How do we know bipolar is one illness rather than two comorbid illnesses?

How do we know bipolar is one illness rather than two comorbid illnesses?

Based on my previous question about ADHD and OCD.

Essentially, ADHD and OCD are kind of opposites in the sense that ADHD people (always? sometimes?) have dopamine deficiency and OCD people (always? sometimes?) have excess dopamine.

I know this may be a stupid question or based on incorrect understanding of bipolar, but how do psychologists know that bipolar is one disorder rather than a comorbidity of mania and depression?

Short answer: Bipolar disorder is probably not composed of two comorbid illnesses, but it may be on a continuum that includes some depressive disorders.

This is a good question, though it does convey some confusion associated with this diagnosis that should be cleared up.

Bipolar symptoms:

The first confusion I think is the idea that "depression", "mania", and "bipolar" are disorders. Depression and mania are not disorders - they are symptoms. And bipolar is a "spectrum" disorder - a collection or continuum of similar diagnoses, that all feature at least one manic or hypomanic episode, and in most cases at least one depressive episode.

It is true that depression without mania is one of the key symptoms of a variety of depressive mood disorders (such as major depressive disorder, sometimes referred to as "unipolar" because of the lack of manic episodes), so it may be confused with a disorder. However, this is not the case for mania, so diagnostically bipolar disorder would not be confused with a comorbidity of 2 disorders - depression and mania - because mania is not a disorder.

Mania rarely presents without other symptoms:

Although bipolar disorder is by far the most common cause of mania, it is a key component of other psychiatric conditions (e.g., schizoaffective disorder, bipolar type; cyclothymia) and may occur secondary to neurologic or general medical conditions, or as a result of substance abuse.

Presumably, a standalone manic episode may be sufficient for a diagnosis of bipolar I disorder or a "not otherwise specified" (NOS) diagnosis, depending on the severity and other symptoms involved. So diagnostically, "mania" as a standalone disorder is actually a sub-type of bipolar.

Bipolar unitarity:

The second confusion I think is the idea that a bipolar diagnosis in some way precludes the symptoms of depression and mania from having separate causes.

Historically, bipolar disorder was not seen as 2 separate illnesses because (1) it was believed that mania and depression were mutually exclusive in time - as 2 extremes (poles) of a single mood continuum, and (2) mania rarely presents without depression. The assumption of mutual exclusivity of mania and depression was called into question by the occurrence of mixed-state episodes - a condition that features symptoms of both mania and depression simultaneously.

Ultimately, many psychiatric diagnostic criteria are encumbered by some historical precedence, common clinical presentations, how patients perceive their symptoms, and also some political influence, as diagnoses are associated with healthcare subsidization, stigma and prejudice, and explanatory power for the patient. So diagnostic criteria should not generally be confused with an understanding of common cause.

The cause of bipolar spectrum disorders is not well understood, and the question of whether unipolar and bipolar disorders are distinct, or part of a single continuum, remains a hotly debated topic. The very common co-occurrence of depressive episodes whenever manic episodes are present suggests that they may be related in some way. On the other hand, depression disorders and bipolar disorders are treated with different medications, suggesting that they may be distinct disorders - depression is typically treated with anti-depressants, while bipolar depression may be more effectively treated with mood stabilizers. The disorders have some predictors (genetic, environmental, comorbidities) in common, and some different. It's also entirely possible that both disorders incorrectly encompass several unrelated sub-types.

The term "bipolar" is used to describe someone who has both manic and depressive episodes - so it is really a name for the combination of the two conditions.

Before bipolar became the popular name for this, it was described as mixed affective state and was characterised as being dysphoric mania or agitated depression depending on whether it was mostly manic or mostly depressive.

I believe it is widely-accepted now that mania and depression are not the opposite ends of a long scale, but are independent measures.

One Illness or Two Comorbid Illnesses?

In short, I don't believe you can answer this in general - I believe it should be considered on a case by case basis.

If you want closure / a "correct" answer, the APA (V) lists bipolar as an Axis I disorder, which suggests their view is a single illness, rather than comorbidity, using the psychological definition of comorbidity. In psychology, comorbidity would be more than one diagnosis. If you can diagnose someone as "bipolar" there would be no comorbidity.

It isn't possible to apply the medical definition of comorbidity in psychology (as of 2015) because you can't detect individual diseases in a lab at this time, so bear in mind that the use of the term is highly interpretive in terms of psychology.

