Bipolar II or Bipolar Too?

There is a lot of web-based information that assists people in identifying symptom sets that serve as criteria for the diagnosis of bipolar disorder. For those whose bipolar mood elevations are quite strong, particularly when their symptom profile fits patterns of bipolar I disorder, identifying the diagnosis is not that difficult. Full mania, however it presents, is usually unmistakable. The salient elements of intense physical energy, accelerated cognition, lessened need for sleep, distorted perceptions of self and very intense mood are not typically seen in other forms of psychopathology, with the exception of substance induced states or florid psychotic episodes that are part of schizophrenia. By the way, mania may or may not entail psychosis.

What distinguishes mania from lesser intensity mood elevation or hypomania is: The manic individual is typically out of control and unable to function safely without close supervision or hospitalization. If one has had one or more manic episodes, he or she usually knows it. It's like wondering whether or not an area has been hit by a hurricane. Usually the downed trees and the interrupted electric service adequately tell the story.

The more challenging aspects of bipolar symptom identification involve the subtler aspects of mood elevation associated with bipolar II disorder. Because BP II mood elevation is not as intense, it’s simply more difficult to spot, especially on the low end of the hypomanic continuum.

Imagine that we had some kind of mood intensity meter that could measure the strength of mood elevation…kind of like a blood pressure cuff. This cuff would be able to determine strength of things like mood, physical energy and speed of thought. Now imagine this BP II cuff could combine these different components and create a five-point range, which would yield the following hypomanic intensity readings:

1=slight elevation

2=mild elevation

3=moderate elevation

4=strong elevation

5=very strong elevation

It’s a nifty cuff.

The interesting piece here, besides the fantasy of a bipolar cuff, is that for many who were experiencing low-end elevation (#1 or #2), had they not measured their BP mood intensity, it’s quite possible they wouldn’t know that they were mildly elevated. After all, our moods exist on a broad continuum. If we graphed people’s mood intensity as well as mood direction (up or down) we’d see that for some the mood graph would remain fairly level, others would have mild dips and elevations, still others would show a high degree of variability with deep lows and highs. The point here is that because mood does vary, it can be difficult to be aware of the progression into low-end hypomania. It isn’t necessarily accompanied by obvious warning signals.

There are two additional dimensions that make symptom identification challenging for those living with bipolar II disorder:

1. Individuals who are in the early stages of their BP II Disorder (first year or two post diagnosis)
2. Individuals with bipolar II whose baseline functioning also entails a fair degree of emotional reactivity.

Imagine experiencing mild to moderately elevated energy for a few days along with rapid thinking and irritability; or mild mood elevation (feeling positive and optimistic), along with a mild degree elevated energy such that your body’s sleep clock isn’t winding down when you’re usually ready for bed. This might not be the norm for you, but think about it. Early on, would it register that something might be wrong?

After all, living with normal mood doesn’t necessarily mean living with flatness. Sometimes mood intensity is a normal reaction to the intensity of life, and sometimes it can mean you’re positioned somewhere on the bipolar spectrum. Without enough experience of bipolarity, how does one distinguish between symptoms of an illness versus times when you're simply stressed and mildly agitated or feeling enthusiastic and productive as a function of positive mood?

The individual who has lived with up and down mood for three to five years is in a better position to have some perspective on what his or her pattern looks like. But what if you’re in the first or second year of mood instability? What if you’ve had a year or two of intermittent depressive episodes and you’ve just been diagnosed with bipolar II following your first week-long hypomanic episode? It is this early period of time, post-diagnosis, when it’s most difficult to distinguish between normal ups and downs vs those that may be bipolar-related.

There’s both good news and bad news here. The bad comes first: during the early course of low-end or mild acuity bipolar II disorder, it's really difficult to arrive at these distinctions with accuracy. Having worked with bipolarity over the last 20 years, I usually don’t see a quick route towards this kind of self-knowledge, as it’s only born out of one’s own unique experience. You won’t find a field manual of bipolar symptoms written specifically for you. Yes, there are websites, mood charting apps and a gaggle of books that describe bipolar II symptoms, but they’re not talking about “you.”

The good news is that over time, your use of available resources as well as your own increasing self-awareness will help sharpen your self-observing capacities. Most with mild bipolarity will have a lot more clarity about their symptom patterns after several years of experience. And, as a function of better clarity, individuals can more effectively take steps to offset the negative impact of mood instability.

