Updated 3/2019

Bipolar 2 and the Mood Spectrum

If you have depressions but not “mania”, you could have a Bipolar 2 diagnosis. You could be “a little bipolar”. You might need a treatment approach to match.

You’ll read here about forms of depression which do not have “mania” yet are not plain depression either. That’s the mood spectrum. Across this spectrum, depression is by far the main symptom, including especially sleeping too much, extreme fatigue, and lack of motivation. What makes for a mood spectrum or bipolar 2 diagnosis is the presence of something else as well.

That “something else” often does not look anything like mania. “Hypomania”, which you’ll learn about here, can show up as extreme insomnia, irritability, agitation/anxiety, and difficulty concentrating. And finally, some people can have some bipolarity without any hypomania at all. Really. You’ll see references here to mood experts who have pioneered this way of thinking about depression.

Wait a minute: isn’t there concern about overdoing bipolar 2 diagnosis? Yes, we’ll talk about that too, after you’ve learned some basics.

What happened to “manic-depressive”?

Somewhere along the way you probably learned about manic-depressive illness: episodes of mania, and episodes of severe depression. Here are the symptoms of “mania”. Not that you have these, as such; the lack of them is the main point here. Hang on.

Mood much better than normal

Rapid speech

Little need for sleep

Racing thoughts, trouble concentrating

Continuous high energy

Overconfidence

Delusions (often grandiose, but including paranoid)

What happened to “manic-depressive”? As our understanding of bipolar disorder has grown, the naming system has changed as well. Now you’ll often hear about a “mood spectrum”, that includes Bipolar 2 but also more subtle forms of bipolarity.

Psychiatry has a diagnostic “rule book” that lists the symptoms people must have in order to meet the definition of a particular “disorder”, called the Diagnostic and Statistical Manual. The most recent edition came out in 2013, the “DSM-5”. If much of what you read on this site seems to describe you well, but someone tells you “you don’t have bipolar disorder”, it could be that they are using a strict interpretation of the DSM rules.

This website describes a different way of looking at depression, a mood spectrum approach. This approach has been endorsed by (among many others):

the chairman of the DSM-5;

the head of the National Institutes of Mental Health bipolar group;

the head of the NIMH’s largest bipolar research project; and

the head of the International Society for Bipolar Disorders’ task force on Diagnosis. (If you look closely you’ll see that I was on that task force, lead author of the “Bipolar Spectrum” subgroup’s paper.)

If you’re still skeptical (fine!), read on. If you like you’ll find a publication about the spectrum idea in full medical jargon here.

What is a Bipolar 2 diagnosis?

Depression for sure. Depression far more than anything else. And then there’s this other little part. The technical name is misleading, and causes all sorts of trouble, so careful, don’t get thrown off by it. We’re talking about a very small amount (sometimes larger) of manic-side symptoms:

Mood better than normal

Rapid speech

Dramatically reduced sleep

Racing thoughts, trouble concentrating

Continuous high energy

Overconfidence

People with Bipolar 2 diagnosis don’t have mania. They don’t have “psychosis” (loss of contact with reality). They don’t have extreme behaviors that people think are “crazy”. They do have phases that their family and friends recognize as “not your usual self”: something unusual along the lines of the bullets above. Notice that “delusions” are gone from the earlier list.

Another variation less severe than Bipolar 2 is the combination of hypomanic phases with separate phases of mild depression. This is called “cyclothymia”. Getting confused? I certainly was, until I began to think of these variations as points on a continuous spectrum. I hope the following discussion will impress you as simpler.

What is the “mood spectrum?”

Until very recently, depression and “manic-depressive illness” were understood as completely independent: a patient either had one or the other. Now the two are seen by most mood specialists as two extremes on a continuum, with variations found at all points in between, even though only some points have names.

On the left, the “unipolar” extreme represents straightforward depression with no complications. There are many forms of depression, of course. The depressions discussed further below are of a more genetic, or “chemical” nature; versus those of a more situational type, like losing a loved one. Situational depressions may respond well to time or therapy and not require “bipolar” thinking.

