Diagnosing Bipolar Disorder

Bipolar disorder sounds simple enough: Isn’t that the manic depression of old, where you swing back and forth like a pendulum from hyper-and-happy to deeply depressed? How do you know if you have a “mild” case? How does the doctor know if it’s bipolar or just plain depression? What are the unique symptoms of this disorder and how can you know for sure that bipolar is the correct diagnosis?

Bipolar disorder is the name applied to a group of mood disorders that are characterized by different mood states: depressed phases or states, and manic phases. How these mood states appear, how often, how severe, and which ones (manic, depressed or “hypomanic” – a milder form of mania in which functioning is less impacted despite the presence of symptoms), all help your doctor make his or her diagnosis. There are three subcategories or types of bipolar disorder: Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified. Within each of these categories a certain amount of variation occurs.

Bipolar I is the more classic of the two main categories, in which there are distinct depressed phases and manic phases. In order to meet diagnostic criteria for Bipolar I, you have to meet criteria for a major depressive episode. That means, first and foremost, when in a depressed phase, the depression you are experiencing must meet the following diagnostic criteria: you must have a depressed mood (this means feeling abnormally sad, low, unhappy, or empty) every day for a two-week period, and this low mood needs to be really different form your baseline “normal” functioning. If you don’t meet this criteria, then you must experience a loss of pleasure in activities you formerly enjoyed again for every day over a two-week period, and again this must be different form your usual, normal self. In children, the sad mood can be an irritable or cranky mood. And these mood symptoms can be noticed and reported by someone else, as sometimes when the depression is long-lasting it can be hard to identify or even remember what you used to feel like and when you felt different. A parent or spouse, for example, could provide that important sense of timeline for the doctor.

Careful consideration to meet the criteria of a “major depressive episode.” You must be able to report at least four of the following seven symptoms: significant weight change (a gain or loss of more than 5% body weight over a one month period), sleep issues (insomnia or oversleeping) every night, psychomotor agitation or retardation every day (this means a slowing down or speeding up of normal motor functions like walking or talking) on a daily basis, feeling tired or “out of energy” every day, feeling worthless or being plagued by guilt every day, problems concentrating or feeling unable to think clearly every day, and thinking about death(including suicide).

In addition to meeting the diagnostic criteria for a major depressive episode, you must also meet criteria for a manic episode. A manic episode must last one full week, and the dominant mood for this whole week must be irritable, elevated, or expansive. In addition, while you are experiencing this expansive mood, you must also have at least three of the following symptoms (four, assuming the mood has been irritable but not elevated or expansive): an unrealistically inflated sense of self, or grandiosity (feeling like you are an Olympic athlete or the next Einstein), a noticeable decreased need for sleep (feeling awake and rested after two to three hours), rapid or pressured speech, racing thoughts, being distracted by everything and anything, a marked increase in activities such as work, school, or in a relationship, going “overboard” in terms of doing fun or pleasurable things like shopping, gambling or indulging in sexual contact.

Most people are diagnosed when they are in one or the other of these phases, so the reporting of symptoms includes describing how you are feeling now (the current phase) and how you were feeling at some point in the past, when you were in the other phase. Still sounds simple enough, right? One major depressive episode plus one manic episode equals bipolar disorder, right? Unfortunately, diagnosing bipolar disorder is still more complex. Although being able to report clear depressive and manic episodes will earn a bipolar diagnosis, now we have to determine which bipolar disorder it is. Bipolar I, the classic manic plus depressive, is further broken down in two main categories: if you have only ever had one manic episode, then you meet criteria for Bipolar I, single manic episode. If you cycle between manic and depressed episodes, then you meet criteria for Bipolar I, recurrent.

Bipolar II is a relatively new diagnosis, based on the prevalence of cases in which people showed clear bipolar tendencies (distinct depressed episodes) but the manic episodes never quite met the diagnostic criteria. In Bipolar II, you must report at minimum one (maybe more) major depressive episode and at minimum one hypomanic episode. In a hypomanic episode, you experience all of the identical symptoms as a manic episode, but unlike a true manic episode, these symptoms never quite increase in severity to the point where they prevent you from functioning. You are noticeably different from your normal self, but somehow you hold it together and function at work and at home.

Bipolar Disorder Not Otherwise Specified is a diagnostic category used to help identify people who definitely have a bipolar disorder but for a variety of reasons don’t exactly meet criteria for Bipolar I or Bipolar II.

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