Bipolar Disorder, Explained

What is bipolarity?

It’s a brain disorder yielding patterns of mood variability and energetic intensity that interfere with healthy adaptive functioning.

For most without bipolarity mood doesn’t shift significantly, at least not without clear reason. People generally experience a fair degree of mood consistency in the absence of strong external influences. If you haven’t won the lottery or fallen in love or gotten fired or faced deep disappointment, your mood is likely to be relatively stable from one day to the next.

And by stable, I’m not implying good or bad. Some people consistently experience good moods while others are consistently unhappy or grumpy. My point is that mood generally has continuity that makes sense to the individual. The non-bipolar brain keeps mood balanced until external influences become strong enough to affect a shift into a different mood state.

The individual with bipolarity lives with a faulty mood gyroscope. Mood can progress upward or downward for no good reason, or at least for no reason that’s clearly tied to external influences. Essentially, living with bipolarity means one can’t rely on the capacity to sustain an even, balanced mood.

With regard to depressed or down mood, there are multiple aspects of experience that become diminished or muted, as if the volume control knob has been turned down. Motivation and productivity are low as are mental activity and alertness. Speed and volume of thinking are also lowered. Somatically-based experiences such as energy, physical activity, appetite, and libido are also lowered.

Emotion during depressed mood is different for different people. Some experience sadness, loss, disappointment, or what could be described as emotional pain or suffering. I’m reminded of one of my patients who describes feeling attacked or assaulted by his own psyche. Self-esteem or perceptions of self are also negative during depression. In fact, depression and positive perceptions of self are antithetical. They don’t coexist.

Given this negative self-experience, most who are depressed also experience a sense of interpersonal disconnection or isolation. They perceive they have nothing of value to offer nor can they imagine others would have any interest in connecting with them.

Alternately I see some individuals whose depressed mood largely entails irritability, agitation, and anger. They don’t just hate themselves. They also hate the world. Their down mood is more that of agitated or angry depression.

There’s also the experience of depressed mood where rather than painful emotion, there is numbness or emotional blunting. The world is experienced as flat, colorless, tasteless, and monotonous. There is little to desire because nothing appears desirable. On the more extreme end of this shut-down, people become dissociated from their experience. They’re observing the world happening around them but they’re not a part of it.

Suicidal ideation or suicidal thinking is a common aspect of bipolar depressed mood, though I’d add that suicidal thinking is present in many who are depressed, regardless of the diagnosis. When people are hurting and they can’t find a way to resolve their pain, they seek relief from their suffering. Non-being becomes perceived as preferable to painful being.

It’s noteworthy that bipolar disorder carries the highest suicidal statistics of any other psychopathology. I understand this as reflecting two significant influences. The first entails the chronicity of bipolar illness and the second involves lessened impulse control that often accompanies mood elevation.

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If you’re distressed but able to perceive that your suffering will lessen over time, then you’re able to connect with hope and motivation to keep going. However, if you perceive that you will recurrently transition back into distress and suffering, then the longer-term outlook will feel bleaker and more hopeless. Exiting through suicide can feel like an appealing option when faced with the prospect of recurrent depressive relapses

Earlier I spoke of agitated depression. This is also referred to as a mixed state. Mixed states are painful negative emotions combined with energetic elevation. Elevated mood states also entail lessened impulse control. Thus, strong suicidal ideation during a mixed mood state represents a high-risk combination. Essentially, despair + energy + disinhibition = high risk for suicidal action.

Mood elevation is the opposite end of the bipolar continuum. I find the strongest misconception is that elevated mood represents “happy.” It can, but that's just a small piece. Usually, mood elevation conveys many more dimensions than just the upper end of the happy/sad continuum. I encourage people to think of mood elevation more as mood intensification. It can be a highly complex mood state. Different individuals will experience widely different sets of symptoms. If there's any unifying thread it’s typically seen through the combined presence of elevated energy, lessened sleep, intensification of affect (emotion), and accelerated cognitive processes. Beyond this cluster, most mood elevation symptoms are very person-specific.

