The Bipolar Spectrum

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There are several different “types” of bipolar. These include bipolar I, bipolar II, cyclothymic disorder, and bipolar, not otherwise specified. Within bipolar there are also other designators like “with mixed features” or “rapid cycling”. There are an awful lot of options on the bipolar menu. [Visit this page for more detailed information about each one.]

It is easy to take these specific, discrete diagnoses, and view each of them as their own little box. If your symptoms match up with one of them, then you go in that box. If they match up with another then you go into that box. And so on.

In truth it is far better to view bipolar as more of a spectrum, with each discrete diagnosis being a point along that line that someone has decided to label. These points may be good guideposts. They may not be. It depends on how much stock you put in them. It is easy to overemphasize them, which is problematic because it can lead to more stigma, and the differences between the different diagnoses can be very small, and there is often an awful lot of overlap between the two.

Let me explain.

The difference between bipolar I and bipolar II is as simple as one manic episode with psychosis. Interestingly enough if you experience psychosis while in a depressed episode then you still have bipolar II. It’s got to be during mania. If you’ve been diagnosed with bipolar II for 20 years and then you experience mania with psychosis just once you magically have bipolar I now. That’s just how it works. Often the perception is that bipolar I has more manic features and bipolar II has more depressed features but that is not always the case, and has virtually nothing to do with the diagnosis.

You could experience hypomania 90% of the time (this would almost never happen – depression is far, far more common than hypomania/mania in bipolar, despite public perception) and if you never experienced “full” mania with psychosis then you’ve got bipolar II. In the same way you could be depressed 99% of the time but if you ever in your entire life experience mania with psychosis then everything else doesn’t matter and you have bipolar I.

The line between bipolar II and cyclothymia is similarly blurred. It rests solely on how disruptive your symptoms are. At some point there is an imaginary line that is crossed moving your disorder from one level of disruptive to the other. Who is to say exactly where that line is? There is no objective way to decide. Your symptoms are either disruptive enough to be bipolar II or they’re not. Maybe you split the difference and are just sort of floating out there somewhere in the mood disorder ether.

Also, somewhere in the mood disorder ether, there is bipolar disorder, not otherwise specified. This is, in my never humble opinion, the most honest diagnosis possible. This diagnosis admits what those of us who live with bipolar already know: bipolar is a spectrum and that everyone’s experience with it is unique to them.

This makes more sense than any of the specific, discrete diagnoses for bipolar. It’s not that they aren’t useful, it’s that they are imperfect and even misleading. They are rough sketches. They are, again, little dots along the line that is bipolar. People really don’t often fit neatly into them, or at least our ideas of them.

Understanding this is important. If someone experiences some symptoms that may be consistent with bipolar disorder they will likely be inclined to start trying to find information to see if they need help, and what help they may need. Having specific diagnoses can be beneficial in describing sets of symptoms, but if that person does not fit neatly into one of the boxes they may be less inclined to investigate further.

If bipolar is understood not as bipolar I, or bipolar II, or cyclothymia, or any of the other discrete diagnoses, but instead as a spectrum disorder, this obstacle between a person who is symptomatic and their treatment is reduced or eliminated. This “spectrum” view of bipolar can also help reduce stigma, both for people with bipolar and for neurotypical people.

Bipolar I is perceived as being “worse” than bipolar II, despite the fact that the only difference between I and II is just one manic episode with psychosis during the entire course of a lifetime. It’s not even the experience of psychosis itself, just the experience of it during an elevated mood episode. Neurotypical people may stigmatize bipolar I more than bipolar II. But it also can work the other way around.

There are people in the bipolar community who make a big deal about specific diagnoses of bipolar I and bipolar II. This creates a divide between people with different diagnoses. People with bipolar I diagnoses sometimes seem perversely proud of this diagnosis, and look down on people who “just” have bipolar II. In that way of thinking people with bipolar II don’t suffer as much as those with bipolar I so they don’t really have bipolar.

The measurement of suffering and the subsequent badge of honor that comes with it isn’t just with the bipolar I and II diagnoses. Do people who have mixed states have it worse than people who don’t? Is it worse to experience more hypomania/mania or is it worse to be more depressed? With every unique designation for bipolar there are inherent questions about exactly what that means and whether that is “better” or “worse” than any other designation. All of this can be toxically stigmatizing, and doesn’t do anyone any favors.

This can be solved by ditching, or at least diminishing the discrete diagnoses and just viewing bipolar as a spectrum. It may be useful to have different diagnoses. I am sure that medical professionals find them informative. But it needs to be understood just how vague the distinctions between them really are. And by and large we should avoid the labels and how they fuel stigma and see it all as bipolar.

Bipolar that is on a spectrum.

Bipolar that doesn’t need to be compared from diagnosis to diagnosis, person to person.

Just bipolar.