On the right, the “manic-depressive” extreme is defined by the presence of manic episodes, just the kind that most people have seen or heard of: full delusional mania. But in between these extremes is a large area which some mood experts think might be the most common form of bipolar disorder: the green zone below.

Got all that? It gets trickier yet. Consider the points A and B on this spectrum:

Point A on the continuum describes people who have a complex depression but who still respond well to antidepressant medication or psychotherapy. Around point B, however, there is some sort of threshold where these approaches are no longer completely or continuously effective: either they don’t work at all, offer only partial relief, or help for a while then “stop working” (which may account for some or much of “Prozac poop-out”, now regarded as a non-manic marker of bipolar disorder, described below).

In the DSM, the entire span between blue and green is still “Major Depression”, the same as the violet end to your left. Only the orange and red zones are clearly “bipolar”.

Light green and yellow is BP-NEC, Not Elsewhere Classified. That diagnosis means you have something that looks like bipolar disorder but does not meet the criteria for Bipolar 2 diagnosis, or BP I. Isn’t it simpler just to think of it as a continuum? That is much closer to reality: as a psychiatrist, I’ve seen all sorts of variations in between these named points on the graph above (more like snowflakes, never any two the same).

What do “bipolar variations” look like?

This is controversial territory. Ironically, your diagnosis could be determined more by the professional whom you see than the symptoms you have. Really. Read that again. This happens all the time. If your therapist or nurse practitioner or doctor uses a DSM framework, and you don’t meet criteria for bipolar disorder, then you just don’t have bipolar disorder at all. Period.

On the other hand, if your therapist/NP/etc uses a mood spectrum approach, then you could get a Bipolar 2 diagnosis that someone else might think was “overdiagnosis”. Starts to sound kind of ridiculous, doesn’t it? But a lot of energy becomes focused here. “Bipolar” carries more stigma than “depression”. Many believe that antidepressants are less risky than mood stabilizers (that’s not so clear either, in my view). So the “yes-or-no” view is still very powerful. You could easily be told “you don’t have bipolar disorder” when someone else has said you do. The solution is to learn more. Read on.

Roller coaster depression

Many people have forms of depression in which their symptoms vary a lot with time: “crash” into depression, then up into doing fine for a while, then “crash” again — sometimes for a reason, but often for no clear reason at all. They feel like they are on some sort of mood “roller coaster”. They wonder if they have “manic-depression”. But, most people know someone or have heard of someone who had a “manic” episode: decreased need for sleep, high energy, risky behaviors, or even grandiose delusions (“I can make millions with my ideas”; “I have a mission in space”; “I’m a special representative for God”). So they think “well, I can’t have that — I’ve never had a manic episode”.

However, a spectrum view of mood disorders invites you to reconsider. Hypomania doesn’t look or feel at all like full delusional mania in some patients. Sometimes there is just a clear sense of something cyclic going on. For a striking version of this, read a patient’s account.

Some mood disorder experts consider depression that occurs repeatedly to have a high likelihood of having a manic phase at some pointFawcett, especially if the first depression occurred before age twenty. Geller, Rao These two features–repeated recurrence, and early onset–are also included among the non-manic markers below: not enough to make a diagnosis, but suggestive, especially if they occur with several other such signs (even if “hypomania” is not detectable at all).

Depression with profound anxiety

Many people live with anxiety so severe, their depression is not the main problem. They seem to handle the periods of low energy, as miserable as they are. Often they sleep for 10, 12, even 14 hours a day during those times. But the part they can’t handle is the anxiety: it isn’t “good energy”. Many say they feel as though they just have too much energy pent up inside their bodies. They can’t sit still. They pace. And worst of all, their minds “race” with thoughts that go over and over the same thing to no purpose. Or they fly from one idea to the next so fast their thoughts become “unglued”, and they can’t think their way from A to C let alone A to Z.

When this is severe, people who enjoy books can find themselves completely unable to read: they just go over and over the same paragraph and it doesn’t “sink in”. They will get some negative idea in their head and go around and around with it until it completely dominates their experience of the world. Usually these “high negative energy” phases come along with severely disturbed sleep (see Depression with Severe Insomnia, below). Thoughts about suicide are extremely common and the risk may be high.