I would question whether for an individual it is more beneficial to treat the two aspects of their condition separately or as a whole. For example, you may decide to only treat the depression and not attempt to suppress the elevated moods - so are you treating the individual for bipolar here, or just for depression?

I am bipolar and I see my mental difference as one unit.

One thing to remember is that the term "bipolar" is just a label for people that exhibit the mood symptoms that are observable. As most bipolar people know, there are a lot of other symptoms such as fatigue/excess energy, dizziness, confusion, short term memory issues, pain, numbness, migraines… And the fact that a lot of us experience these same symptoms leads me to believe that they are all related to a singular cause in some way.

If you think about people with MS, they all experience similar symptoms that many docs attribute to lesions in the brain and such. Since these can often be seen with an MRI, docs have now named the disease based on the cause not the symptoms.

Unfortunately, we can't see the chemicals moving around the brain or the synapses at work. So until we can, we only label the condition based on the two symptoms that cause the most disruption.

As such, these mental differences have been treated for a long time using the spaghetti-to-wall technique. Throw meds at the patient to see which ones stick. And that's how it had to be since it wasn't until recently that they've been able to use better MRI imaging techniques and such to see more of the structure of the brain.

This was how most "research" was done in the field. "We think this drug targets dopamine, so therefore if a patient responds to this drug then they must have a dopamine problem which means that bipolar in general must involve dopamine." Not the most accurate way to do research, but it was the only way possible for a very long time.

So with all this said, I believe that the symptoms originate from a singular cause. However, we are talking about the brain which is the most complex organ known to man so anything is possible.


In addition, people with bipolar disorder are at higher risk for thyroid disease, migraine headaches, heart disease, diabetes, obesity, and other physical illnesses.12,13 These illnesses may cause symptoms of mania or depression, or they may be caused by some medications used to treat bipolar disorder.

The most we can say is that, in general, certain psychiatric illnesses probably involve abnormalities in specific brain chemicals; and that by using medications that affect these chemicals, we often find that patients are significantly improved.

Also known as manic depression, bipolar disorder causes swings in mood, energy, and the ability to function throughout the day.

Symptoms: Bipolar disorder is defined by alternating periods of depression and mania that can last from days to months. Unlike borderline personality disorder, the mood swings of bipolar disorder are not triggered by interpersonal conflicts, last for days to weeks or months rather than minutes to hours, and episodes are, by definition, accompanied by changes in sleep, energy, speech, and thinking

During times of mania, symptoms might include:

  • An excessively happy or angry, irritated mood
  • More physical and mental energy and activity than normal
  • Racing thoughts and ideas
  • Talking more and faster
  • Making big plans
  • Risk taking
  • Impulsiveness (substance abuse, sex, spending, etc.)
  • Less sleep, but no feeling of being tired
  • Poor judgement


During periods of depression, symptoms might include:

  • Drop in energy
  • Lasting sadness
  • Less activity and energy
  • Restlessness and irritability
  • Problems concentrating and making decisions
  • Worry and anxiety
  • No interest in favorite activities
  • Feelings of guilt and hopelessness suicidal thoughts
  • Change in appetite or sleep patterns

Treatment: Most people with bipolar disorder need lifelong treatment to keep their condition managed. This usually includes medicine -- usually mood stabilizers, and sometimes also antipsychotics or antidepressants. Therapy can also help people with bipolar disorder understand it and develop skills to handle it.

What Bipolar II Disorder Really Looks & Feels Like

Many believe bipolar II is not as serious as bipolar I because symptoms of mania aren’t as severe. But bipolar II has another aspect to it that can also be serious if not treated.

Bipolar II is a chronic mental illness, defined by episodes of depression and periods of elevated or irritable mood, called hypomania. This is similar to mania but less extreme.

It’s a common misconception that bipolar II is less severe than bipolar I. Indeed, the mania is less pronounced, but this doesn’t mean the condition is any easier.

In fact, people with bipolar II often experience more severe depressive episodes.

We’re taking a look at how bipolar II looks and feels from the perspective of a woman living with the condition as well as the medical viewpoint of Dr. Joseph Patrick McEvoy, professor of Psychiatry and Health Behavior at Augusta University in Georgia.

