Last "Up" - Can Bipolar Include Ups That Seem Normal?

John McManamy Health Guide
  • How high is up? What separates bipolar disorder from clinical depression is how high we determine “up” should be. The official debut of bipolar disorder in the DSM-III of 1980 set the excessively restrictive standard of mania, which typically involves 911 intervention and a long course in medications treatment.

    The DSM-IV of 1994 came up with the more realistic threshold of hypomania and the new diagnosis of bipolar II. This is the type of "up" behavior that is certain to raise eyebrows, but no one is about to dial 911, and for many people medications treatment - at least for the up phase of the illness - may not be necessary.

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    In 1999, Hagop Akiskal of UCSD proposed a “bipolar IV” subtype involving “depression associated with hyperthymic temperament” and “bipolar V” characterized by “recurrent depressions that are admixed with dysphoric hypomania.”

    Okay, some quick explanations: “Hyperthymic” refers to one’s natural temperament. Some individuals are naturally upbeat. “Hypomania,” by contrast is an unnatural state, “uncharacteristic” is the DSM term. Two individuals could be behaving exactly the same way, but one is in his natural element while the other is whooping it up on borrowed time.

    Likewise, both may be cycling in and out of depression, but one is cycling from depression to hypomania while the other is cycling from depression to - in effect - “normal.” Can it be? Can “up” be normal? Can normal be considered a phase of bipolar?

    Dr Akiskal’s proposed “bipolar V” asks us to take into account that “up” isn’t all that it’s cracked up to be. “Dysphoric hypomania” is a sort of energized depression. We’re cranky and agitated and miserable. Many never get to experience the blue sky of a euphoric hypomania. If this is “up,” you wouldn’t recognize it as such.

    Dr Akiskal’s spectrum approach to bipolar begs taking matters a step further. Suppose, for instance, your version of up doesn’t even rise to normal. Perhaps like a dysphoric hypomania, but with less oomph. In effect, you cycle up to “less depressed” than you were before, only to cycle back down to more depressed.

    Basically, then, in asking how high does “up” need to be, we are replying with, “simply higher than down.” But no one is truly suggesting that we reclassify practically all forms of depression as bipolar, are they?

    What’s in a name? In the early 1900s, the pioneering diagnostician Emil Kraepelin coined the term “manic-depression” that embraced most of what we now refer to as unipolar depression, and this remained the standard well into the last half of the twentieth century. The DSM-II of 1968, which was in service till 1980, included under its “manic-depressive” diagnosis a “depressive type” that consisted “exclusively of depressive episodes.”

    Why this is important is that bipolar needs to be conceptualized as a “cycling” illness, a notion which dates back to 1854 when Jean-Pierre Falret came up with the term, "la folie circulaire" (circular insanity). Everything is moving, nothing is standing still. Kraepelin was acutely aware of this. So is Dr Akiskal.

  • Obviously, a person who remains stuck forever in depression is in a very different condition than someone who regularly bounces off walls and ceilings. But it is useful to entertain the idea that the same underlying cycling dynamic may be driving both.This may explain why antidepressants do not work - and may even be harmful - to a good many in the so-called unipolar population.

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    There are no easy answers here. I am presenting an expanded version of “up” simply as food for thought. Obviously, if up looks a lot like normal, it does not have to be treated. But what about those depressions? If we see clear evidence of “up,” how should down be treated?

    Please feel free to join in the discussion. Comments below ...



    This is the eleventh article in my series on “Up” that investigates mania, hypomania, hyperthymia, and any state that can be regarded as higher than “down.” Previous pieces:


    First Up: Mania
    Does Anyone Truly Understand Up?
    Dysphoric Mania
    Mania and Hypomania’s Dark Side
    Mania, Hypomania, and the Dark Side of Bipolar
    Mixed Bipolar States, Dysphoric Mania and Hypomania
    Treating Mania

    Recognizing Hypomania

    Is There a Hypomanic Advantage?

Published On: June 26, 2011