Adjusting the dosing of one or two of your meds, becoming stricter with your adherence to a stable sleep schedule, increasing exposure to daylight or darkness (depending on which end of the mood continuum one is trying to modulate), increasing session frequency with your psychotherapist, incorporating regular exercise into your weekly routine; these are all part of the adjustments one will make in the process of trying to lessen the negative impact of bipolar mood intensity.

The second challenging dimension of living with BP is a bit trickier. On top of your bipolar II instability, what if you’re also someone with strong emotional reactivity? If that’s the case, how do you distinguish between emotional reactivity and bipolar mood variability?

Some people have big emotions. They react strongly to life and to relational issues. In the intensity of the moment they’re not always good at keeping things in perspective. Instead, their emotional responses are full, strong, and passionate. Taken more to the extreme, this kind of reactivity can represent someone positioned on the personality disorder spectrum. Again, we’re talking about continuums of intensity. The point at which individuals identify psychopathology vs normal intensity entails the relative degree adaptiveness of their emotions and accompanying behaviors. If life works for them, if they flow with their fullness without there being a recurrent downside, then we might just say they’re fortunate to experience a fair degree of “joie de vivre.”

But what happens when the emotional intensity causes repeated difficulties and relationship ruptures, when the aftermath of big feelings involves frequent conflict, hurt, disagreements and a long trail of relational debris? One simple answer is that when emotional intensity comes with a lot of negative cost, we’d probably agree that it’s less of an attractive or desirable attribute. Potentially it’s problematic. Potentially one may be living with maladaptive personality traits in the realms of borderline or narcissism (see post “Misdiagnosis of Bipolar Disorder, Part II”). But let’s be cautious. Big emotions in and of themselves, do not a personality disorder make!

OK, now to the essential piece.

Bipolarity reflects two distinct ends on a continuum of mood. The bipolar diagnosis is rendered when there are enough repeated symptoms of elevation and depression that create problems in living for the individual. BP II mood elevation can often entail strong emotions, along with a host of other mood-elevated symptoms. These can include, but are not limited to: elevated energy, lessened need for sleep, rapid cognition, strong optimism, feelings of elation or euphoria, elevated self-confidence sometimes bordering on grandiosity, elevated libido (felt and sometimes acted upon), impulsivity, excessive spending, irritability, strong impatience, distractibility, intense strong goal-directed behavior, and preoccupation with religion, spirituality or any other kind of central organizing ideal that the BP II mind latches onto. And there are more, but the ones just listed tend to be more common. With regard to the broader picture, think of an energetic system that is overcharged, running at peak intensity and doesn’t need as much recharging at night (sleep).

I’m not delving into the depressive end of the spectrum here as it tends to be more commonly understood. Most people have had some direct experience with depression, or they have a close connection with someone who has.

In addition to elevation and depression, there’s the experience of bipolar mixed symptoms where an individual experiences a blend of symptoms from each side of the continuum. Mainstream bipolar literature used to refer to the mixed symptom picture as relatively uncommon. More recently, J. Phelps, MD, has spoken to the frequently overlooked aspects of mixed symptoms in the context of bipolar spectrum disorders (see J. Phelps, MD, Psychiatric Times; plus his two books, “A Spectrum Approach to Mood Disorders.” Phelps, 2016, Norton and “Bipolar, Not So Much.” Aiken and Phelps, 2017, Norton).

An example of a mixed symptom set would be high energy, rapid thought, negative pessimistic thinking, irritability, impulsive expressions of anger and lessened need for sleep. One of my patients described it as “being positioned on a sharp electrified edge and being unable to get down.”

There’s an equally important part of the bipolar symptom pattern that’s not often written about, called “episodicity." Bipolar symptoms tend to occur as a cluster. The period of time during which they are present represents an episode and the symptom set remains “on” until it has run its course and the symptoms begin to remit or transition into different symptoms. Mood elevation, including mixed symptom elevation, typically lasts between a few days to several months (though one of my patients once experienced a two-year long bout of strong hypomania). Depressed mood episodes tend to remain in place for longer – several weeks, up to six months, and sometimes more. The point is, when bipolar mood becomes destabilized, then the individual’s unique symptom sets become activated.

Now I want to loop back to my earlier reference regarding the challenge of living with emotional reactivity while also living with bipolarity. The critical piece here is that they can be different.

