Bipolar 1 vs. Bipolar 2: Recognizing the Differences
Please do not use the following article for self-diagnosis or the diagnosis of others. We cannot diagnose ourselves. It is intended instead for information and to provide useful subject matter to discuss with a psychiatrist or therapist.
One of the most common questions I face in my bipolar Meetup group is the difference between bipolar 1 disorder and bipolar 2 disorder. I have written up list of all bipolar symptoms, but I thought I’d write a post that deals with the specific symptoms that differentiate bipolar 1 and bipolar 2, so that there can be a handy resource available for understanding the specific differences.
I won’t mention here all of the symptoms of bipolar disorder. This article only discusses the differences between bipolar 1 and bipolar 2. There are a number of shared criteria that must be met before these differences can come into play, and I discuss those in the list linked to above.
One Manic EpisodeAccording to current diagnostic criteria, what differentiates bipolar 1 and bipolar 2 is whether or not someone has had a single manic episode. In some ways, this is a strange distinction, as some people may have had one manic episode during their entire life, while some may have a few per year. Nonetheless, the reason for the distinction is that even a single manic or mixed episode shows that there is likely a different cause, and therefore, different medications and treatment options are ideal.
The question, then, is what differentiates a manic episode from a hypomanic episode. However, one exception must be mentioned before I begin. If a manic episode is brought on by medication, that episode does not count towards a diagnosis of bipolar 1 disorder. In other words, even if someone has had several manic episodes, if all of those episodes were brought on by medication (usually by antidepressants), then that person is not considered to have bipolar 1.
Someone who has had a mixed episode is also considered to have bipolar disorder I. However, since someone is only considered to have a mixed episode if that person also meets all of the criteria of a manic episode, it doesn’t add anything to the diagnosis.
DurationOne difference between manic episodes and hypomanic episodes is their duration. A manic episode must last one week, while a hypomanic episode must last at least four days. Of course, a hypomanic episode may last a week or longer, but if an episode doesn’t last a full week, then it cannot qualify as a manic episode.
There is one exception to this, however. I someone is hospitalized, then the duration doesn’t matter, and can be considered manic, regardless of how long it lasts. This is an especially odd criterion, since it would seem that someone who has an episode that lasts one day is having the exact same episode, regardless of whether or not someone notices and takes that person to the hospital (imagine, for instance, someone who lives alone). Nonetheless, if someone is hospitalized, then the duration criterion is waived.
The Three Special Criteria
Let’s look at one of the primary ways manic episodes are differentiated from hypomanic episodes:
The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
This is really quite interesting. One of the most common misunderstandings of the difference between a manic episode and a hypomanic episode is that a manic episode necessarily includes psychotic symptoms. You’ll notice above that the criterion mentioned above only includes psychotic symptoms as a possible criterion. In fact, if any of the three criteria above are met, it is considered to be a manic episode:
This is, unfortunately, a rather vague criterion. The DSM-IV is actually full of these vague criteria, and hopefully the DSM-V will sort out some of this ambiguity. The reference to “marked” doesn’t mean that just any impairment is enough. It must interfere in a significant way, and the degree that will qualify as “marked” may vary from psychiatrist to psychiatrist. Some psychiatrists will be agnostic about whether a given episode meets this criterion, which may mean they end up being agnostic about the type of bipolar disorder someone has.
A hypomanic episode must have “unequivocal” impairment, which is again somewhat ambiguous. The distinction here is between certainty and degree. “Unequivocal” means that there is no doubt as to the impairment, but “marked” means that the impairment is severe.
Necessitating Hospitalization to Avoid HarmAnother common misunderstanding of the distinction between bipolar 1 and bipolar 2 is that any hospitalization implies a manic episode. This is not correct. However, if that hospitalization is done to prevent harm to prevent harm to the patient or other people, then that is considered sufficient to consider it a manic episode (and remember that duration doesn’t matter is someone is hospitalized).
This implies that if someone is hospitalized to prevent self-harm (that is, the person is suicidal or self-destructive enough that the person ends up in the hospital), that person has had a manic episode, regardless of whether or not that person had psychotic symptoms.
Psychosis is tricky, because there are actually several different types of psychosis. Moreover, the criterion calls for “psychotic features” rather than full-blown psychosis. There are several of these that are common. Remember that any of these are enough for a diagnosis of a manic episode:
- Catatonia: The person stops acting in a marked way.
- Delusions: Delusions are firmly held beliefs that have no evidence and are not commonly held in one’s culture. So, the belief can’t be shaken through counter-evidence, and will not be normally held by that person. The reason for the “culture” reference is that it is assumed that common beliefs that do not have evidence (like superstitions) are caused by the culture rather than a problem in the brain.
- Delusions of Reference: A delusion of reference means that people give special significance to objects. So, for instance, that person may believe that, as Carrie Fisher put it, God is saving them parking spaces. Objects are considered to be put there just for them.
- Paranoia: Paranoia is a specific type of delusion in which we believe that certain people are out to get us, for example. It is a firmly held belief that one is in danger from some person or event.
- Hallucinations: Hallucinations include seeing and hearing things that aren’t really there. Note that hallucinations are different from illusions. An illusion is seeing something that is there in a way that it really is not. So, for instance, synesthesia, which is when our senses get mixed up and we see sounds, for instance, would not be considered a hallucination.
Some of the above differences are open to interpretation. For instance, what makes a belief “firmly held” as opposed to just a passing fantasy? The idea is that the belief isn’t open to evidence and isn’t held as a “perhaps” type of belief. Nonetheless, these criteria, too, are open to interpretation.
One thing you’ll notice is that several of the above symptoms are open to interpretation. While some symptoms are obvious and definitely indicate mania, such as hallucinations or hospitalization to prevent harm, others leave a lot of interpretation in the hands of psychiatrists. This interpretation is especially present in what constitutes “marked” impairment as opposed to “unequivocal” impairment, and in what constitutes a delusion. This is why some people will have their diagnosis changed when they get a new psychiatrist. The new psychiatrist may interpret episodes differently.
Nonetheless, the difference between bipolar 1 and bipolar 2 is a real one, but a distinction on a spectrum. Some people find themselves in the middle of this spectrum with occasionally shifting diagnoses. It is a distinction with a difference, but also a continuum rather than a firm line.