The bipolar spectrum

I wonder why I have to be in this group of patients who have presented with symptoms that appear to fit the theory of the bipolar spectrum disorders.

There seems to be a number of patients who are suffering from anxiety, depression, and other symptoms that don’t exactly fall within the DSM classifications. In most cases, the symptoms experienced by individuals like these are moreerratic and change over time. Both depression and anxiety symptoms are atypical and any present hypomania tends to be more
dysphoric than is strictly defined in the DSM.

Many patients with these characteristics have been previously prescribed anxiolytic medications or antidepressants by their general practitioner or psychiatrist. They often don’t have the desired response to these drugs, with some only experiencing partial relief and others actually regressing into more intense episodes of depression and/or hypomania.

All of these patients that seem to defy your typical bipolar diagnosis are lumped into a group that is known as “soft bipolars”.

There are a number of symptoms that can be attributed to soft bipolar disorder. These include the following: Episodes of Mood Instability, Episodes of Atypical Depression, Hypomania (often dysphoric), & Mixed Symptoms.

This group hasn't yet been officially defined within the DSM, its more of a concept. As such it has no clear management model. Awesome. That gives me confidence.

Bipolar Spectrum Disorder Treatment Guide with Symptoms and Diagnosis

Who placed you in that group?

And what makes it softer than other types of BP? What makes it different from cyclothymia? How is it different from an anxiety disorder and (unipolar) depression? Do you have any perceptual changes that go along with your changes is mood? Do you feel somewhat in control, does it feel as if you influence your mood, just not very well?

I don't think it's as clear-cut as you might (now) think. But maybe it is.

It's what my original pdoc first said when he prescribed me lithium. On further assessment it's somewhat agreed upon to be bipolar 2.

Most of what I've written in my post was taken directly from the article attached so I'm not quite sure what makes it "softer" besides the lack of clear mania/hypomania. My hypomania, if that's what it is, is mainly dysphoric although in retrospect I can probably attribute some experiences in my life to euphoric hypomania. I think the "soft" bipolar spectrum is meant to include cyclothymia & pretty much covers bipolar NOS/NEC.

How it's different to anxiety & unipolar depression I'm not 100% sure, theres so much overlap between them all, how is it different to unipolar depression with mixed features? (I think that's a DSM 5 diagnosis?)

I have had perceptual disturbances, derogatory auditory hallucinations, paranoia. I had a sense of losing control, I think that was dysphoric hypomania, I began self harming & became properly suicidal for the first time ever.

I do feel like I can influence my mood sometimes, usually when I feel forced to, like for work, mostly I'm able to be appropraite, sometimes not. Often I just am in whatever mood I'm in, it seems out of my control, particularly low moods, it's hard to snap out of it.

I'm sure none of its clear cut, I just want it to be.

This is very interesting. Do you know how well this info is read and utilized by pdocs and therapists? I'm wondering if any of these types will pop up in my future appointments.

The changes in the DSM-5 reflect the "discovery" that BP and unipolar depression (as I see it, my theory/theories, only one of two types) should be seen as part of a mood disorder continuum (and I believe it stretches further: a psychotic spectrum that is part of a continuum including everyone).

That unipolar depression was part of a continuum together with BP was already proposed by the man that made the distinction between manic-depressive psychosis/insanity and dementia praecox, the latter later being called the schizophrenias (DSM-5 is the first DSM to do away with the old schizophrenia types).

The DSM removed the BP mixed episode and replaced it with a specifier (ironically less specific) that can be used together with all mood disorders.

So far the theory. I'll write more later.

Ok, a bit more theory, mostly mine. It's all a bit unstructured. Please bear with me.

First a bit more about the DSM.

They also added the specifier "with anxious distress" which can apply to basically everything. But it implies that some people have more anxiety, having the same type of disorder, than others. I guess.

Specifiers are added because the DSM is basically a mess, hinging on two ideas or approaches: a categorical and a dimensional.

