilizing drug to a patient with bipolar 2, he would likely use a lower dose than for a patient with bipolar 1.
Follow Your Doctor’s Advice
“Medications are the bedrock” of treatment, McIntyre says. And sticking with the protocol for the rest of your life can make living with bipolar disorder far more manageable.
In general, clinicians say patients need to stay on medications (when it’s determined they work for that patient) over the long term to avoid relapse, or serious mood swings returning.
“They would need to have treatment through their lifetime because this is a serious disorder, but there are excellent treatments,” Rothschild says. “If you’re one of the majority of the people who are fortunate to have a good response to treatment, you can lead a completely normal life.”
McIntyre also recommends peer support, such as that offered via the Depression and Bipolar Support Alliance, the nation’s largest peer support group for people with depression or bipolar disorder. “There’s hundreds of chapters around America. People find it very beneficial to hear from others about how they manage their illness. They also develop more literacy on their illness, treatment and day-to-day tactics on how to manage their illness effectively.”
With any medication — particularly those taken on an ongoing basis — experts say it’s important to talk with your provider about side effects. With lithium, those can be minor to severe, from increased thirst and urination to hand tremor, weight gain and issues with thyroid or kidney function. These side effects can be addressed by altering medication options, doses and adding lifestyle interventions. If you’re having side effects, let your provider know so they can adjust your protocol.
It’s also important to underscore that if it’s left untreated, bipolar disorder can be debilitating, severely undermine quality of life and increase the risk for suicide.
If you have concerns that you might have bipolar disorder, see a mental health professional — and, Gao says, share all your symptoms.
A family history of bipolar disorder can increase risk for the condition — and should be taken into consideration if you’re experiencing symptoms that could be mania or hypomania.
“There are people who are reluctant to get help. Sometimes my patients feel like they can’t talk to anybody about it,” Rothschild says. But “bipolar disorder is a medical illness. It’s nothing to be ashamed of, (and) there’s treatment for it.”
Misquitta adds it’s possible to have a full and rewarding life with bipolar disorder. “Know that you can live the life you want, and that bipolar disorder needn’t keep you from your goals and dreams. Learn about the disorder, find a good psychiatrist (and perhaps additionally a therapist), and keep up with both regular appointments but also with healthy sleep and diet habits. As with chronic medical conditions like diabetes or hypertension, there are great, great treatments available that can control symptoms and allow for a thriving life and wellness.”
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Update 07/26/21: This story was previously published at an earlier date and has been updated with new information.