The Bipolar Spectrum: The Different Types of Bipolar Disorder

Bipolar disorder is a serious clinical entity that often generates bewilderment and fear. In addition, there are up to nine different forms of bipolar disorder. In this article, we're going to explain the different types.
The Bipolar Spectrum: The Different Types of Bipolar Disorder

Last update: 25 December, 2022

Bipolar disorder is a serious and disabling clinical entity. Its onset usually occurs around the age of 20. This clinical entity is made up of depressive episodes (of intense sadness) that alternate with episodes of euphoria (manic episodes). In addition, mood swings cause immense suffering in sufferers and in the people around them.

Various subtypes of this disorder have been described and, in this article, we’re going to talk about the bipolar spectrum. We consider it important that, before explaining it, we clarify some doubts. Firstly, we’ll define manic-depressive illness and its symptoms.

woman with bipolar disorder
According to Belloch, it’s estimated that ten to 13% of people who’ve experienced a major depressive episode will suffer a manic or hypomanic episode at some point in their lives, leading to their diagnosis being changed to bipolar disorder.

Bipolar disorder

Bipolar affective disorder (hereafter BPAD) usually begins with a depressive episode. In fact, it’s when a hypomanic, manic, or mixed episode appears that the diagnosis is finally made. Thus, we can distinguish between hypomanic, manic, and mixed episodes.

Bipolar disorder has also received the name of manic-depressive illness. It presents periods of euphoria alternated with those of deep sadness.

Hypomania

The hypomanic episode is far from being as serious as its big brother: mania. For the World Health Organization (WHO), hypomania consists of a euphoric and extreme state of mind that lasts for at least a week. Among its symptoms are euphoria but also irritability.

Motor and mental activity increases and the level of energy experienced by the sufferer are higher. As a consequence, they may have a decreased need for sleep. In addition to other symptoms, their language is rapid (ie, verbose).

Mania

Unlike its little sister, mania requires hospitalization. Indeed, it’s more serious and, therefore, more noticeable to those surrounding the sufferer. For the WHO, it constitutes a high and expansive state of mind that lasts several days and is characterized by euphoria and psychomotor activation.

Among the most characteristic symptoms of mania are the ideas the sufferer possesses that they’re pretty amazing and invincible, with high self-esteem, Brainstorming, in the form of disjointed thoughts in rapid succession and in multiple directions, may occur. Additionally, manic behavior is often impulsive.

“Brief manic episodes are a good prognostic factor.”

-Belloch-

Mixed episodes

The WHO claims that mixed episodes imply a rapid alternation of manic and depressive symptoms during the majority of the time over a period of at least two weeks.

The discomfort caused by mixed episodes is usually severe and interferes with the sufferer’s daily life. Sometimes, it may require hospitalization.

The bipolar spectrum

Now that you know what bipolar disorder is, we’ll explain the different ways it can present itself.

The first is subsyndromal bipolar disorder. This form occurs when the clinical picture, despite having a clinical and functional impact on the person’s life, far from meets the criteria required for diagnosis.

“An episode lasting less than that described in the diagnostic manuals or that does not comply with all the symptoms, but that has a negative impact on the patient’s quality of life would be an example of a subsyndromal or subthreshold presentation.”

-Belloch-

Akiskal’s proposal

Why does an individual develop bipolar disorder? What types of bipolar disorder are there? To answer these questions, in 1980, Akiskal and colleagues proposed a classification that describes manic-depressive illness according to its onset or form:

Bipolar 1/4 (0.25)

This subtype consists of the development of manic episodes in response to taking antidepressants. As we mentioned earlier, most cases of bipolar disorder begin with the development of a depressive episode.

If, when faced with such a clinical picture, an antidepressant is prescribed, with the objective to improve and increase mood, but the individual is actually suffering from bipolar disorder, the antidepressant will cause a manic episode to appear earlier.

This subtype of bipolar disorder responds rapidly, but not sustainably, to antidepressants: a response often referred to as ‘ poop-out ‘ or burnout.”

-Stahl-

Bipolar 1/2 (0.5) and schizoaffective disorder

Schizoaffective disorder consists of symptoms of psychosis alternated with manic, hypomanic, and depressive episodes. In this subtype of bipolarity, the psychotic symptoms are less severe than in other psychotic disorders (such as schizophrenia). However, the symptoms related to mood are worse.