A dimensional approach can be more specific, but it can also be less specific if specific categories are replaced by less specific ones (so not really dimensions or a binary dimension, which is a category), which, more like sets, can be combined.

In other words, in making concessions, the DSM-5 might have made things worse, not better.

The chair of the DSM-IV BP working group is developing a competing, dimensional theory, just to show you how political all this is.

Never create a theory (or try to unify theories) with a committee.

So here's my dimensional theory.

I believe anxiety, sensitivity/fear and susceptibility for psychosis together determine the length and severity of mania and depression. These things are not independent, but this way its more like the DSM theory.

I think they can all be reduced to one dimension. But that's not relevant yet.

If all are high, you have a very extreme mixed state, going from one extreme to the other, aspects from one mood overlapping with the other.

Less susceptibility for psychosis causes less severe mixed states. Less sensitivity/fear causes longer cycles (so it might not be "mixed"). Less anxiety causes less severity.

Anxiety causes depression, no anxiety mania.

To reduce these three factors: the more susceptible to psychosis, the more anxiety (two types) and sensitivity/fear. But in a complex way I won't go into now.

It's not completely independent as one dimension either: it depends on your personality, opportunities and other environmental factors.

To come to a conclusion: other than what they imply/propose by making the DSM as it is, I think anxiety and how fast mood states are mixed are actually (very) much dependent on the susceptibility for psychosis, so I believe that if you have a mixed state, you likely have BP-I, but it may be BP-II together with something else that increases anxiety, environmental and/or having to do with you personality.

Considering what you described earlier, elsewhere, I think at least your personality adds to the anxiety (caused by confusion basically).

There's one more important thing: past psychosis/mania can make things worse by making you more susceptible to psychosis and by making you fear psychosis/mania/depression/instability. It can be traumatic, make you more sensitive/vigilant/wary.

So artificial psychosis due to dopaminergic or serotonergic agonists (such as methamphetamine) may cause lasting anxiety problems as well as a heightened susceptibility to psychosis.

It makes the susceptibility to psychosis less influential—relatively speaking—than if you hadn't experienced the effects of meth. So your BP would be more towards BP-II and unipolar depression.

The question that remains is whether your personality caused you to do things that have a negative impact. If not, GAD is probably a good diagnosis besides BP.

So your diagnoses might be spot on or you knowingly do things with great negative impact. You said earlier you didn't do that with relationships, so you might not have a borderline personality, but the treatment may still help you.

I believe personalities always have aspects that are beneficial and that they may reduce the severity of your underlying problem(s), which would be BP. That is another reason it might be correct to assume BP-II or unipolar depression, mood disorders being syndromes, so it's the effects that count.

Ellie Jo, I'm not sure how well accepted it is within the psychiatric community as my first pdoc began with this dx, he being much younger than my new pdoc who uses the DSM in the strictest sense. He says he doesn't see a "clear" bipolar disorder but attributes most symptoms to anxiety & depression & doesn't see evidence of improvement on lithium or APs as an indication of bipolar, I don't either really but first pdoc felt it to be further indication of bipolar.

Icaredixit thanks for your detailed reply, it's a lot to take in so bear with me.

I'm interested in the with "anxious distress" specifier, that muddies the waters even more between whether my anxiety is in fact apart of a bipolar disorder or a stand alone problem. Something it seems neither of my pdocs would agree on. I can see your reasoning for mixed states leaning more toward bipolar 1 but I really never reach the altitude of bipolar 1 so I think hypomanic/depressed with mixed features, not sure which state was most dominant but probably hypomania.

Past psychoses increasing the risk of further psychosis is like the kindling effect yes? I very much believe my abuse of methamphetamine has either brought out a genetic vulnerability that would otherwise not have been expressed, or caused neuronal damage that has resulted in mood disturbance, or both. It did bring on intense states of agitation & obsession that occurs now without having used the drug for years. Infact almost all my symptoms I experience now I experienced first when using, the highs & lows. I never imagined it could be the develpment of an illness, I never sought help because I presumed it was all the drugs, but it hasn't stopped just because I've stopped.