Bipolar II is one of several subtypes of bipolar disorder.

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the subtypes of bipolar disorder include:

  • Bipolar I: Diagnosis requires the presence of at least one manic episode, with or without a history of depressive episodes.
  • Bipolar II: Diagnosis requires at least one hypomanic and one major depressive episode.
  • Cyclothymic disorder: Characterized by periods of hypomanic symptoms and periods of depressive symptoms lasting for at least 2 years in adults. However, symptoms don’t meet the diagnostic criteria for a hypomanic or depressive episode.
  • Other types: Drug/substance-induced bipolar disorder bipolar disorder due to another medical condition other specified bipolar disorder and unspecified bipolar disorder.

Bipolar I and II are the most common subtypes.

But when it comes down to splitting hairs between the two, they seem to have more similarities than differences if someone experiences mania and depression in bipolar I.

“The symptoms and signs are the same except that only mild mania is … (by definition) in Bipolar II. … The treatments are the same. The outcomes are the same with high-quality treatment (sustained remission) and the outcomes are the same if there is no (or poor quality) treatment.”

Symptoms of bipolar disorder can begin at any age, but they typically begin between the ages of 15 and 19. Males and females from all backgrounds are equally likely to develop the condition.

It is estimated that almost 3% of adolescents have bipolar disorder. And it tends to run in families. Research suggests that diagnosis received within a family line is about 60-80% .

“I was 15 when I was diagnosed. It was suspected since every female on my dad’s side has bipolar II rapid cycling,” says 20-year-old Ava Rose.

The hallmark symptoms of bipolar II are hypomania and depression. Let’s take a closer look at both from Rose’s perspective.

What hypomania looks and feels like: Rose’s account

According to some people with bipolar II, hypomania feels less like an illness and more like a great mood. This makes it harder to pinpoint in the early years because increased energy and confidence aren’t necessarily things you’d complain about to your doctor.

“Through the early years of my diagnosis, it was much harder to detect when I was in a hypomanic state,” recalls Rose.

“I remember feeling invincible and taking much more risks — like running in the street, starting fights and arguments, having more of a god-complex way of thinking where nothing could hurt/affect/bring me down.”

In many cases, it’s friends, family and peers who notice the behavior changes first. Rose recalls how difficult it was at that time, because she felt unable to fully trust herself or her feelings.

“I remember it was so tough that it wasn’t something I could mask. I remember just talking and someone made a joke about me seeming manic, and it just destroyed my heart, since they never even knew I have bipolar disorder.”

“It felt like I could never be myself — cause being myself just felt crazy.”

What does bipolar II depression look and feel like?

Although hypomania is the core feature that defines bipolar II, the depressive episodes tend to be more frequent, long-lasting, and disabling over a person’s lifetime.

According to the DSM-5, the depressive aspect of bipolar II is defined by at least one major depressive episode resulting in depressed mood or loss of interest or pleasure in life.

“[Depression] feels like the world is crumbling around me, like I’m 10-feet underground and can’t dig myself up,” Rose says.

But as different as the hypomanic and depressive states have felt, Rose reveals that they were similar in one way: They both felt like they would never end.

Other bipolar II experiences

Bipolar II is a different experience for every individual living with it.

In clinical terms, the disorder can include extra “specifiers” that further clarify the condition and the type of bipolar disorder.

For Rose, one of the most difficult symptoms was the rapid cycling aspect of her disorder. While rapid cycling can occur in any subtype of bipolar disorder, it’s most often seen in bipolar II.

“It felt impossible to control any other aspect of my life while being flooded with such rapid changes in my mental state,” says Rose.

She describes how disorienting it could be: “Imagine walking in a straight line, but gravity is changing so rapidly, that… right after one step it was like the switch flipped, and I was thrown against the ceiling, then abruptly back on the floor, then up and down all over again. Making it impossible to actually function.”

Rose also had significant difficulties with irritation and frustration, symptoms she feels aren’t talked about enough in bipolar disorder.

“Something that should trigger a [particular] reaction in others, would affect me to a much larger degree, and it felt like there was nothing in my power to control my reactions to make them appropriate.”

“I had an awful temper and reacted with anger much more abruptly and more often than now.

“The hardest part was this all happened in the span of middle and high school and school quickly became on the bottom of my priority list.