Strong emotions such as euphoric feelings during hypomania or irritability during an episode of mixed symptoms can absolutely be reflective of bipolar mood. But they can also be more personality based. When strong reactivity is personality based you’ll see it peppered throughout one’s experience. It will almost always be interpersonally and situationally based. In other words, if you’re struggling with personality-based issues (how you relate to the world), your strong reactions will be in response to the world. But if you're going from mid-range (not up/not down) into elevated mood for no good reason and your cluster of mood intensity symptoms remains in place for few days or longer, that’s more likely to be a manifestation of hypomanic mood.

One of the common errors I see being made by individuals new to their bipolarity is that they can over attribute the illness as the cause of most of their difficulties. This isn’t good for a number of reasons. First, it gives the illness more of a role than it deserves. And second, by seeing bipolarity as the universal culprit, it further dis- empowers the individual. The perception that bipolar disorder sits at the root of all of one’s strong emotions will cause you to feel worse about the journey that lies ahead.

Two brief case examples:

Jorge is a 22-year-old, Latino male 4th-year university student who has lived with bipolar II disorder since his first significant hypomanic episode during his second year at school. He was also diagnosed with attention deficit disorder during middle school. The combination of his mildly impaired executive skills as well as some mild cognitive side effects from his mood stabilizing medication have him feel increasingly concerned or insecure about his ability to stay on top of things while multi-tasking.

Jorge recently had a job interview for a post-graduation position. The interview went well enough but following the interview he found himself filled with self-doubt as to whether he could perform adequately if he were offered the position. When Jorge came to his next psychotherapy appointment he was distressed by his interpretation that his bipolarity shuttled him from a strong job interview into an anxious, worried, self-doubting frame of mind.

Janice is a 32-year-old, unmarried female diagnosed with bipolar II when she was in her mid 20s. She experiences mild to moderately depressed mood much of the time but several times each year she’ll find herself spiking into elevated mood (mostly positive) for several days duration. Additionally, she’s very emotionally insecure about finding and keeping a quality love relationship. The presence of her bipolarity has her even more concerned due to her perception of self as “damaged goods.” Janice does experience some borderline personality traits, though she’s become good at modulating the intensity of her behavioral expression of intense emotion.

Janice teaches fifth grade at a private boarding school and she was recently asked out by a male colleague. Janice felt thrilled since she had had fantasies about a relationship with this teacher since they had first met. For the next two days her mood was up. She had difficulty falling asleep. She was preoccupied with anticipatory thoughts about the wonderful new man in her life…until she saw him on Sunday afternoon walking with an attractive female at a nearby shopping mall.

Janice plummeted. She was convinced she was getting her hopes up for nothing. In fact, she was certain he was going to call and convey that he recently met someone new and was having second thoughts about going out with Janice. In therapy Janice lamented that she could never have an on-going relationship due to the roller coaster life she lived as a function of her bipolarity.

What’s wrong with these pictures?

Each individual was struggling with their own unique vulnerabilities and the activation of intense emotions secondary to self-esteem/self-doubt. In Jorge’s example his self-esteem was shaken as he questioned his ability to manage complex employment-related tasks and responsibilities. In Janice’s case, she was feeling lonely and desirous of a love relationship. The recent interest from a colleague activated strong idealized fantasies of fulfillment and a rapidly plummeting sense of disappointment based on very flimsy evidence. Both were sure that their bipolar disorder was responsible for their distress.

And both were wrong. Jorge’s medication side effects may have added to his concerns about his employment-related performance. But he’s also had difficulties staying on top of complex detail since his early teenage years. Beyond that, he was worried about the approach of his first real, grown-up job following college graduation, as are most twenty-somethings who are about to receive their degree and enter the work force.

Janice is very insecure about finding a love relationship. But Janice is also insecure about most of her relationships. Her strongly felt needs lead her into prematurely idealized attachments, corresponding fears of loss and rapidly changing intense emotions.

Both Janice and Jorge live with bipolar too (no typo here), but in the midst of their situational and relational difficulties, that which calls out for their close attention is not their bipolar II disorder.

_{Russ Federman, Ph.D., ABPP is in private practice in Charlottesville, VA (www.RussFederman.com). He is co-author of Facing Bipolar: The Young Adult’s Guide to Dealing with Bipolar Disorder (New Harbinger Publications) and Contributing Author: Healthy Living with Bipolar Disorder (International Bipolar Foundation)}