Depressive episodes with irritable episodes

Many people with depression go through phases in which even they can recognize that their anger is completely out of proportion to the circumstance that started it. They “blow up” over something trivial. Those close to them are very well aware of the problem, of course. Many women can experience this as part of “PMS“. As their mood problems become more severe, they find themselves having this kind of irritability during more and more of their cycle. Similarly, when they get better with treatment, often the premenstrual symptoms are the “last to go”. Others can have this kind of cyclic irritability without any relationship to hormonal cycles. Many men with bipolar variations say they have problems with anger or rage.

Depression that doesn’t respond to antidepressants (or gets worse, or “poops out”)

Many people have repeated episodes of depression. Sometimes the first several episodes respond fairly well to antidepressant medication, but after a while the medications seem to “stop working”. For others, no antidepressant ever seems to work. And others find that some antidepressants seem to make them feel terrible: not just mild side effects, but severe reactions, especially severe agitation. These people feel like they’re “going crazy”. Usually at this time they also have very poor sleep. Many people have the odd experience of feeling the depression actually improve with antidepressants, yet overall —perhaps even months later —they somehow feel worse overall. In most cases this “worse” is due to agitation, irritability, and insomnia.

In some cases, an antidepressant works extremely well at first, then “poops out”.Byrne The benefits usually last several weeks, often months, and occasionally even years before this occurs. When this occurs repeatedly with different antidepressants, that may mark a “bipolar” disorder even when little else suggests the diagnosis.Sharma

Depression with periods of severe insomnia

Finally, there are people with depression whose most noticeable symptom is severe insomnia. These people can go for days with 2-3 hours of sleep per night. Usually they fall asleep without much delay, but wake up 2-4 hours later and the rest of the night, if they get any more sleep at all, is broken into 15-60 minute segments of very restless, almost “waking” sleep. Dreams can be vivid, almost real. They finally get up feeling completely unrested. Note that this is not “decreased need for sleep” (the Bipolar I pattern). These people want desperately to sleep better and are very frustrated.

Non-manic markers of bipolarity?

You have probably figured it out by now: making a diagnosis of bipolar disorder can be pretty tricky sometimes! You’re about to read a list of eleven more factors that have been associated with

bipolar disorder. None of these factors “clinches” the diagnosis. They are suggestive of bipolarity, but not sufficient to establish it. They are best regarded as markers which suggest considering bipolar disorder as a possible explanation for symptoms. They are not a scoring system, where you might think “the more I have of these, the more likely it is that I have bipolar disorder.” That way of thinking about these factors has not been tested.

Here’s the list of items which are found with bipolar disorder more often than you would expect by chance alone. These factors are well accepted. (e.g. see International Society for Bipolar Disorders reviews: Mitchell et al; Phelps et al). The particular list below is adapted from a landmark article by Dr. Ghaemi and Goodwin and Ko. (Drs. Goodwin and Ghaemi are among the most respected authorities on bipolar diagnosis in the world.)

The patient has had repeated episodes of major depression (four or more; seasonal shifts in mood are also common). The first episode of major depression occurred before age 25 (some experts say before age 20, a few before age 18; most likely, the younger you were at the first episode, the more it is that bipolar disorder, not “unipolar”, was the basis for that episode). A first-degree relative (mother/father, brother/sister, daughter/son) has a diagnosis of bipolar disorder. When not depressed, mood and energy are a bit higher than average, all the time (“hyperthymic personality”). When depressed, symptoms are “atypical”: extremely low energy and activity; excessive sleep (e.g. more than 10 hours a day); mood is highly reactive to the actions and reactions of others; and (the weakest such sign) appetite is more likely to be increased than decreased. Some experts think that carbohydrate craving and night eating are variants of this appetite effect. Episodes of major depression are brief, e.g. less than 3 months. The patient has had psychosis (loss of contact with reality) during an episode of depression. The patient has had severe depression after giving birth to a child (“postpartum depression“). The patient has had hypomania or mania while taking an antidepressant (remember, severe

irritability, difficulty sleeping, and agitation may — but do not always — qualify for “hypomania”). The patient has had loss of response to an antidepressant (sometimes called “Prozac Poop-out”): it worked well for a while then the depression symptoms came back, usually within a few months. Three or more antidepressants have been tried, and none worked.