“Also, the relationships with my friends and family were heavily affected, it created a lot of conflict in every aspect of my life, making me constantly feel like I was drowning,” says Rose.

The Impact of Comorbidity and Constraints to Treatment

Comorbidity, if left untreated, can lead to a slew of problems for the person. Comorbidity patients have severe symptoms, a likeness socialism factor, and physically comorbidity disorders like kidney or liver disease and recurrent suicidal thoughts, even though they are treated. The are vulnerable to little weather changes, environmental changes, or emotional changes and end up falling sick easily more than they already are. Feeling unhealthy most of the time makes a person feel pity for themselves and often end up hating themselves. They often have feeling of uselessness making the suicide option more easy and practical.

According to Biomed Central Psychiatry, comorbidity diseases have historically been classified as two different disorders, with one being treated after the other.

Newer research findings suggest that combined therapy, rather than concurrent or simultaneous treatment, is the optimal form of treatment for Dual Diagnosis. Unfortunately, individuals having comorbidity continue to face challenges in recovery due to insufficient or inaccessible services, longer diagnosis times, and lower treatment enforcement. They are the most common victims of late diagnosis and have to undergo several diagnostic tests until they actually find the main cause of all their suffering. This useless but necessary medical test adds to the pain which only the individual and their family can feel in comorbidity. Just thinking about being in pain continuously and not being able to find its main cause gives chills. This condition applies no medicine for pain relief even after all the advancement in the field of medical science.

Key Points to Remember

  1. Bipolar Type 2 has its own, distinct Bipolar symptoms.
  2. You need an evaluation to assess for Bipolar Disorder by a competent professional experienced in diagnosing and treating people with the disorder. Do not self-diagnose.
  3. Treatments are slightly different for Bipolar II versus Bipolar I.
  4. Hypomania should not be considered a blessing

If you think that you have Bipolar II, make an appointment to discuss your concerns with a licensed mental health professional. Don’t just concentrate on describing your depressive symptoms. Make sure you are also discussing the hypomania. Leaving out those episodes is one reason misdiagnosis could occur. If they still won’t listen, don’t give up. For some people it takes years to be accurately diagnosed.


Our results are consistent with, and extend the findings of, previous studies that have shown that ‘atypical’ depressive features (such as hypersomnia and weight gain) may be more common in bipolar disorder than in major depression. Reference Bowden 7– Reference Mitchell, Wilhelm, Parker, Austin, Rutgers and Malhi 9 Compared with previous studies, our study has several advantages, including the large number of participants and the high degree of consistent and comprehensive clinical data collected.

Distinguishing between bipolar disorder and major depressive disorder is of great clinical importance because optimal management of the two conditions is very different. For example, anti-depressants should be used with caution in bipolar depression because of the risk of precipitating mood switches, cycling, or mixed or agitated states. 10 It is desirable that clinicians use all available information to guide management (including choice of treatment, advice to patient and intensity of monitoring). The clinical features of depression are not a definitive guide to diagnosis but can help to alert the clinician to a possible bipolar course. These findings also have important implications for future research on type II bipolar disorder and sub-threshold bipolar disorders. Evidence suggests that 25–50% of individuals with recurrent major depression (particularly those within atypical, early-onset or treatment-refractory subgroups) may in fact have a broadly defined bipolar disorder. Reference Angst 11 We currently know little about how best to treat such patients. Future studies will need to move beyond strict diagnostic categories and examine subgroups of patients defined by extended phenotypic measures such as dimensional assessments of bipolar features, bipolar symptom clusters and longitudinal illness course variables.

An important limitation of our study is that there might have been differences between the two groups of participants that we were not able to examine, such as subtle differences in treatment regimens or patterns of comorbid illness. We also note that although the proportion of women in the major depressive disorder sample is typical of studies of this nature, the proportion of women in the bipolar disorder sample is higher than is typically reported (nearly three-quarters compared with a half) and that this may limit the generalisability of our findings. A further limitation was the use of retrospective rather than prospective assessments, even though we used an in-depth semi-structured clinical interview supplemented by case-note review. Prospective ratings, though preferable, can be prohibitively expensive.

