Manic, Hypomanic and Major Depressive Episodes: Bipolar I and II, the Prequel
This would be a continuation of the post that I did on bipolar disorder. It would be focusing on manic and hypomanic episodes. In order to be diagnosed with bipolar I disorder, according to the DSM-5, there has to be evidence of a manic episode and there has to be evidence of a past or future hypomanic or major depressive episodes. However to be diagnose with bipolar II disorder, there has to be evidence of both a current or past hypomanic and major depressive episodes. Judging by this requirement alone, you could see that bipolar disorder can manifest as a drastic emotional change from one extreme to the other. So next I’m going to give the diagnostic criteria for the manic, hypomanic and major depressive episodes. The post following this one will be the diagnostic criteria for bipolar I and II using this post as a reference point.
Manic Episode
There are four criterion that are needed to be met for a person to be classified as having a manic episode.
A. “A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary)”
For this criterion to be met there are some key parts to pay attention to
Abnormal and persistently elevated, expansive or irritable mood
Imagine someone who is overwhelmingly upbeat but it doesn’t seem “normal” for the situation that they are currently in or experiencing.
Abnormally and persistently increased goal-directed activity or energy
This would be a person that has their focus on a goal, but this is their main focus. For example, a person that may be experiencing a manic episode may be going to the gym daily but staying there for the entire day, every day of the week.
Lasting at least 1 week and present most of the day, nearly every day
An important part of this criterion is that there is a time frame for it. A person must be exhibiting this mood for at least a week and for a good portion of each day that week.
B. “During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is irritable) are present to a significant degree and represent a noticeable change from usual behavior”
For this criterion, for time period (at least a week) of the disturbance there has to be at least 3 or more of the below symptoms. If the person was exhibiting the irritable mood, then they would need to be exhibiting at least 4 symptoms. Now the important aspect of this is that the symptoms must present differently than their normal behavior. For example, a person may be goal oriented normally so this may not be a symptom that could be attributed to the episode.
“Inflated self-esteem or grandiosity”
This would be a person who thinks extremely highly of themselves and may even manifest as someone to be overly pretentious
“Decreased need for sleep (e.g. feels rested after only 3 hours of sleep)”
“More talkative than usual or pressure to keep talking”
“Flight of ideas or subjective experience that thoughts are racing”
This person may experience various thoughts and they may not be able to maintain focus on any single idea
“Distractibility (i.e. attention to easily drawn to unimportant or irrelevant external stimuli) as reported or observed”
The important aspect of this symptom is that the individual doesn’t have to state that they have been distracted but it can be observed by the clinician during the session.
“Increase in goal directed activity (either socially, at work or at school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity”
“Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)”
C. “The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features”
Like the previous disorders that I have discussed in this blog, the disturbance that the individual’s mood causes is significant enough that it impacts their personal or professional life. As stated it could be severe to the point that the person may need hospitalization to reduce the possibility of harm to themselves.
D. “The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition”
There was a note in the DSM-5 based on this last criterion. It stated that if a person exhibits a manic episode because of antidepressant treatment, there is a possibility that the manic episode criteria can be met if they symptoms persist after the treatment is completed
This basically means that the episode isn’t a side effect of any drug use or medications.
After each of these criteria are met, a person can be diagnosed with a manic episode. For Bipolar I disorder only this type of episode is needed for the diagnosis. Now in the next two sections I will run through the diagnostic criteria for a hypomanic and major depressive episode. These two episodes are needed for someone to be diagnosed with Bipolar II disorder.
Hypomanic Episode
There are 6 criterion that are needed to be met for a person to be classified as having a hypomanic episode.
A. “A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day”
So just like the first criterion of the manic episode, there must be an out of the ordinary period of increased mood however the time frame is a few days shorter.
B. “During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree”
This criterion is similar to criterion B of the manic episode.
“Inflated self-esteem or grandiosity”
“Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)”
“More talkative than usual or pressure to keep talking”
“Flight of ideas or subjective experience that thoughts are racing”
“Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed”
“Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation”
“Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)”
C. “The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.”
This criterion is stating that when the person is symptomatic it is an unequivocal or doubtless change in functioning that is not part of the individual’s normal life pattern. For example, the person may be a calm individual on a regular basis but when symptomatic it is the complete opposite and completely out of character.