Bipolarity with no hypomania at all?

There is a very radical idea buried in the above 11 items, which we should look at before going on. But be aware that this idea is likely be dismissed with a “hmmmph” by many practicing psychiatrists. The idea is this: Dr. Ghaemi and colleagues propose that there might be a version of “bipolar disorder” that does not have any mania at all, not even hypomania. They call it “bipolar spectrum disorder”.

This is strange, you are saying to yourself. “Don’t you have to have some hypomania in order to be bipolar? How could it be ‘bi’ – polar if there is no other pole!?”

But Dr. Ghaemi and colleagues assert that there are versions of depression that end up acting more like bipolar disorder, even though there is no hypomania at all that we can detect (or, as in item #9, only when an antidepressant has been used). These conditions often do not respond well, in the long run, to antidepressant medications (which “poop out” or actually start making things worse). They respond better to the medications we routinely rely on in bipolar disorder, the “mood stabilizers” you’ll be introduced to in the Treatment section of this website (including several non-medication approaches). And these patients have other folks in their family with bipolar disorder or something that looks rather more like that (e.g. dramatic “mood swings”, even if the person never really gets ill enough to need treatment).

In Dr. Ghaemi’s description, then, there are people whose depression looks so “unipolar” that even a “fine-toothed comb” approach to looking for hypomania will not identify their depression as part of the “bipolar spectrum”. According to Ghaemi and colleagues, these people should be regarded as “bipolar”, in a sense, because of the way they will end up responding to treatment. In other words, there is something in these people which doesn’t look like our old idea of bipolar disorder, or even our newer idea of bipolar disorder (bipolar 2, etc.), but will still better describe their future and the medications that are most likely to help them.

Remember that this is the very purpose of “diagnosis”, to describe the likely outcomes with and without treatment, and to identify effective treatments. So, on that basis, it seems reasonable to include these patients on the “bipolar spectrum”, like this:

The idea that someone can “have” bipolar disorder and yet not have any hypomania at all is not widely understood. You probably would get blank looks from most psychiatrists if you mention it, and frank disbelief from nearly all primary care doctors, who don’t have time to read the literature on the diagnosis of bipolar disorder. So, if you mention this idea to anyone, be prepared for some serious resistance. Read more of this site, it may help you be ready.

Anxious depression could be “bipolar”?



An international group of expertsISBD described anxiety in bipolar thus:

General hyperarousal

Inner tension

Irritability /impatience

Agitation

“Frantically anxious”

These symptoms are not generally regarded as symptoms of bipolar disorder. Unfortunately, the very name “bi-polar” is misleading. As noted above by Dr. Jamison, mania can be negative as often as it is positive. The “racing thoughts” can have a very negative focus, especially self-criticism. The high energy can be experienced as a severe agitation, to the point where people feel they must pace the floor for hours at a time. Sleep problems can show up as insomnia: an inability to sleep, a desperate wish to be able to sleep to get out of the agitated state.

One way to understand these symptoms is called “mixed states”. Bipolar disorder is an unfortunate name, as it implies a North/South Pole experience. A better picture looks like this graph:

Both manic symptoms and depressive symptoms at the same time? Sure enough. Not intuitive, if you think North/South pole. But these symptoms can vary independently or occur together.

This is not controversial. Mixed states were officially recognized in the 1994 version of the DSM, and expanded to look more like the graph above in the 2013 version.

What’s the difference between “anxious depression” and a bipolar mixed state? Not enough to easily be able to tell them apart, unfortunately. The same group of experts quoted above also said: “some but not all agitated depressed states are bipolar.”ISBD

Worst of all, mixed states can be caused by antidepressants.ISBD Yet antidepressants are what depressed patients commonly receive, of course, right? But some of those depressed folks have bipolar depression. The antidepressants can take them from pure depression to agitated depression. The good news is that slowly coming off the antidepressant is one way to address anxiety.Phelps Don’t do that on your own, of course. Here are some guidelines on stopping antidepressants in bipolar disorder.