Compulsive Behavior vs. Idiosyncrasies

Compulsive behavior is the sign of a mental health disorder, such as a personality disorder, which indicates a decreased ability to cope. Idiosyncrasies, on the other hand, are simply quirks that do not necessarily reflect problems with daily functioning. Idiosyncratic speech&mdashwhich may be better described as &ldquoexcessive talking,&rdquo &ldquouninterrupted talking,&rdquo or even &ldquounwanted talking&rdquo &mdash does not have the same urgency as compulsive speech, which is pressured and urgent. Idiosyncratic speech may indicate a personality trait, a thought pattern, or simply a preference. Personality traits or thought patterns that can lead to increased talking include insecurity, a desire for connection, or simply a lack of social skills.


Compulsive Talking as a Symptom

Compulsive talking is a symptom of a number of mental health conditions, including some personality disorders. Compulsive talking may include speaking on a certain topic, at a certain time, or at a certain pace, or it may mean speaking in response to fear or other triggers. Compulsive talking differs from excessive talking in a number of ways for one thing, compulsive talking does not necessarily mean speaking in excess. People who experience the compulsion to talk may not always talk at length but rather speak compulsively at certain times, at certain intervals, or when certain topics are brought up. They may also speak compulsively out of anger or frustration.

Compulsive talking differs from uninterrupted talking, too, in that compulsive talking does not necessarily mean mowing over other people&rsquos speech. A compulsive talker may take a break from speaking but will likely resume when triggered again&mdashfor example, if they believe someone is whispering about them.

Compulsive talking also differs from unwanted talking. Unwanted talking can result from the inability to read social cues or simply out of disregard for the desires of others. Compulsive talking, in contrast, may not always be seen as unnecessary or unwanted by those who are listening. Unwanted talking suggests misunderstood or ignored social cues, while compulsive talking suggests an intrinsic need to speak.

Potential Mental Health Disorders Presenting with Compulsive Talking


A number of mental illnesses are commonly accompanied by compulsive talking. These include the following:

  • Bipolar Disorder. Bipolar Disorder is a mood disorder that may present with compulsive talking. Compulsive talking usually occurs during periods of mania rather than periods of depression, and is often identified by a rapid-fire pattern of speaking that seems to leave little room for thought or even taking a breath.
  • Narcissistic Personality Disorder. Narcissistic Personality Disorder may include compulsive talking as a symptom. In this disorder, compulsive talking often manifests as a compulsive need to build oneself up or put others down. An individual with Narcissistic Personality Disorder may, for instance, experience a compulsion to describe all their accomplishments and achievements, even at the expense of their audience&rsquos comfort or interest.
  • Schizotypal Personality Disorder.Schizotypal Personality Disorder may also include compulsive talking as a symptom. Specific ideas or beliefs are likely to be the topic of the compulsive speech. Topics might include conspiracy theories, ESP, or paranoid beliefs. People with this personality disorder may exhibit speak in ways that seem strange or unusual for example, they may use unusual phrasing or terminology.

The above is not an exhaustive list of mental health disorders that include compulsive talking as a symptom, but it offers some examples of how compulsive talking might reflect an underlying mental illness. Compulsive talking is often accompanied by extreme discomfort and high levels of anxiety and fear.

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Nerves of the brain and autonomic nervous system firing inappropriately can explain bipolar disorder comorbid with cardiovascular disease, diabetes, and/or thyroid disorders. A low blood calcium level can lower the trigger threshold of nerves such that they fire without appropriate stimulus. discographer December 27, 2011

@fify-- Are you sure? I assumed that diseases which are comorbid don't have to be linked to each other because my younger brother also has bipolar comorbidity with attention deficit disorder. I asked his doctor if they are related, specifically if the attention deficit is caused by bipolar disorder and he said no.

Maybe it changes from individual to individual or maybe we don't know enough about all diseases to know if they are related or not. I guess we should say that comorbid diseases might or might not be related to one another until science proves us otherwise. fify December 26, 2011

@burcidi-- I think comorbidity is a little different than a medication for something resulting in another disease. Your mom might have comorbidity if her diabetes resulted from high blood pressure.

The way I think about comorbidity is that two or more diseases tend to appear together and might possibly be linked or resulting from one another. Like my sister who has depression and chronic migraines. There are studies which say that most depression patients also have migraines and vice versa. So depression and migraines are comorbid problems.

The same is said for bipolar disorder which has comorbidity with other psychotic disorders most of the time. burcidi December 26, 2011

What the article said is so true. Comorbidity makes treatment much more confusing and difficult. I've seen this in my family.

