When I was (re)diagnosed as bipolar last May, initially, that was quite big enough for me to digest. But as the months went by, and I talked to more and more bipolar people online, one further question kept recurring: was I a bipolar I or a bipolar II? Many people I met strongly identified as one or the other, and some asked me outright which category I fell into. I couldn’t answer, because it was something my psychiatrist had never addressed. I looked up some first person accounts and some clinical definitions online, but found myself not much the wiser. Some of the descriptions of bipolar II sounded much less severe that the symptoms I’d had for decades; sufferers wrote about hypomanias characterised by “productivity” or “useful energy” which bore little resemblance my own sleepless, euphoric, reckless, or panciky highs. Many people with bipolar I, however, talked of psychosis and frequent hospitalisations which were also outside my experience.
Maybe, I began to think, I didn’t fit into either category? Maybe I was a kind of bipolar v1.5?
The American DSM-IV psychiatric diagnostic manual states that if you have ever had a manic or mixed episode (and perhaps, but not necessarily, a depressive episode), you have bipolar I; whereas if you have depression and your highs involve hypomania rather than true mania, you have bipolar II. Its European equivalent, the ICD-10, states that bipolar is diagnosed when a person displays at least two episodes of significantly disturbed mood/activity, sometimes showing elevation (mania or hypomania) and at others showing decreased mood and activity (depression). It does not distinguish between bipolar I and bipolar II at all. The Royal College of Psychiatrists’ booklet on bipolar defines bipolar I as involving at least one “high or manic episode” lasting longer than a week, and if untreated around 3-6 months, and depressive episodes lasting 6-12 months without treatment (although it agrees that some people with bipolar I will not have depressions at all). The RCP states that the key factor in diagnosis of bipolar II is that the patient will experience hypomania and not “true” mania.
So if hypomania versus mania is the boundary between bipolar I and bipolar II, where is the boundary between hypomania and true mania? A much-referenced article by Guy Goodman, “Hypomania: what’s in a name?” appeared in the British Journal of Psychiatry in 2002 and explores this very issue. Goodman suggests that in the UK, bipolars more often get diagnosed with hypomania than mania, almost out of politeness; mania, after all, can have a pejorative ring to it (historical use of terms such as “maniac” certainly don’t make the diagnosis particularly palatable). He notes that in the DSM-IV, the term mania covers all elevated mood with functional impairment but specifies that mania can then be subdivided into mild, moderate or severe. So the kind of elevated mood that gets you admitted to hospital, or involves hallucinations or delusions, is definitely mania, and probably severe. But by this definition, other elevated moods which impair your functioning – your ability to go to work or hold down a job, fulfil your social or family obligations, care for yourself and keep yourself safe – are also manic, though possibly moderate or mild forms of mania. A burst of reduced sleep, however, with improved mood and increased productivity/creativity which allows you to get more, rather than less, done at home or at work, would definitely constitute hypomania. “The upper boundary,” suggests Goodman, “between hypomania and mania hinges on a definition of functional.” The ICD-10 also states that hypomania involves persistent mild elevation of mood and feelings of increased energy and mental efficiency; increased sociability and libido, and a decreased need for sleep, “but not to the extent that they lead to severe disruption of work or result in social rejection.”
Eventually I plucked up the courage to ask my psychiatrist about the issue. His view was that the distinction was really not very important in a clinical sense. After all, supposing he saw me as bipolar I? Well, he would probably start me on an antipsychotic or lithium, and consider referring me for talking therapies. And if I were diagnosed with bipolar II? Then he would probably start me on an antipsychotic or lithium, and consider referring me for talking therapies. He had a point. Yet the issue continued to come up, because I mixed with so many other bipolar people online. My perception of the bipolar community is that there is a hierarchy according to where on the “bipolar spectrum” (from cyclothymia, through bipolar II, to bipolar I) you sit. It shouldn’t be that way, but that’s how it feels.
The question arose again a couple of weeks ago when I headed to the University of Oxford’s Department of Psychiatry to participate in a large cohort study on bipolar disorder. This involved me giving blood and saliva samples and completing some computer tests, but first of all I was interviewed by a researcher and a psychiatrist about my experiences of living with bipolar. I had been asked to bring along a letter from my own consultant confirming my diagnosis, but still had to answer a number of questions to ensure I met the study’s criteria for inclusion. I was asked about the onset of my illness, when I was first diagnosed, whether I used any illegal substances, and whether I worked (I explained that I was in the process of losing my job due to my poor mental health). The next set of questions were along the lines of, “can you tell me about a time when…?”, starting with being asked to describe a time when my mood was very low. I tried to explain how my last serious depression, which occurred this time last year, had affected me. I told the researchers that once I began my period of sick leave I had struggled to get out of bed and that when I did so, I rarely managed to move from the sofa, staring out of the window all day clad in pyjamas and dressing gown. I described how I began to sleep more and more, until I was in bed for at least 12 hours a night and napping for 1-2 hours a day. How if I did go out, I was terrified of having to interact with people, so I stopped going into shops because “please” and “thank you” were too scary. I outlined the horrible intrusive visions of bizarre and violent means of self-harm I saw, and how they fed into my frequent thoughts of death and suicide.
Next, I was asked to describe a time when I had been high and not slept much. I decided to tell them about one of the most painful times in my life, an episode from around 10 years ago. Following a period of depression and hypersomnia, something had switched inside me so that I was not sleeping very much at all. I didn’t even bother to go to bed, but lay on the sofa while my husband and preschool children slept upstairs, tossing and turning and growing more and more irritable about my inability to sleep. During the day, I was completely preoccupied with being on the internet and, in particular, with being in chat rooms. I had friends in the chat rooms, but was also continually flirting and developing online relationships with strangers. This was all I wanted to do; I left my husband to get the children dressed and out to nursery and before they had even left, I was on the computer. I would often chat for 12 hours at a stretch, barely moving to visit the bathroom. Whatever I ate or drank, I ate in front of the computer, and there wasn’t much of it; one time when I did go out with friends (just to the supermarket), I almost fainted due to lack of sleep and food. Sometimes I gave the strangers from the chat rooms my phone number, and continued the flirtation over the phone. I even started calling men in other countries, without thought of the phone bill; all I cared about was feeling attractive and sought after, and when my husband challenged me, I grew angry and defensive. This went on for several weeks, over which I grew more and more agitated and slept less and less. Eventually something snapped, and I took an overdose, landing me with several days’ inpatient treatment to try to reverse any damage to my abused liver.
As I was telling the team about these particular episodes, it was if I were listening to a stranger talk about their lives. Part of me was thinking as I talked: wow, Charlotte, that stuff sounds crazy. Really crazy. You have been through some crazy stuff. The research psychiatrist looked at me. “I see you’ve brought this letter from your consultant, thank you; and that it confirms you have a diagnosis of bipolar disorder. Did your consultant ever give you a more precise diagnosis?” Ah. I explained my consultant’s feeling on the bipolar I/bipolar II issue. “Hmm,” said the research psychiatrist, “the definition of someone with bipolar I is anyone experiencing marked impairment in social or occupational functioning. And-“ he looked down at my notes “-yes, well there you are.”