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Bipolar Disorder

The Shape of Bipolarity

The presentation of bipolar disorder symptoms is highly variable.

In 1980 The American Psychiatric Association replaced the Diagnostic and Statistical Manual’s (DSM) use of "manic-depression" with "bipolar disorder." The bipolar label introduced the view that mood and accompanying emotion exist on a broad continuum and that individuals with bipolarity typically experienced symptom sets at both ends or polarities of the mood continuum. Hence “bipolarity.”

Despite the change that’s now been in place close to 40 years, I don’t perceive that the term "bipolar disorder" has helped to shift the public’s perception of the disorder. Much of what’s found online continues to convey this notion that people with bipolarity live in an up-down roller coaster world where mood phases frequently transit between depression and mania. Below are some examples of introductory descriptions taken from websites providing information about bipolar disorder.

  • "Bipolar disorder is a mental illness marked by extreme shifts in mood. Symptoms can include an extremely elevated mood called mania. They can also include episodes of depression..."
  • "Bipolar disorder is a mental illness that causes dramatic shifts in a person’s mood, energy and ability to think clearly. People with bipolar experience high and low moods—known as mania and depression—which differ from the typical ups-and-downs most people experience."

​Unfortunately much of what is offered as public education doesn’t come close to conveying the complexities or subtleties of bipolar symptomatology.

Of the two poles, most people can better relate to depression as opposed to mood elevation. After all, many have experienced some aspects of it, or they know someone who has. Based on data from the National Institute for Mental Health (NIMH) we see that 6.7% of Americans have experienced major depression. Women experience almost twice as much depression (8.5%) as do men (4.8%). Adults between 18 and 25 report even higher prevalence of depression – 10.5%. A recent 2018 article in Clinical Psychiatry News cites a study from JAMA - Psychiatry (Journal of the American Medical Association), where it was reported that the lifetime prevalence of major depression (percent of people who have experienced a major depressive episode at least once in their lifetime) - is 21%. That's approximately one in every five people.

What tends to be more common for bipolar depressed individuals are feelings of helplessness in response to the chronicity of their illness. They’re not just having a bad week or a bad winter. The person who has lived with their bipolarity for 10 years isn’t just saying “I’m depressed.” More accurately, the message may be closer to – “I'm repeatedly depressed and it's difficult to envision a time when I'll be free of it."

Depressed mood phases usually last longer than mood elevations. I’ve seen some people remain depressed for up to six to nine months. Others may only experience a brief depressive dip lasting a few days before returning to comfortable mid-range. That said, most living with bipolar disorder have had at least one major depressive episode lasting two weeks or longer. Bipolar depressive acuity can range between mildly melancholic to soul sucking, energy flattening, acute depression.

Mood elevation is another story. 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.

Below is a list of elevated mood symptoms. It’s important to note that individuals will experience different clusters of these symptoms. One individual's bipolar elevation may be quite different from another's. If there's any unifying thread we typically see it through the presence of elevated energy, lessened sleep and accelerated thought processes. Beyond these three, most mood elevation symptoms are very person specific.

  • Sustained and strong positive, euphoric mood lasting longer than a day or two
  • Higher than normal physical energy
  • Difficulty sitting still (needing to move, exercise and discharge physical energy)
  • Lessened need for sleep (feeling rested after less than usual amount of sleep)
  • Experiencing one or more nights without any sleep while also not feeling fatigued
  • Intense goal directed activity – sometimes becoming focused on an activity almost to the exclusion of everything else
  • Compulsive cleaning or organizing, or excessive disorganization
  • Accelerated thinking
  • Rapid speech
  • Talking louder than usual
  • Not being able to stop talking – not making verbal “space” for the other.
  • Increased sociability – gregariousness
  • Strong optimism and confidence (more than is usual)
  • Unrealistic, grandiose perceptions of one’s capabilities
  • Stronger attachment to spiritual or religious beliefs (stronger than is common for the individual)
  • Increased creativity
  • Unrealistically positive perceptions about one’s creative endeavors
  • Elevated libido (sexual feelings)
  • Increased sexual behavior
  • Increased risk-taking behaviors
  • Poor judgment in relation to behavioral choices
  • Impulsive spending – purchasing things that are not needed
  • Spending more than one would typically spend
  • Irritability – feeling on edge
  • Treating others harshly due to one’s irritable feelings
  • Disorganized and/or scattered thinking
  • Difficulty maintaining focused attention and concentration
  • Delusional thinking (distorted thoughts about reality)

If we interviewed 100 people with bipolarity, we'd find the list would become even longer. Each individual has their own list of symptoms that are unique. I recall a patient once stating that she could always tell she was hypomanic when she had urges to bake chocolate chip cookies well into the early morning hours.

Central to the understanding of elevated mood intensity is the recognition that mood intensity can vary greatly. Low level elevation (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 appear strong enough to be identified as representing anything maladaptive. In the first few years of living with the disorder, mild elevation can be difficult for an individual to identify as it doesn't necessarily feel like anything is wrong. Conversely, elevation can also have rapid onset and progress towards such intensity that psychiatric hospitalization becomes necessary due to the reality that one is no longer in control of behavior (mania). There is no one-size-fits-all with bipolarity.

If we could graph the mood intensity of bipolarity, we’d find that different people’s graphs revealed very different patterns. Some patterns would appear to have some regularity with regard to duration, intensity and frequency of elevated or depressed mood. Others would be more chaotic and unpredictable. Some individuals with bipolarity rarely experience any sustained mid-range experience. They are mostly in depression with brief periods of mood elevation. Some people with bipolarity who are more fortunate can remain in mid-range mood for many months without the presence of any symptoms that would be indicative of their bipolar disorder.

I’m recalling one patient I saw who had an initial manic episode at age 17, a second manic episode at age 40 and a third at 56. He remained asymptomatic and off of medication throughout the intervals between manic episodes. Unfortunately for him, following the third onset of mania he went through a full year of mood instability with three hospitalizations – two for mania and one for acute depression. I include this example simply to say that with bipolarity, there will always be individuals whose symptom patterns are atypical.

Last, bipolar mood shifts occur for many different reasons. Sometimes they can be stress induced, which tends to most often be the case. Sometimes there are seasonal components where the progression of mood is affected by changes in daylight and darkness concurrent with the changing seasons. Mood shifts can be initiated by inadequate sleep, substance abuse or even prescribed medications. There are also those times when individuals experience significant mood shifts with no clearly identifiable reason why mood has progressed up or down, except for the fact that they live with bipolarity. All are possible.

What is clear is that, in general, those living with bipolarity have difficulty maintaining relatively balanced mid-range mood. When outside of mid-range, their symptoms present with a lot of variability. Their mood instability tends to persist over time. It can be helped through psychiatric medications, psychotherapy and healthy lifestyle choices. But the fact that bipolarity typically persists through the life cycle isn’t reflective of a person’s lack of effort, lack of discipline or lack of character strength.

My point is that bipolar disorder presents with many different shapes and forms. People don't just transit between happy and sad. They traverse a very broad continuum of mood symptoms and patterns that are unique to each individual.