The Two Types of Bipolar Disorder
The DSM-IV (the diagnostic Bible) divides bipolar disorder into two types, rather unimaginatively labeled bipolar I and bipolar II. “Raging” and “Swinging” are far more apt:
Raging bipolar (I) is characterized by at least one full-blown manic episode lasting at least one week or any duration if hospitalization is required. This may include inflated self-esteem or grandiosity, decreased need for sleep, being more talkative than usual, flight of ideas, distractibility, increase in goal-oriented activity and excessive involvement in risky activities.
The symptoms are severe enough to disrupt the patient’s ability to work and socialize, and may require hospitalization to prevent harm to themselves or others. The patient may lose touch with reality to the point of being psychotic.
The other option for raging bipolar is at least one “mixed” episode on the part of the patient. The DSM-IV is uncharacteristically vague as to what constitutes mixed, an accurate reflection of the confusion within the psychiatric profession. More tellingly, a mixed episode is almost impossible to explain to the public. One is literally “up” and “down” at the same time.
The pioneering German psychiatrist Emil Kraepelin around the turn of the twentieth century divided mania into four classes, including hypomania, acute mania, delusional or psychotic mania, and depressive or anxious mania (ie mixed). Researchers at Duke University, following a study of 327 bipolar inpatients, have refined this to five categories:
- Pure Type 1 (20.5 percent of sample) resembles Kraepelin’s hypomania, with euphoric mood, humor, grandiosity, decreased sleep, psychomotor acceleration and hypersexuality. Absent was aggression and paranoia, with low irritability.
- Pure Type 2 (24.5 of sample), by contrast, is a very severe form of classic mania, similar to Kraepelin’s acute mania with prominent euphoria, irritability, volatility, sexual drive, grandiosity and high levels of psychosis, paranoia, and aggression.
- Group 3 (18 percent) had high ratings of psychosis, paranoia, delusional grandiosity and delusional lack of insight; but, lower levels of psychomotor and hedonic activation than the first two types. Resembling Kraepelin’s delusional mania, patients also had low ratings of dysphoria.
- Group 4 (21.4 percent) had the highest ratings of dysphoria and the lowest of hedonic activation. Corresponding with Kraepelin’s depressive or anxious mania, these patients were marked by prominent depressed mood, anxiety, suicidal ideation and feelings of guilt, along with high levels of irritability, aggression, psychosis and paranoid thinking.
- Group 5 patients (15.6 percent) also had notable dysphoric features (though not of suicidality or guilt) as well as Type 2 euphoria. Though this category was not formalized by Kraepelin, he acknowledged that “the doctrine of mixed states is … too incomplete for a more thorough characterization …”
The study notes that while Groups 4 and 5 comprised 37 percent of all manic episodes in their sample, only 13 percent of the subjects met DSM criteria for a mixed bipolar episode; and of these, 86 percent fell into Group 4, leading the authors to conclude that the DSM criteria for a mixed episode is too restrictive.
Different manias often demand different medications. Lithium, for example, is effective for classic mania while Depakote is the treatment of choice for mixed mania.
The next DSM is likely to expand on mania. In a grand rounds lecture delivered at UCLA in March 2003, Susan McElroy MD of the University of Cincinnati outlined her four “domains” of mania, namely: