Many mental disorders seem to lie on a spectrum in which symptoms can subtly blend and vary in degree. Some people develop clear and incapacitating symptoms, while others have less severe symptoms, combinations of symptoms, or a personality with traits that remind people of more serious problems. These variations of mental disorder may be related.
Classifying and Refining the Concept of Bipolar Disorder
Because patients are seen at different stages in the course of their illnesses and symptoms vary, psychiatrists have developed a variety of classifications to describe the different types of problems for which patients seek help. For example, someone might have bipolar I with a single manic episode.
Someone with recurring mood fluctuations might be described as having recurrent bipolar disorder with a recent episode of mania or hypomania. Other individuals might best be described as having recurrent bipolar I disorder with one of the following episodes: depressed, mixed, or even unspecified. In addition to bipolar I, II, and cyclothymia, doctors sometimes diagnose bipolar disorder NOS, or not otherwise specified, if they can't pin down a more specific diagnosis.
Sometimes a person with bipolar I can have symptoms of mania and depression at the same time. Also known as depressed or dysphoric mania, this mixed state can cause a person to be irritable and short tempered. Negativity and hopelessness can combine with agitation. It might be difficult for some people not familiar with bipolar disorder to imagine, but being in a mixed state may mean feeling very sad or hopeless and highly energized at the same time. There is no euphoria as there is in mania; euphoria is replaced by agitation in a mixed episode.
Mixed episodes can be confusing to the onlooker who does not know someone's history of bipolar disorder. It is easy to lose patience with someone having a mixed episode, because it seems no matter what you say or do, it makes the person unhappy, and no matter how reassuring you are, you fail to reassure or calm her.
On occasion, a patient has symptoms that look like bipolar disorder, yet don't seem to fit any of the known patterns. In these instances, she might be diagnosed as having bipolar disorder not otherwise specified, or bipolar NOS. This classification enables a doctor to classify the patient as bipolar and see how the illness is or is not being manifested according to established diagnostic guidelines. A formal classification is also required by insurance companies before they consider reimbursing or paying for treatment.
Rapid cycling of bipolar symptoms is associated with more severe symptoms of the disorder. It refers to the experience of having a major depressive, manic, hypomanic, or mixed episode at least four times in the previous year, each cycle lasting for a relatively short time. The order of the moods or their combination does not matter. For a diagnosis of rapid cycling, the different moods must immediately follow one another, or a mood must be followed by a brief period free of extreme mood swings.
In extreme cases, some people rapid cycle several times a day. All told, 10 to 20 percent of bipolar patients experience rapid cycling, often in the first few years of the illness. It happens more often with bipolar II than bipolar I, but it can occur in both. It affects women, who account for 70 to 90 percent of the cases, much more often than men. It also tends to coincide with earlier onset; people who recycle have their first episode about four years earlier than people with nonrecycling bipolar disorder. This means they are more likely to be teenagers when they first show signs of the disorder.