In order to better understand elevated mood complexity, I’ve grouped elevated mood symptoms into clusters of symptoms that are thematically similar. I’m not implying that the clusters necessarily present as a group. In fact, the opposite is more common. We see a lot of mixing of symptoms from different clusters. Additionally, different symptoms may appear at different points during the course of mood elevation. For now, my aim is to simply share the wide range of what can occur during elevated mood.

• Energetic intensification: higher than normal physical energy, lessened need for sleep, difficulty sitting still—needing to move, exercise, and discharge physical energy, elevated libido (sexual feelings)
• Positive mood: positive, pleasurable euphoric mood, behavior that is pleasure-seeking. increased sociability, strong optimism, confidence, grandiose perceptions of one’s capabilities
• Cognitive and creative intensification: accelerated thinking, rapid speech—sometimes not able to stop talking, expansive thinking, increased creativity, cognitive disorganization, impaired attention and concentration, obsessional thinking, intensification of spiritual beliefs (stronger than is common for the individual), delusional thinking—distorted thoughts about reality
• Goal-directed activity: becoming focused on an activity almost to the exclusion of everything else, compulsive cleaning or organizing
• Impaired judgment and impulse control: increased sexual behavior, impulsive excessive spending, impulsive travel, increased risk-taking behaviors,
• Irritability: feeling on edge, agitation, argumentative towards others

Central to the understanding of elevated mood intensity is the recognition that elevation intensity can vary greatly. The top of the elevated mood continuum is referred to as mania. Mania or “being manic” is that realm of experience where symptom intensity is strong enough to cause severe impairment to an individual’s capacity to organize and direct behavior while maintaining reasonable judgment and impulse control. With acute mania, it’s also common to have psychotic symptoms involving delusional thinking, extreme grandiosity, paranoia, and even hallucinations. With this level of symptom acuity, psychiatric hospitalization is usually necessary, as one is no longer able to make safe, rational decisions.

Mood elevation with lesser intensity than mania is referred to as hypomania (hypo = below). It represents a wide range of the elevated mood continuum—more so than does mania. In its upper range, individuals are often adversely impacted by the combination of lessened impulse control and impaired judgment; however, not to the degree of severity that we observe with mania.

Further down the continuum, lower-level hypomania can be subtle and only mildly above normal positive mood. Elevation can arrive gradually over the course of several days. Its presence may not be strong enough to be identified as representing anything maladaptive. During the first few years post-diagnosis, mild elevation is difficult for an individual to identify, as it doesn't necessarily feel like anything is wrong.

If we could graph the mood intensity of bipolarity, we’d find that different people’s graphs reveal very different patterns. Some patterns would appear to have regularity. Others would be more chaotic and unpredictable.

Bipolar depressed moods tend to have a longer duration than mood elevations. We can see depressions stretch from a week or two up to several months, sometimes even a year or two. Mood elevation is typically briefer—several days up to several weeks; occasionally as long as a few months. But the brain isn’t able to sustain the intensity of ongoing elevation without an individual’s functioning beginning to unravel after a period of time. Following a bipolar mood elevation, we almost always see mood head downwards into depression.

I’ve already addressed the fact that hypomania represents lower-level mood elevation than mania. This is also relevant to the difference between bipolar I disorder and bipolar II. In Bipolar I, individuals have had at least one full manic episode, whereas bipolar II elevations remain within the hypomanic range and do not progress into mania.

Another common misconception is that bipolar II is less severe than bipolar I. This is not so, at least not across the board. Assume person A has had a one-week-long manic episode followed by a two-month depression and then only mild mood variability for the next two years. Contrast that with person B who rapid cycles between several days of strong hypomania and subsequent month-long depressive episodes while rarely spending any time in the mid-range mood. Clearly, person B is going to have a more difficult time. The severity or degree of dysfunction experienced with bipolarity has everything to do with overall mood patterns as opposed to whether one is diagnosed with bipolar I or bipolar II.

If any of this rings true for you, I strongly suggest you seek consultation from a mental health professional who is knowledgeable about bipolarity. It’s not something that’s easily manageable if you’re flying solo.