Bottom line here: bipolar disorder is complicated, much more complex than “bipolar” (North/South) implies. Anxious depression can be bipolar. Tense, irritable agitation can be bipolar disorder. For more, see the Mixed States page.

What does hypomania feel like?

It’s true that hypomania is a milder version of mania — just how mild, you’ll see in a moment. Mind you, a Bipolar 2 diagnosis is not a milder version of Bipolar I, though it is very often described that way, to my utter dismay. The suicide rate in Bipolar 2 is the same or higher than the rate for Bipolar I, for example.Dunner So the Bipolar 2 diagnosis is definitely not a “mild” illness. The depression phases are as bad as in BP I, and often more common (that is, they occur more frequently and represent a more dominant part of the person’s life).

Nevertheless, hypomania can indeed by subtle, certainly by comparison with full mania, as shown in this graph (from Smith and Ghaemi). Here are the symptoms which people with clear-cut hypomania actually experience — and how often. For example, at the bottom of the graph you see that nearly 100% of people with hypomania will have an increase in their activity. By comparison, optimism is prominent only about 70% of the time in hypomania.

As you can see, these “symptoms” are not clearly abnormal. Everyone experiences these feelings from time to time. When they are extreme; and when they show up over and over again in cycles of mood/energy change; when they are accompanied by other signs of bipolarity, such as phases of depression; that’s when we should think of this as “abnormal”, or at least as warranting caution if someone wants to treat those depressed phases with an antidepressant.

However, hypomania is not always positive. Just as manic phases can be very negative (so-called “dysphoric mania”), hypomania also can be very unpleasant. Here is an example of how hypomania can change from a positive experience to a very negative one (from a blogger who wrote eloquently about bipolarity).

First, the positive phase:

Increased energy. A extraordinary feeling of happiness with myself and the world. A very loving feeling towards the people I care about. An uncommon ability to get things done. A huge burst of energy from the moment I awaken until I go to bed. An expanded ability to multi-task. An organizational acuity that is second to none. A willingness to engage with people. A desire to spend more time with people I care about–and even those I don’t.

Then, the negative phase of hypomania (still pretty subtle):

I start feeling burned out. While I still have a lot of energy, I don’t have that “I love the world” feeling. If I’ve been playing my Autoharp at my mother’s assisted living facility, and jumping up and down to help all the participants turn the pages and stay with me, I suddenly feel that the staff should be more helpful in doing this. … things don’t just slide off my back. While I try not to “snap” back at people, I am not always successful. I am certainly less willing to ignore things that days or weeks earlier wouldn’t have bothered me at all. I become far less happy, joyful, and kind. I dislike being criticized in any which way.

How short or long can an episode be?

For hypomania, officially the answer is “4 days” (DSM). But in real life, it’s very clear that episodes can be shorter, and that’s agreed upon by nearly all mood experts. They might disagree whether we should shorten the required duration in the DSM, as that would “admit” a lot more people into the bipolar camp which is already a controversial issue. But no one really seems to think that a hypomanic episode lasting only 3 days instead of four is anything other than hypomania; it just doesn’t “meet criteria”, that’s all.

Indeed, a recent studyBauer showed that episodes lasting as little as one day are common. So don’t get hung up on length of episodes as an issue if you’re trying to figure out if you “have bipolar disorder” or not. Remember, that’s the wrong question anyway… Instead, ask “how bipolar are you?” as affirmed in a recent editorial Smith in the British Journal of Psychiatry (one of the biggies…).

What does bipolar depression actually feel like?

Theoretically, bipolar depression is exactly the same as “unipolar” or straight Major Depression. Theoretically, you can’t distinguish between the two, so you can’t tell if someone has bipolar disorder just by looking at their depressions.

But I think there is a different quality to the depressions that people with bipolar disorder experience, because before they start feeling sad and having difficulty experiencing pleasure from their usual activities, they very often have problems with energy. To emphasize this I’d just like you to look at this list of symptoms which people with bipolar disorder said they have when they’re just starting to get depressed.

If you think “that’s me!”, careful: this does not mean you have bipolar depressions. But it might help to see what people with bipolar disorder have said about their experience. I don’t hear about these symptoms so much when people have a more purely “unipolar” — not bipolar — depression.

(from Lobban and colleagues, 2011)

Granted, people in this study also endorsed “loss of interest in activities” and “feeling sad, wanting to cry” but those are typical symptoms in official “Major Depression”. And low energy can also be seen in Major Depression. But look at how prominent low energy is in this study. I think this might be telling us something about the nature of bipolar depression. Certainly matches what I hear from patients.

Finally, the original intent of this list was to help people identify symptoms that mark the beginning of another episode of depression. You might find it useful in that respect also.

Overdiagnosis?

I hope it may now make sense to you to think of mood symptoms as falling on a continuum between plain depression and “depression plus”, the far end of which is Bipolar I, with many variations falling in between.

If you are wondering whether what you’ve just read is “mainstream” or “fringe” (that’s a good thing to wonder), you’ll find the same “spectrum” concept coming from the head of the Harvard Bipolar Clinic, in this 2005 interview.

By contrast, sticking to the DSM rules, you’ll hear that bipolar disorder is overdiagnosed (the most widely cited paper also shows a notable underdiagnosis rate as well, by the way. Here is a close examination of their findings. ) They’re right: bipolar disorder is overdiagnosed, if one sticks to the DSM rules. But psychiatry is moving beyond that rigid approach; here are more examples of that movement.

At least one thing is clear: when there’s a question, you’ll be better off if you understand more about “bipolarity”, as you have done here. You are an important part of the diagnostic process.

Is there a test fo r bipolar 2 diagnosis?

Not exactly, but…

This used to be simple. When “manic” only meant one thing (classic mania) one could ask “have you ever had a manic episode?” and many people knew what was being asked:

Mood much better than normal

Rapid speech

Little need for sleep

Racing thoughts, trouble concentrating

Continuous high energy

Overconfidence

Loss of contact with reality (delusions)

As you now know, this list looks for obvious mania. It misses all the complexity we have just discussed. What you might be wanting is a “no way!” bipolar test. Something to provide a clear

statement, like: “no, you don’t have it, or anything like it”. Or you might be looking for the opposite: “you definitely have bipolar 2”. Sorry, that is not possible, but please read on.

On other websites you’ll find a test called the Mood Disorders Questionnaire (MDQ) which is supposed to give you a “yes or no” answer. But another test came along after the MDQ which is better suited to looking for subtle versions of bipolar 2 .Ghaemi

Think about it: if by this point on this website you’re saying to yourself “that’s me!”, which some people do, then you really don’t need some test to tell you that you should go ahead and learn more about treatment. On the other hand, if someone else thinks you might have it, but you don’t think you do, is a test result going to make a difference to you? If so, go ahead and take one of these tests.

Family or friends could “take the test”, answering as if they were you, on the basis of what they’ve seen you do or heard you say. And then they could gently wonder out loud if perhaps the test might mean something, who knows, no one can tell for sure, but darn it sure seems like your life is a struggle sometimes, wow, what if there was a tool out there that would make life a bit smoother sometimes, not even necessarily a medication treatment, oh well, just thinking about this, of course you’d want to decide for yourself, not for me to say of course, etc. etc.

The people who are in a position to benefit from taking one of these diagnostic tests are those who are wondering if a “bipolar” variation might be worth considering to explain their symptoms. Here’s the test I’d recommend for you, called the Bipolar Spectrum Diagnostic Scale. It won’t give you a yes-or-no answer. I hope by this point you understand why that’s a good thing. If after all that you still want to use a “fine-toothed comb” to look for hypomanic/manic symptoms, as I sometimes do when people are still wondering about the diagnosis after learning all this, here is a 32-item checklist of such symptoms.

Thank you for patiently reading all the way to this point. It’s a lot to swallow at once, isn’t it? From here you can review, or read more about diagnosis questions on the Diagnosis FAQ page, or go on to Bipolar 2 Treatment.