Do I have bipolar I or II? What are the differences?
Okay, so what in the hell is the difference between bipolar I and II? As a therapist, I get this question all the time, and it's pretty damn confusing even for most therapists, myself included. So for this post, I went back through the DSM-V and looked through some of the literature to try to find a clear and concise way for clients and clinicians to understand the differences.
The DSM-V describes bipolar I as replacing what was known for many years as manic-depressive disorder. This phenomenon of individuals exhibiting extreme mood states has been observed throughout history. Though we can't say for sure, it's thought that historical figures including Sir Isaac Newton, VanGough, Hemmingway Hendrix, and potentially Winston Churchill had manic-depressive symptoms. Individuals with bipolar disorder tend to be vastly creative and often ingenious, though not all individuals can successfully manage their condition and achieve professional success.
So let's take a look at our modern understanding of bipolar disorder and how we diagnose it. Right off the bat, the DSM states that for bipolar I, you do not need to have a depressive episode though most will. However, for bipolar II, you have to experience at least one depressive episode. This was a bit of a shocker to me as I always thought there needed to be at least one depressive episode hence bipolar. Yet, the DMS has always maintained that the manic feature of the disorder is what makes it unique.
The most significant difference between the two is that bipolar I has manic episodes vs. bipolar II having hypomanic episodes. Both are elevated mood states with racing thoughts, irritability, impulsiveness, reckless behavior, excess energy, lack of sleep, and partaking in goal-directed behaviors. It's like drinking coffee on steroids that last days-weeks or even longer.
So what the hell is the difference between hypomanic and manic? When you pick apart the wording in the DSM, there are a couple of key differences. First, the DSM states a hypomanic episode lasts at least four days and a manic at least seven. Okay, not the most helpful. So, what else?
Here is where I differentiate the manic and hypomanic when diagnosing. Manic episodes cause enough impairment to have a significant impact on your ability to function in your day-to-day life. This includes work and personal responsibilities, to the point where you cannot fulfill them. Your functioning is clearly different from the norm with hypomanic, but you can still mainly function without severe consequences.
A manic episode is more severe than a hypomanic episode. If a client is having psychosis or requiring hospitalization, it is automatically manic and therefore labeled as Bipolar I. That's what most look for.
In reviewing the DSM, I found it interesting that they note Bipolar II as not necessarily a less severe disorder. The greater prevalence of depressive episodes can impair functioning just as badly. This makes sense, as depressive episodes can lead to a severe loss of functioning and even psychosis. Yes, there is depressive psychosis that is similar to that manic episodes. Sometimes the delusions are wrapped in guilt. Also, catatonia is often present, which is essentially a slowing of motor functioning and affect.
So there you have it, that is the best way I make sense of the differences. But, in the end, I think the best way to summarize the contrast is through the significant disruption of functioning, often present through psychosis or leading to hospitalization.
You likely have a better grasp than most mental health professionals if you read this, so congratulations!
-Evan the Counselor
