Recently, someone posted the following on Instagram: “I am clinically #bipolar, which means that I don’t know what my mood will be like in the next 20 minutes.”
This sparked some discussion among doctors on Twitter, who noted, correctly, that mood episodes in bipolar disorder last days to weeks, not minutes or hours. The Instagram post and Twitter discussion also sparked discussion among people who live with bipolar disorder, which made me think that an expanded conversation would be helpful.
In this post, I highlight the distinctions between moodiness and bipolar disorder, and explain why these distinctions matter.
Characteristics of Moodiness
Moodiness is characterized by quickly changing moods (hour-to-hour or moment-to-moment), which is a common emotional experience that has a wide range of causes. This pattern of mood changes is also commonly referred to as “mood swings” or, if the mood changes frequently to anger, “irritability.”
Transient periods of moodiness, unrelated to any psychiatric diagnosis, are common to most people. For example, some people may become irritable when they are very tired or hungry. High levels of stress also can trigger moodiness. Longer term, but still transient causes of moodiness include puberty/adolescence, pregnancy, and menopause.
More persistent, excessive moodiness — and especially irritability — can be a symptom of a variety of illnesses across the spectrum of the body and brain. In psychiatry, irritability is a common finding in many diagnoses including ADHD, autism, anxiety, depression, bipolar disorder, and borderline personality disorder. Moodiness is like a fever; it tells us that something is happening, but it is only a symptom and not the disorder itself.
Characteristics of Bipolar Disorder
Bipolar Disorder Type 1, is characterized by periods of mania lasting at least seven days, but often weeks or months, that may or may not alternate with periods of depression. At least one manic or hypomanic episode is necessary to make a diagnosis of bipolar disorder. Bipolar Disorder Type 2 is characterized by chronic depression, punctuated by periods of hypomania — a period of time with similarities to mania, but less intense, which by definition does not cause problems in function and must last at least four days.
During a manic (or hypomanic) episode, a person is not their usual self in many ways beyond their mood. A diagnosis of mania/hypomania is defined as a distinct period of:
- Elevated or expansive mood or sometimes irritable mood AND
- Extremely high energy
- This period must be a change from a person’s usual function, and must last at least one week for mania and four days for hypomania.
- During this period, the person must exhibit at least three of the following symptoms or four if the primary mood state is irritability:
- Big grandiose thoughts and ideas; inflated sense of self-esteem
- Little need for sleep
- Engaging in activities that are high risk/impulsive/dangerous
- Increased activity level for all activities, even ones that are not high risk
- Distractibility — drawn to irrelevant details and stimuli
- Flight of ideas (changing topics frequently) and/or the sensation that one’s thoughts are racing
- Speaking rapidly and intensively, which is referred to as pressured speech
In mania, but not hypomania, thinking can become severely disrupted and evolve into psychosis — delusional thinking that is not grounded in reality. If psychosis occurs, the episode is, by definition, manic.
Key things to note are that the symptoms of mania show a clear difference from a person’s baseline, must include both mood and energy changes and three or four other specific symptoms, and the episode must persist for more than minutes or hours. If a person has chronic irritability and impulsivity, that irritability and impulsivity become visibly much more extreme during a manic episode, and they must remain at that level for at least seven days.
A Challenging Diagnosis
Bipolar disorder/mania is not always an easy diagnosis, because people can experience what are commonly referred to as mixed episodes — a manic episode accompanied by symptoms of depression or a depressive episode that contains manic features. If psychosis is a symptom (which can occur in mania, depression, or a mixed episode), distinguishing between bipolar disorder and schizophrenia can be difficult.
Between the specified mood episodes, people with bipolar disorder may be irritable, moody, and impulsive at their baseline. That moodiness/irritability, though, is not why they are diagnosed with bipolar disorder Having moodiness/irritability is not the same as having bipolar disorder. And some people with bipolar disorder do not have a lot of moodiness/irritability between episodes.
Ultra-Rapid Cycling Bipolar Disorder
Extreme and rapid moodiness has sometimes been called “ultra-rapid cycling bipolar disorder,” but this sub-classification has not been borne out by research to date. In other words, these symptoms have not been shown to consistently co-exist with or turn into classical bipolar disorder. Some people with bipolar disorder can have “rapid cycling” features, which means four episodes per year. But the episodes must still be full blown mania or depression, and they must last days to weeks, not hours or minutes.
If mood changes that come within moments or hours are the primary symptoms, and the other symptoms of mania or hypomania don’t occur, then it is not bipolar disorder.
Understanding Why These Distinctions Matter
The reason we care so much about distinctions among different diagnoses is that our treatments are researched and developed based on specific symptom pictures and diagnoses. Being as accurate as we can with the diagnosis helps us build the best possible treatment plan with our patients and their families.
If the diagnosis is bipolar disorder, we have protocols in place to provide the most effective treatments based on each patient’s specific symptoms. If, however, a patient experiences moodiness that does meet the criteria for a diagnosis of bipolar disorder, it is critical to look carefully for the underlying cause(s) of those types of mood changes so those cause(s) can be addressed.