Schizoaffective disorder is characterized by the presence of psychosis and mania, in addition to other mood symptoms.”

-Stahl-

Bipolar I and 1/2 (1.5)

This subtype is characterized by the presence of hypomanic episodes in the absence of depressive episodes. These patients have prolonged hypomania.

These patients can be treated for hypomania while watching for a future onset of depressive episode.”

-Stahl-

Bipolar II and 1/2 (2.5)

This type consists of the presence of depressive episodes with cyclothymic temperament. To better understand it, cyclothymia is a less severe, but more chronic picture similar to BPAD. It’s important to be aware of this clinical picture because treatment of cyclothymia, when performed solely with antidepressants, can have a boomerang effect of increasing mood swings and, ultimately, inducing a manic episode.

“Many cyclothymic patients are simply considered ‘moody’ and do not consult professionals until they experience a full-blown depressive episode.”

-Stahl-

Bipolar III (3)

This subtype consists of the existence of depressive episodes. Added to these are hypomanic episodes caused by the consumption of antidepressants. In diagnostic manuals, it’s called substance-induced bipolar disorder. This is a really apt name because it reminds professionals that bipolar patients are far from good candidates for taking only antidepressants as part of their treatment.

“Patients who develop a manic or hypomanic episode with an antidepressant are often referred to as bipolar III.”

-Stahl-

Bipolar III 1/2 (3.5)

This type of bipolar consists of the development of depressive and hypomanic episodes as a consequence of drug use. In Stahl’s words, “the combination of bipolar disorder with substance abuse is a direct route to chaos”.

The use of drugs to modulate our emotional states is something we’re all familiar with. For instance, when we’re tired we might drink coffee. However, when harder drugs (cocaine, marijuana, ecstasy) are taken in the context of BPAD, the repercussions can be much greater.

“Although some patients may use substances of abuse to treat depressive episodes, others have previously experienced drug-induced or spontaneous mania and take substances of abuse to induce and experience mania.”

-Stahl-

Bipolar IV (4)

This subtype is formed by the presence of depressive episodes with hyperthymic temperament. Hyperthymia causes people to appear excessively cheerful, optimistic, and productive. They’re successful people whose personality has remained stable over time but who, without warning, suffer severe depression.

“Even if they don’t have formal bipolar disorder, these patients respond better to mood stabilizers than to antidepressants.”

-Stahl-

Woman taking a pill
Patients with bipolar type IV respond better to mood stabilizers than to antidepressants.

Bipolar V (5)

The fifth bipolar constitutes the presence of depression with mixed hypomania.  There’s a complete picture of depression but only some symptoms of mania.

“Whether these patients can be treated with antidepressants alone or whether they require mood stabilizers such as lithium or antipsychotics is still ongoing.”

-Stahl-

Bipolar VI (6)

Can individuals with dementia suffer from bipolar disorder? Unfortunately, the answer is yes. Thus, the last subtype is constituted by the presence of BPAD in the context of dementia. This can make the diagnosis of both clinical entities difficult.

“Bipolarity may be mistakenly attributed to dementia symptoms instead of being recognized as a separate disorder and treated with mood stabilizers.”

-Stahl-

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The Different Types of Bipolar Disorder
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The Different Types of Bipolar Disorder

There are several types of bipolar disorder, describing different mental states, and a challenge for the sufferer and those around them.



  • Stahl, S. M. (2014). Psicofarmacología esencial de Stahl: bases neurocientíficas y aplicaciones prácticas (4a ed.). UNED. Universidad Nacional de Educación a Distancia.
  • Belloch, A. (2022b). Manual de psicopatología, vol II.
  • American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (Dsm-5-Tr(tm)) (5.a ed.). American Psychiatric Association Publishing.
  • Akiskal, H. S., Hirschfeld, R. M., & Yerevanian, B. I. (1983). The relationship of personality to affective disorders: A critical review. Archives of general psychiatry, 40(7), 801-810.
  • Akiskal, H. S., & Pinto, O. (1999). The evolving bipolar spectrum: prototypes I, II, III, and IV. Psychiatric Clinics of North America, 22(3), 517-534.

The contents of Exploring Your Mind are for informational and educational purposes only. They don't replace the diagnosis, advice, or treatment of a professional. In the case of any doubt, it's best to consult a trusted specialist.