My mom for example has both high blood pressure and type two diabetes. She has to take separate medications for both daily. Sometimes when she's experiencing a lot of side effects, she gets confused as to which medication is causing it. And her circulation has definitely gotten worse since she also developed diabetes. She only had high blood pressure prior to that.

I've experienced comorbidity as well. I took an anti-anxiety medication for several years which was really hard on my stomach. It gave me acid-reflux and upset stomach. When I told my doctor about this, he prescribed a proton pump inhibitor to treat the acid-reflux. But this medication also had a side effect, it caused iron deficiency when used in the long term. So then, I also had to take an iron supplement in addition to everything.

It was so chaotic, one thing led to the next which led to the next problem. I wish illnesses only came one at a time and medications had no side-effects so that we wouldn't have to deal with comorbidity.

How to Treat Bipolar Disorder

While the term ‘manic depression‘ is still widely used in everyday language, in 1980 it was replaced by a bipolar disorder in the formal psychiatric classification. Bipolar disorder is severe and is not always experienced in the same way by those affected.

This is recognised by the DSM-5, which mainly, but not exclusively, divides bipolar disorder into bipolar disorder I, bipolar disorder II, cyclothymic disorder (often referred to as bipolar III) and bipolar disorder, which is not otherwise specified.

Mania is a defining phase in bipolar disorder, in which the person experiences periods with an intensely elevated mood. Bipolar mania can last for several months or just a few days. This may include irritability, raging thoughts, unusually intense energy, or extreme manifestations of various behaviours.

This can be interspersed with periods of depression that show symptoms such as bad mood, greatly reduced morale and motivation, feelings of hopelessness and physical sluggishness.

Hypomania is a slightly less intense version of mania. Hypomanic episodes occur with a diagnosis of bipolar II disorder along with alternating episodes of depression. Hypomania can sometimes turn into mania. Cyclothymic disorder is the least severe bipolar disorder, and diagnosis requires that the person has had frequent symptoms of hypomania and depression for at least two years.

These do not have to be serious enough to be classified as either a hypomanic episode or a depressive episode. Cyclothymic disorder tends not to be unable to act or to be particularly debilitating. However, it can become more serious if it is not recognised and answered. From understanding how the fault works to practical steps to restore stability, understanding the condition you are suffering from helps reduce anxiety and provides a foundation on which to take measures to restore well-being.

Examining the way the person lives their life can reveal things that are jeopardising mood stability. Psychotherapy or counselling can help them identify patterns, particularly warning signs that mood is going in one direction or another, and develop prevention or coping strategies.

Medications are often an integral part of any treatment plan to avoid disruptions caused by dramatic and intense fluctuations from one extreme to the other. Ines Santiago of leading Swiss Health & Wellness facility Clinic Les Alpes explains that, ‘typically, treatment entails a combination of at least one mood-stabilising drug and/or atypical antipsychotic, plus psychotherapy’. The most widely used drugs for the treatment of bipolar disorder include lithium carbonate and valproic acid (also known as Depakote or generically as divalproex).

Practical steps to ensure that medications are taken consistently as prescribed are advisable such as storing a reminder in a mobile phone. The aim of the therapy is to achieve as much stability as possible in the mood as well as in related thoughts, behaviours and sensory sensitivity. This can be achieved through a combination of health education, lifestyle changes, psychotherapy, and prescribed medication.

As with many health problems, isolation and social separation should be avoided. A good support system is crucial. Other people sometimes see signs of an upcoming episode of hypomania, mania, or depression in front of the person himself. Well-informed family and friends can help provide a safety net and recovery resources if this should occur.

Dennis Relojo-Howell is the founder ofPsychreg.

Disclaimer: Psychreg is mainly for information purposes only. Materials on this website are not intended to be a substitute for professional advice, diagnosis, medical treatment, or therapy. Never disregard professional psychological or medical advice nor delay in seeking professional advice or treatment because of something you have read on this website. Read our full disclaimer here.

The History of Bipolar: Through the Ages—It’s Been There

There’s no time like the present to be diagnosed with bipolar disorder. Comparisons between what we know now versus what we knew then reveal that, indeed, our understanding of the disorder has come a long way.