I don't think I usually knowingly do things with great negative impact, but when dysphoric can become quite self destructive. I can identify with some borderline traits.

My heart goes out to you. I experienced my first manic episode before ever touching drugs. I experienced my first psychosis while on Amphetamine. I worry and believe that if I never touched the drugs, my illness would not be so bad. if I didn't experience mania before ever trying any street drugs, I would definitely question any diagnosis I was given. I do believe drugs made me worse though. I'm not sure of the science behind what I believe, I just know it to be true in my case. I get the same type of psychosis now, even after nearly 2 decades off the drug. Can flashbacks happen decades later? I wonder what the science says.

You could call it a kindling effect, though it's often used for things that (probably) work slightly differently, but yes.

It's probably both a memory and a biochemical kindling of sorts and brain damage. It hopelessly interacts, of course. Delusions probably mostly memory and hallucinations mostly brain damage. But again, both feed into one another, of course. Also because your entire brain is pretty much a storage of memory. Maybe not just yours. Darwin might've been (somewhat) wrong.

I believe if you have delusions as well, BP is likely. If it's hallucinations not really fuelled by delusions, it might be more "isolated". Delusions take time to come to fruition, the earlier you have them, the bigger the impact. Hallucinations become more intertwined with hallucinations. Interacting more. If hallucinations aren't your problem, I'd say it's likely it's more developmental, so BP is likely. BP-II more so than BP-I, just based on that.

The earlier the memories, the bigger their impact, but their inherent impact or contrastive impact, their salience, matters most. Emotions are the aspect of memories that matters most, but association combines sensory and emotional aspects, not co-occurrence per se.

It's a theory. But most parts of it anyone may verify by their own experiences.

Any feeling of losing control is delusional. As you just have delusions, it's probably mostly a vulnerability and fear of mood changes that you associate with bad memories, loss of control, creating fear, anxiety, changing your mood.

That meds don't work (well) might mean anxiety is a big part of the problem. Maybe not. But that doesn't mean there's no problem with mood changes and perceptual changes, (mildly) delusional states.

It might mean you need stronger meds to desensitise, so that anxiety becomes less severe, the vicious circle gets broken. You may then lower the dosages or you may need no meds at all (since based on the extra information you gave, it probably BP-II). Psychotherapy might also work. But I wouldn't know.

That's at least what I think may be best. Maybe psychostimulants may help you after a mes increase. They may make things worse if you aren't stable enough.

So as far as flashbacks are concerned, they can go back many, many years. And emotions can stay connected or not. If not, no strong emotions, they are probably more likely to fade.

In my case, it's not unlikely my strongest memories are caused by birth complications. It's just emotions that remained, but they can be brought back by emotions. SZ, for example, has been linked to birth complications.

It could have caused biochemical, epigenetic changes as well as memories, which is basically the same thing. It depends on your definitions.

Science depends on definitions. I think mine of memory is most useful, properly/usefully reduced/broadened.

Wanderlust, I know a website about this exact set of patients you wrote about! I'm one of them too!

Psycheducation.org

This website is how I found out about my bipolar. It talks about the bipolar spectrum and people whose bipolar looks different than typical bipolar.

My bipolar has NO euphoric hypomania. My hypomania is anxiety, irritability, panic, agitation, insomnia,

I have mixed bipolar disorder. I almost without exception have symptoms of both hypomania and depression at the same time. I also have ultradian rapid cycling bipolar. The link you posted said

I was misdiagnosed for almost a decade. It made my bipolar worse and worse. I was hospitalized three times. I was the one that found the right diagnosis, and I found it through the website above. I'd said maybe five sentences about it to my therapist before he was like, "THAT MAKES SO MUCH SENSE. Everything finally makes sense."

Thanks for posting that link! I saved the article.