Allan Schwartz, LCSW, Ph.D. was in private practice for more than thirty years. He is a Licensed Clinical Social Worker in the states ...Read More
This is a hypothetical case study that demonstrates some of the difficulties associated with getting an accurate diagnosis of Bipolar II Disorder.
“A fifty year old man, Mr. George, was referred to a psychiatrist because of chronic depression. For him, this was nothing new because he suffered from depression most of his life.
Mr. George was married, with three children. They lived in a typical suburban home and his career was moderately successful. However, episodes of depression and anxiety robbed him of energy and concentration so that he never reached his full potential. He also had a conflicted relationship with his wife and teenage children because of his sudden outbursts of anger.
In the past he was diagnosed with dysthymia and was treated with psychotherapy alone. However, his depression. He continued to experience episodes of severe depression. As a result, the diagnosis was changed to Major Depression. He was prescribed Prozac and this seemed to help him for several years. However, it must be pointed out that while his symptoms improved overall, he continued to have unexplainable episodes of depression with irritability. During the intervals of stability, he felt relatively free of symptoms.
After a few years Mr. George’s depression again worsened and his medication no longer worked. In fact, he was having periods of depression that we so bad that he was tearful and admitted to suicidal thoughts but denied any intention act on those thoughts. He was told that it is common for anti depressants stop working after a while. He was prescribed Effexor and, again, had an excellent response.
This cycle was repeated, dosages of medication adjusted and new anti depressants prescribed. Ultimately, his diagnosis was changed from Major Depression to Bipolar 2 disorder without manic symptoms. Mr. George was started on a regimen of Lamictal. This time Mr. George gradually improved but without the euphoric feelings he would experience when starting a new antidepressant. His diminished and, for the first time, he was free of cycles of extreme depression.
This hypothetical case occurs more commonly than most of us may believe. Why is this?
According to Dr. Jim Phelps, MD, Department of Psychiatry, Health Services Hospital, Corvallis, Oregon, it is possible for people to have Bipolar Disorder without cycles of mania or hypomania. His conclusion is based on observations he made with many of his patients who were initially diagnosed with Major Depression but did not improve on the antidepressants. When they were taken off of the antidepressants and put on medication for Bipolar their moves stabilized. Dr. Phelp’s observations are supported by a lot of recent research on Bipolar disorder.
According to Dr. Phelps, Bipolar II falls along a spectrum from Unipolar or Major Depression all the way to Bipolar 1 and Bipolar II. Along this spectrum it is possible for patients to suffer from episodes of depression but without either manic or hypomanic symptoms.
According to Dr. Phelps there are “soft symptoms” of Bipolar II without mania. A patient need not have all of these symptoms to fall under the Bipolar diagnosis:
1. Repeated episodes of major depression
2. The first episode of major depression occurred before age 25 or even 18.
3. A first-degree relative, such as: mother or father, brother or sister, daughter or son, has a diagnosis of bipolar disorder.
4. When not depressed, mood and energy are a bit higher than average.
5. When depressed, symptoms are “atypical”: extremely low energy and activity; excessive sleep (e.g. more than 10 hours a day); mood is highly reactive to the actions and actions of others; and (the weakest such sign) appetite is more likely to be increased than decreased.
6. Episodes of major depression are brief, for example, less than three months.
7. The patient has had psychosis during an episode of depression.
8. Severe postpartum depression after childbirth.
9. Hypomania or mania while taking an antidepressant: (severe irritability, difficulty sleeping, and agitation may indicate hypomania).
10. Loss of response to antidepressants. They may have worked well for a while but the depression symptoms return, usually within a few months.
11. Three or more antidepressants have been tried, and none worked.
According to Dr. Phelps these eleven items point to a Bipolar Spectrum Disorder and he cites research to support his view point.
To repeat, one does not need to have all eleven of these symptoms to have Bipolar two disorder.
To learn more about this new type of formulation of bipolar disorder, I suggest you go to the following web site where this is comprehensive information:
Never make a diagnosis on your own. If this problem seems familiar to you in terms of yourself or a loved one, Please seek the advice and guidance of your family physician or psychiatrist.
Readers are encouraged to submit their opinions, experiences and questions. I look forward to hearing from you.
Allan N. Schwartz, PhD