Though it’s impossible to trace the first case of bipolar depression or mania, much is known about the evolution of its identification and subsequent classification and naming as manic depression—now known generally as bipolar—and about those specialists whose breakthroughs have contributed so much to our present-day treatment expertise.


As might be expected, the early history of bipolar and other mental disorders is not pretty, but rather a testimony to ignorance, misunderstanding, and fear. Consider that in 300 to 500 AD, some people with bipolar disorder were euthanized, according to Cara Gardenswartz, PhD, who is in private practice in Beverly Hills, California, with specific expertise in bipolar disorder and in its history.

“In the earliest days of documentation, these people were viewed as ‘crazy,’ possessed by the devil or demons,” Dr. Gardenswartz says. Their treatment or punishment, she explains, included restraint or chaining their blood was let out they were given different potions, or electric eels were applied to the skull—“much in the way witches have been treated in various cultures. In fact, witchcraft was often used to try and ‘cure’ them,” Gardenswartz says. “Less is known about bipolar disorder from 1000 to 1700 AD, but in the 18th and 19th centuries, we adopted a healthier overall approach to mental disorders.”

Consider these developments in the evolution of bipolar disorder, which was observed and studied in the second century by physician Aretaeus of Cappadocia—a city in ancient Turkey. In his scholarly work, On Etiology and Symptomatology of Chronic Illnesses, Aretaeus identified mania and depression he felt they shared a common link and were two forms of the same disease. The ancient Greeks and Romans coined the terms “mania” and “melancholia” and used waters of northern Italian spas to treat agitated or euphoric patients—and, in a forecast of things to come, believed that lithium salts were absorbed into the body as a naturally occurring mineral. In 300–400 BC, the ancient Greek philosopher Aristotle had thanked “melancholia” for the gifts of artists, poets, and writers, the creative minds of his time. Conversely, in the Middle Ages, those afflicted with mental illness were thought to be guilty of wrongdoing: their illness was surely a manifestation of bad deeds, it was thought.

In 1621, Robert Burton—English scholar, writer, and Anglican clergyman—wrote what many deem a classic of its time, a review of 2,000 years of medical and philosophical “wisdom”: The Anatomy of Melancholia, a treatise on depression that defined it as a mental illness in its own right. In 1686, Swiss physician Théophile Bonet named “manico-melancolicus” and linked mania and melancholia.

Measurable progress was made in the early 1850s when Jean-Pierre Falret, a French psychiatrist, identified folie circulaire or circular insanity—manic and depressive episodes that were separated by symptom-free intervals. He broke substantial new academic ground when he chronicled distinct differences between simple depression and heightened moods. In 1875, because of his work, the term “manic-depressive psychosis,” a psychiatric disorder, was coined. Scientists also credit Falret with recognizing a genetic link associated with this disease.

“We owe the categorization of bipolar disorder as an illness to Falret,” write Jules Angst, MD, and Robert Sellaro, BSc, of Zurich University Hospital in Switzerland, in their September 2000 paper, “Historical Perspectives and the Natural History of Bipolar Disorder,” published in Biological Psychiatry.

“It is remarkable how Falret’s description of symptoms and hereditary factors are so similar to descriptions found in present-day books and journals,” writes Erika Bukkfalvi Hilliard, MSW, RSW, of Royal Columbian Hospital in New West-minster, British Columbia, in her 1992 book Bipolar Disorder, Manic-Depressive Illness. “Falret even encouraged physicians to diversify medications used in the treatment of manic-depressive illness in the hopes that one of them might one day discover an effective drug therapy.”

Dr. Angst and Sellaro note that con-currently in 1854 French neurologist and psychiatrist Jules Gabriel François Baillarger used the term folie à double forme to describe cyclic (manic–depressive) episodes. Baillarger apparently also recognized a distinct difference between what we now know as bipolar and schizophrenia.

In their treatise, the Swiss specialists detail more specifics about the face of an emerging illness, particularly as it relates to “mixed states.” They write, “The history of the concept of mixed states [symptoms of mania and depression occurring simultaneously] … were probably already known at the beginning of the 19th century and named ‘mixtures’ … and ‘middle forms.’” A 1995 paper by French psychiatrist T. Haugsten, “Historical Aspects of Bipolar Disorders in French Psychiatry,” also traces the term “mixed states’ to J. P. Falret’s son, Jules Falret.

