This discussion will focus on the conditions between major depressive disorder and bipolar I (true manic depressive). In the prior blog I discussed bipolar II which is the most common intermediary disorder. They almost always present as being depressed and so deliberate effort should be exerted to uncover a hypomanic state. The characteristics of hypomania include cheerfulness, gregariousness, increased sexual drive, garrulousness, overconfident or overoptimnistic, racing thoughts, reduced need for sleep, vigor, overinvolved in relationships or projects. In order to qualify as hypomanic, one must have three or more of these characteristics. DSM-IV requires a duration of four days. I find that the duration is inversely correlated with the number of such episodes but should be at least one to two days. This is distinguished from happiness by its recurrent nature as well as its ability to be precipitated by antidepressant therapy. When precipitated by antidepressants, it is designated bipolar III. While hypomanic states can result in enormous productivity and creativity, often insight and judgment are lost so that these states can result in disastrous consequences similar to manic states.
Another intermediate form of bipolarity are those patients who are temperamentally cyclothymic and who experience a superimposed depression. Cyclothymia is a condition characterized by many of the following: 1) ability to think varies from sharp to dull, 2) sudden shifts in mood and energy, 3) constant shifts between being lively and sluggish, 4) see things as vivid or lifeless, 5) sudden mood changes without reason 6) frequent shifts between being outgoing and withdrawn, 7) moods and energy are either high or low, rarely in between, 8) feeling of overconfidence alternate with feeling unsure 9) need for sleep varies from just a couple of hours to nine hours or more, 10) sometimes go to bed feeling great and awaken feeling life is not worth living, 11) feeling about other varies from liking a lot to no interest at all, 12) can be happy and sad at the same time. An individual would need at least six of the above characteristics to meet criteria for cyclothymia. These patients are quite unstable and are often misdiagnosed with borderline personality disorder. These patients are variants of bipolar II and are designated bipolar II 1/2.
Another intermediate form of bipolar disorder is designated bipolar IV. In this condition, the individual has hyperthymia prior to a depressive episode and between depressive episodes. The characteristics of hyperthymia include feeling: 1) upbeat and exuberant 2) articulate and jocular, 3) overoptimistic and carefree, 4) overconfident and boastful 5) high energy level, lots of plans, 6) versatile with broad interests, 7) overinvolved and meddlesome, 8) uninhibited and risk-taking, 10) short sleeper i.e. less than 6 hours. One must have at least four of the foregoing characteristics and are habitual long-term functioning, not in episodes. So these individuals are energetic and active where as cychothymics are characterized by mood lability. The biphasic disturbance in bipolar illness often consists of the development of episodes that are opposite in polarity to the baseline temperament.
Soft bipolar conditions have many coexisting disorders. Among the most common are substance and alcohol abuse. Substances are often used to enhance the up periods especially with stimulants. Bulimia is comorbid as are other impulse disorders such as gambling and kleptomania. ADHD is another comorbidity which needs to be distinguished from emotional dysregulatory periods in the children of bipolar patients. Professional outstanding achievement is often overrepresented in healthy relatives of bipolar patients.
Part III will focus on other characteristics that can be used as clinical pointers to bipolar disorder.