I'm struck by how many times I see patients that have previously been diagnosed with bipolar disorder and they don’t know whether they are bipolar I or II. Furthermore if they have been diagnosed with bipolar II they will often say something like - "I have the milder form of the disorder." While hypomania associated with bipolar II is less destabilizing than the mania seen in bipolar I, it doesn't necessarily make bipolar II easier to live with. In fact, sometimes it can be just the opposite.
Bipolar disorder represents a very broad spectrum of experience; broad enough, that the American Psychiatric Association's DSM-IV-TR separates the disorder into two diagnoses: bipolar I (BP I) and bipolar II (BP II). Let's look at what these two ranges of the bipolar spectrum have in common as well as what distinguishes them from each other:
To begin with, we have the depressive end of the diagnosis. With both BP I and II, an individual must have a history of at least one major depressive episode. Major depression is severe depression lasting two weeks or longer. For some with the disorder, depression is clearly a factor but it's not the piece that creates the most difficulty. Conversely, there are those who are stuck in fairly serious depression much of the time. For these individuals, the depressive end of the bipolar continuum is their nemesis.
With elevated mood there's an important distinction to be made pertaining to acuity. When elevated mood reaches a level of intensity causing significant difficulties with social and occupational functioning and/or requiring hospitalization, it's regarded as mania and therefore fits the picture of BP I. But if the level of elevated mood intensity is not sufficient to require hospitalization, or creates only mild to moderate interference with social and occupational functioning, then it is referred to as hypomania (below mania) and is consistent with mood states of BP II. Furthermore, if an individual's elevated mood is typically hypomanic but he or she has had one or more full manic episodes, then the diagnosis is still BP I, even when mood elevation is mostly hypomanic in nature.
When reflecting on the distinctions between BP I and II, a key difference involves how elevated or how intense one's mood might become. Once full mania enters the picture, the ceiling is raised, and along with this elevated potential we have the designation of BP I. But if mood elevation doesn't push up any higher than hypomania, the lower ceiling receives a BP II diagnosis rather than BP I.
I must admit, the distinction between the two can be a bit fuzzy. One person's upper level hypomania can be the equivalent of another person's mania. DSM IV-R isn't very helpful in parsing these distinctions. My own rule of thumb is that once mood and behavioral intensity reaches a level which requires hospitalization, that's the point which distinguishes BP I from BP II.
Now let's consider matters of episode sequencing. A question I often receive goes something like - "If I'm in the early stages of my BP II disorder, will my hypomanic episodes possibly progress towards mania and BP I?” The answer is “possibly” but there's also no certainty here. If you're committed to embracing healthy lifestyle choices such as obtaining adequate and consistent nighttime sleep, refraining from psychoactive substance use, developing effective stress management techniques, getting regular exercise, etc., then these strategies will lessen the possibility of progressing towards higher symptom acuity.
Additionally, the more years post-diagnosis that you have had without a full manic episode, the more you can count on the hypomanic ceiling remaining in place. However, if you're early in the course of your emerging mood instability, the future course of the illness is really up for grabs. If this is where you're at, you’ll likely find yourself feeling anxious about what lies ahead. You feel as if you’re walking on eggshells in relation to your mood stability… and that’s a fully understandable reaction to have. With more time post BP-onset you’ll have a clearer sense of the course of your disorder and your anxiety will lessen.
Let's return to the issue I initially alluded to: that is, whether BP I is worse or more disabling than BP II. One reason for the lack of clarity around this question is that the answer is both yes and no.
If you're unfortunate enough to live on the more unstable end of BP I continuum, then life indeed can be rough. In this realm of the illness we see conditions that are highly unstable and treatment resistant. Traditional medication approaches are ineffective, relapse is frequent and symptom acuity is severe. Essentially these individuals are disabled by their BP I disorder and they're often living on the margins of society. According to researchers Jamison and Goodwin (2007), this is the case for approximately 1/3 of those with BP. For these individuals, the bipolar illness is truly disabling.
But this leaves a full 2/3 of bipolar individuals living with the disorder and not being disabled. Essentially, they receive treatment, experience intermittent periods of unstable mood and are able to function reasonably well within mainstream society.
For those in this 2/3 who are diagnosed with BP I, the incentives to be treatment compliant and to adhere to healthy lifestyle norms are quite high. Once an individual with BP I is derailed and needs hospitalization, particularly if such occurs multiple times, then the motivation to avoid future relapse is strong. In fact among the bipolar university student population that I work with I see much less denial and treatment resistance with those who are BP I as opposed to BP II.
The situation for the BP II individual isn't as clear. When hypomania is in the mild to moderate range, it's easy for denial to interfere with acceptance. Mood variability can be perceived as simply being mercurial or being highly emotionally sensitive as opposed to being indicative of a psychiatric disorder. In fact, the intensity of hypomania may be something that's welcomed rather than avoided. Many would rather see themselves as simply experiencing wide ranging moods rather than acknowledging that something is seriously wrong.
A variation on this theme involves those in the early phases of their disorder who have not yet developed the kind of self-observing mindfulness needed to identify the onset of their hypomanic symptoms. It's more like they get swept up in the intensity and consequently don't recognize the need for help. Feeling good doesn't necessarily activate warning alarms and it can take some time for the BP II individual to recognize that the "feel good" experience of hypomania may indeed not be good for them.
The real problem with denial is that when repeated hypomanic relapse is not successfully modified then such can potentially lead to a worsening of bipolar symptoms. With each successive relapse, symptoms can become worse, subsequently leading to increased relapse frequency and increased symptom acuity. In other words, denial or lack of recognition of the illness usually leads to a worsening of the illness. The longer term outcome of this repeated derailment can leave life, love, career and self-esteem in tatters.
The flip side of elevated mood is bipolar depression and for many with BP II, far more time is spent in depression than when compared to those with BP I. Bipolar depression is not any different than unipolar depression. It's basically the same blah, pleasureless, low-energy, miserable, unhappy experience that most with depression report. The one big difference is that antidepressants are the last line of choice as they have strong potential to activate elevated mood. Instead, one must rely on the antidepressant properties of mood stabilizers along with healthy lifestyle enhancements such as regular exercise, healthy diet, stable sleep and a healthy dose of daily sunlight exposure (which also happens to be helpful for depressed mood).
Bipolar depression can also be more difficult to endure because of its chronicity. It's one thing to say - "Here I am stuck in a depressive funk." But there's a more potent downward pull when the individual is thinking - "here I am stuck in my bipolar depression for the sixth time!" This kind of recognition can contribute to increasing pessimism about the future. Instead of hoping for future improvement the individual becomes convinced of a bleak prognosis.
I don’t not want to mislead anyone into thinking that BP II is an easier road to travel than BP I. In terms of basic symptom acuity, this may be accurate. But when we ask whether BP I or BP II is more easily managed by those with the disorder, the answer is complex and less than clear.
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Russ Federman, Ph.D., ABPP is Director of Counseling and Psychological Services at the University of Virginia. He is also co-author of Facing Bipolar: The Young Adult’s Guide to Dealing with Bipolar Disorder (New Harbinger Publications). www.BipolarYoungAdult.com