“At the end of the 19th century, in spite of the contributions of Falret, Baillarger, and [German psychiatrist Karl Ludwig] Kahlbaum (among others), most clinicians continued to consider mania and melancholia as distinct and chronic entities with a deteriorating course,” José Alberto Del Porto, Paulista School of Medicine of the Federal University of São Paulo, states in an October 2004 research paper published in Revista Brasileira de Psiquiatria. However, the acceptance of this theory would not prevail forever.


German psychiatrist Emil Kraepelin (1856–1926) is one of the most recognizable names in the history of bipolar. He is sometimes referred to as the founder of modern scientific psychiatry and psycho-pharmacology. He believed mental illness had a biological origin and he grouped diseases based on classification of common patterns of symptoms, rather than by simple similarity of major symptoms, as those who preceded him had done. This forward-thinking specialist postulated that a specific brain or other biological pathology was at the root of each of the major psychiatric disorders. Kraepelin felt that the classification system needed revising, and so he did just that.

In the early 1900s, after extremely detailed research, he formulated the separate terms “manic-depression” and “dementia praecox,” the latter later named schizophrenia” by Eugène Bleuler (1857–1940). Widespread use of the term “manic depression” prevailed until the early 1930s—it was even used until the 1980s and 1990s. Also during the early 1900s, Sigmund Freud broke new ground when he used psychoanalysis with his manic-depressive patients: biology then took a back seat. He implicated childhood trauma and unresolved developmental conflicts in bipolar disorder.

In the early 1950s, German psychiatrist Karl Leonhard and colleagues initiated the classification system that led to the term “bipolar,” differentiating between unipolar and bipolar depression. Dr. Gardenswartz notes that “once there was a difference between bipolar and other disorders, individuals suffering from mental illnesses were better understood, and in turn—along with the progress in psychopharmacology—were able to receive better treatment.”

The term “bipolar” logically emphasizes “the two poles” of mood episodes, according to the prominent psychiatrist Robert L. Spitzer, MD, who was a major force in developing the modern approach to classifying and diagnosing psychiatric illnesses. People with unipolar depression experience low mood episodes only, while people with bipolar depression experience both depressed and elevated moods in a cyclical manner. (In some cases of bipolar I disorder, people have manic episodes only.)

Dr. Spitzer led the task force that wrote the third version—an undeniably major revision—of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). After DSM-III was published in 1980, the reference work became so influential it is often referred to as the “bibIe” of American psychiatry. (Specialists in many other countries use the International Classification of Mental and Behavioural Disorders, or ICD.)

Among the monumental changes in the DSM-III, the term “manic-depression” was dropped and “bipolar disorder” introduced—eliminating references to patients as “maniacs.” Further revisions of the DSM over the years have clarified inconsistencies in diagnostic criteria and incorporated updated information based on research findings, according to the American Psychiatric Association (APA). The APA issued the latest edition, DSM-5, in 2013.

Noted American neuroscientist and psychiatrist Thomas Insel, MD, former director of the National Institute of Mental Health, has said that whatever the changes in the DSM over the years, the reference work ensures that clinicians use the same terms in the same way.

Each edition has also reflected changes in philosophy in psychiatric practice. For example, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) noted that the DSM-5 takes a “lifespan” perspective that recognizes the importance of age and development on the onset, manifestation, and treatment of psychiatric disorders.

When the DSM-5 came out, an editorial in the International Journal of Bipolar Disorders predicted that some of the changes should address an “under-recognition” of bipolar disorders. The chapter traditionally covering “mood disorders” was broken into separate chapters for unipolar depressive disorders and bipolar disorders. In addition to bipolar I (“classic” manic-depression), bipolar II (depression plus hypomania), and cyclothymic disorder (mood episodes that don’t meet the full diagnostic criteria for either bipolar I or II), the new chapter includes a more flexible category for “bipolar-like phenomena.”

Furthermore, the criteria for diagnosing elevated mood states now includes an emphasis on shifts in energy level and goal-directed activity. The editorial writers felt this would make it easier to distinguish bipolar depressions from unipolar depressions in the absence of a current hypo/manic episode, since notable upticks in energy and activity would be easier for individuals to identify and recall in self-reports.

Continue Reading “The History of Bipolar”

Printed as “The History of Bipolar,” Winter 2020
(Updated and expanded from the Spring 2006 issue to incorporate advances over the past decade.)