Bipolar disorder classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Charmaine Patel, M.D. [2]

## Overview

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Bipolar disorder is commonly categorized as either bipolar type I, where an individual experiences full-blown mania, or bipolar type II, in which the hypomanic "highs" do not go to the extremes of mania, and cyclothymic disorder where mood cycles between episodes of hypomania and dysthymia. The latter two are much more difficult to diagnose, since the hypomanic episodes may simply appear as a period of successful high productivity and is reported less frequently than a distressing depression. Psychosis can occur, particularly in manic periods. There are also 'rapid cycling' subtypes. Because there is so much variation in the severity and nature of mood-related problems, the concept of a bipolar spectrum is often employed. There is no consensus as to how many 'types' of bipolar disorder exist. Bipolar disorder can also be classified based on the phase of illness the patient may be in.[1] Many people with bipolar disorder experience severe anxiety and are very irritable (to the point of rage) when in a manic state, while others are euphoric and grandiose.

## Classification Based on Type of Bipolar Disorder

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The bipolar disorder spectrum includes the following:

* Bipolar I Disorder
* Bipolar II Disorder
* Cyclothymic Disorder
* Substance/Medication-Induced Bipolar Disorder
* Bipolar Disorder Due to Another Medical Condition
* Other Specified Bipolar Disorder Due to Another Medical Condition
* Unspecified Bipolar Disorder

### Bipolar I Disorder

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Bipolar I disorder is a mood disorder that is characterized by at least one manic or mixed episode. There may be episodes of hypomania or major depression as well. It is a sub-diagnosis of bipolar disorder, and conforms to the classic concept of manic-depressive illness. The essential feature of bipolar I disorder is a clinical course that is characterized by the occurrence of one or more manic episodes or mixed episodes. Often individuals have also had one or more major depressive episodes. Episodes of substance-induced mood disorder (due to the direct effects of a medication, or other somatic treatments for depression, a drug of abuse, or toxin exposure) or of mood disorder due to a general medical condition do not count toward a diagnosis of bipolar I disorder. In addition, the episodes are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.

### Bipolar II Disorder

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Bipolar II Disorder is a bipolar spectrum disorder characterized by at least one hypomanic episode and at least one major depressive episode; with this disorder, depressive episodes are more frequent and more intense than manic episodes. The presence of a hypomanic episode is used mainly to differentiate it from unipolar depression. It is believed to be underdiagnosed because hypomanic behavior often presents as high-functioning behavior. Patients with bipolar II disorder are less likely to seek help from providers. Although a patient may be depressed, it is very important to find out from the patient or patient's family or friends if hypomania has ever been present using careful questioning.

### Cyclothymic Disorder

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Cyclothymia is a mood disorder. This disorder is a milder form of bipolar II disorder consisting of recurrent mood disturbances cycling between hypomania and dysthymic mood. A single episode of hypomania is sufficient to diagnose cyclothymic disorder; however, most individuals also have dysthymic periods. The diagnosis of cyclothymic disorder is never made when there is a history of mania or major depressive episode or mixed episode.

## Classification Based on Phases of Illness

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### Depressive Phase

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Signs and symptoms of the depressive phase of bipolar disorder include: persistent feelings of sadness, anxiety, guilt, anger, isolation and/or hopelessness, disturbances in sleep and appetite, fatigue and loss of interest in usually enjoyed activities, problems concentrating, loneliness, self-loathing, apathy or indifference, depersonalization, loss of interest in sexual activity, shyness or social anxiety, irritability, chronic pain (with or without a known cause), lack of motivation, and morbid/suicidal ideation.[2]

### Mania

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Mania is generally characterized by a distinct period of an elevated, expansive or irritable mood state. People commonly experience an increase in energy and a decreased need for sleep. A person's speech may be pressured, with thoughts experienced as racing. Attention span is low and a person in a manic state may be easily distracted. People may feel they have been 'chosen', or are 'on a special mission', which are considered grandiose or delusional ideas. At more extreme phases, a person in a manic state can begin to experience psychosis, or a break with reality, where thinking is affected along with mood. In order to be diagnosed with mania according to DSM-IV, a person must experience this state of elevated or irritable mood as well as other symptoms for two or more weeks.

### Hypomania

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Hypomania is generally a less extreme state than mania, and people in the hypomanic phase generally experience fewer of the symptoms of mania than those in a full-blown manic episode. During an episode of Hypomania, one might feel an uncontrollable impulse to laugh at things he or she does not normally find funny. The duration is usually also shorter than in mania. This is often a very 'artistic' state of the disorder, where there is a flight of ideas, extremely clever thinking, and an increase in energy.

### Mixed State

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In the context of bipolar disorder, a mixed state is a condition during which symptoms of mania and clinical depression occur simultaneously (for example, agitation, anxiety, aggressiveness or belligerence, confusion, fatigue, impulsiveness, insomnia, irritability, morbid and/or suicidal ideation, panic, paranoia, persecutory delusions, pressured speech, racing thoughts, restlessness, and rage).[3] Mixed episodes can be the most volatile of the bipolar states, as moods can easily and quickly be triggered or shifted. Suicide attempts, substance abuse, and self-mutilation may occur during this state.

### Rapid Cycling

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Rapid cycling, defined as having four or more episodes per year, is found in a significant fraction of patients with bipolar disorder. It has been associated with greater disability or a worse prognosis, due to the confusing changeability and difficulty in establishing a stable state. Rapid cycling can be induced or made worse by antidepressants, unless there is adjunctive treatment with a mood stabilizer.[4][5] The definition of rapid cycling most frequently cited in the literature is that of Dunner and Fieve: at least four major depressive, manic, hypomanic or mixed episodes are required to have occurred during a 12-month period. [6] There are references that describe very rapid (ultra-rapid) or extremely rapid [7] (ultra-ultra or ultraradian) cycling. One definition of ultra-ultra rapid cycling is defining distinct shifts in mood within a 24-48 hour period.

## References

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1. ↑ Akiskal HS, Benazzi F (2006). "The DSM-IV and ICD-10 categories of recurrent [major] depressive and bipolar II disorders: evidence that they lie on a dimensional spectrum". J Affect Disord. 92 (1): 45–54. PMID 16488021. Retrieved 2007-06-29. Unknown parameter `|month=` ignored (help)
2. ↑ "Bipolar Disorder: Signs and symptoms". Mayo Clinic.
3. ↑ "Bipolar Disorder: Complications". Mayo Clinic.
4. ↑ "Treatment of refractory and rapid-cycling bipolar disorder".
5. ↑ Sachs, GS, MD, et al (2007)Effectiveness of Adjunctive Antidepressant Treatment for Bipolar Depression New England Journal of Medicine, Volume 356:1711-1722 (Abstract)
6. ↑ Mackin, P; Young, AH (2004), "Rapid cycling bipolar disorder: historical overview and focus on emerging treatments", Bipolar Disorders, 6 (6): 523–529, doi:10.1111/j.1399-5618.2004.00156.x
7. ↑ Papolos, DF; Veit, S; Faedda, GL; Saito, T; Lachman, HM (1998), "Ultra-ultra rapid cycling bipolar disorder is associated with the low activity catecholamine-O-methyltransferase allele", Molecular Psychiatry, 3 (4): 346–349

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