D. “The disturbance in mood and the change in functioning are observable by others”
Just like the criterion states, other people notice the drastic change in mood.
E. “The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. “
This criterion, in my opinion, is what makes the difference between a manic and hypomanic episode. Even though it was stated in the last sentence of this criterion, it is also important to note that this change of mood isn’t too severe that it would cause a disturbance in their everyday life. In a manic episode, the mood change is severe enough to cause change in the individual’s life and even warrant a hospitalization. When diagnosing bipolar disorder, this is an important distinction to pay attention to.
F. “The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment)”
Once all the criteria is met, an individual can be diagnosed with experiencing a hypomanic episode. It was noted in the DSM-5 that even though it is possible for an individual with Bipolar I to experience these episodes, it is not required for the diagnosis. However, for Bipolar II, a current or past episode of hypomania and major depressive is needed for an accurate diagnosis.
The last episode that will be discussed will be major depressive episodes. As previously stated, this type of episode as well as an hypomanic episode is needed for a diagnosis of bipolar II.
Major Depressive Episode
There are 3 criterion that are needed to be met for a person to be classified as having a major depressive episode.
A. “Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure”
“Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful)”
This is one of the symptoms that if the individual doesn’t have a “loss of interest or pleasure” they must have this one so that they would be able to be diagnosed with this disorder. Another important aspect is that it has to be nearly every day for the 2-week period. We all have our ups and downs but one distinction to always pay attention to when it comes to diagnosing is the time frame required.
“Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation)”
Like I stated for the first criterion, if there is no indication of a “depressed mood” then this is a required symptom that will be needed for diagnosis. The difference between this and the first criterion is that with the depressed mood the person is at their low point whereas a person with this symptom just lacks interest in most of the activities that they regularly enjoy.
“Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month) or a decrease or increase of appetite nearly every day.”
This is an interesting criterion to me and you should take note of this as well. This is a good example of how an issue of the mind could lead to somatic (relating to the body) effects. I’m sure you’ve seen various tv shows and movies where a character had depression and they point out they have been eating more or less and that would attribute to their weight change.
“Insomnia or hyposomnia nearly every day”
Another interesting criterion because it shows that depression can manifest with two extremes. A person may have issues with sleeping (insomnia) or issues with staying awake (hyposomnia).
“Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down)”
Let’s break this down a bit to make it more understandable. First, we’ll look at psychomotor. This is related to the physical movement that is a result of mental activity. For example, driving a car or playing an instrument. Anyone can get in a car or pick up an instrument but there is a certain level of mental activity that is needed to do these activities effectively. Now that we have a better understanding of psychomotor, we can now look at agitation and retardation. Psychomotor agitation may manifest as restlessness but for this criterion it’s observable every day. Imagine an individual that is pacing back and forth every day. That would be an example of psychomotor agitation. On the opposite side of the spectrum, psychomotor retardation is the feeling of slowing down. Now this is a little tricky to explain so I’ll give an example. Someone that has difficulty doing “simple” tasks due to their depression such as brushing teeth or getting dressed. Normally this would be considered an easy activity that we don’t even have to think about but for a person with psychomotor retardation, these activities are almost unbearable.
“Fatigue or loss of energy nearly every day”
“Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)”
Another take away from all these criteria is that these aren’t experienced at its base level. What I mean by this is basically what has been in said in between most parentheses up until this point for this disorder. Nobody is 100% happy or down all the time. As humans we experience various feelings throughout each of our days. There is a certain level that can be looked at as a regular functioning but there is a point where it can become an issue for your everyday life and with most, if not all, these disorders, that’s how the symptoms should be looked at.
“Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)”
“Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide”
B. “The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning”
Like I stated under the “g” symptom of criterion A, these symptoms have to cause such distress in their life that help is sought out.
C. “The episode is not attributable to the physiological effects of a substance or another medical condition”
Like other disorders, it can’t be attributed to drug use or another medical condition
Once the three criteria are met, an individual can be diagnosed with a major depressive episode.
For any extra explanations about anything that has been discussed in this post please comment OR reach out to me directly and I will try to provide a bit more clarity. The next post will be focused on Bipolar I and II as well as their specifiers. For the symptoms or criterion that have no explanation under it, it’s because I felt like any explanation would be overkill however if there is a need for further explanation, I have no issues providing them.