Decoding Your Bipolar Diagnosis

Bipolar disorder comes in many different combinations. Diagnostic specifiers help describe your particular diagnosis based on when mood episodes happen and what they look like.

Saying “I have bipolar” is like saying “I like pizza.” Not because a serious chronic illness in any way resembles a tasty dish, but because both statements disguise an underlying diversity of experience.

Take any two people who both like pizza: One might want a thin, crispy crust and lots of toppings, while the other goes for simple cheese and pepperoni on a doughy disc. Two people who have bipolar disorder both have moods that shift beyond the norm in either direction, but can be quite dissimilar in how often they have mood episodes and what happens when they do.

Thus the need for diagnostic nuance, which is provided by something called specifiers. Think of the basic diagnosis — bipolar 1 or bipolar 2 — as the broad strokes of a portrait. Specifiers shade in detail to create a fuller, more accurate picture.

In a way, the more specifiers tagged onto your diagnosis, the better. It means your clinician has drilled down into your individual reality in order to better treat you.

The Individual Bipolar Diagnosis

Kevin’s current diagnosis is bipolar 1 with rapid cycling, mixed features, and psychotic features. To a clinician, that means Kevin has had at least one lifetime episode of mania, that he’s had four or more mood episodes in a year, that his manic episodes may have features of depression and vice versa, and that he’s experienced some element of psychosis — in his case, visual and tactile hallucinations.

Kevin has been dealing with full-blown symptoms since his teens. After logging time in hospitals, day programs, and support groups, working with psychiatrists and therapists, and learning from his own mistakes, he’s now holding down a full-time job and has solid relationships.

“Every day you get through is a success and you say, ‘Hey, I can do this,’” he reflects.

Success takes groundwork. Kevin touches base with his psychiatrist monthly, and meets weekly with a peer coach through an integrated care program. He walks between his home in Hackettstown, New Jersey, and the home improvement store where he works as a mill sales specialist — about three miles round-trip. He watches his sleep and caffeine consumption, and enriches his life through writing poetry and building models of military ships.

Although he’s found a medication cocktail that’s “working wonderfully, pretty much” and practices good self-care, Kevin still cycles through mood shifts fairly often. He occasionally spots someone who isn’t actually there and sometimes feels things he knows aren’t real, such as a sensation as if his skin is on fire.

“When that happens, I try to get out of wherever I am and go home … it’s just part of the broader bipolar,” he explains.

What’s in a Name?

Does it help Kevin to know his diagnosis in detail?

“I’d rather be able to describe what I’m feeling than say to a doctor, ‘I have this,’” he says. “One of my psychiatrists said that a diagnosis is important to understand, but it’s more important to know the symptoms you have. If you treat the diagnosis, you treat it broadly. If you know the symptoms, you treat it specifically.”

He wouldn’t get an argument from experts like Erika F.H. Saunders, MD, chair of the department of psychiatry and behavioral health at Penn State.

“Sometimes the diagnosis is less important than the presenting symptoms,” says Dr. Saunders. “There are times when the diagnosis doesn’t match in terms of prognosis or treatment — it’s merely an academic issue of what we call something. There are other times when it matters very much.”

To make a psychiatric diagnosis, healthcare professionals turn to a reference guide called the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Every possible diagnosis, from acute stress disorder to unspecified trauma, lists a set of criteria — symptoms that must or may be present to rule in that condition. (Each specifier has its own qualifying criteria, too.)

Criteria for a Bipolar Diagnosis

A bipolar diagnosis involves multiple sets of criteria, since it is based on episodes of depression and hypomania (for bipolar 2) or mania (for bipolar 1).

The particulars of your diagnosis may shift slightly or significantly over time, depending on what symptoms come to the fore at each visit. Many people with bipolar 2 initially get misdiagnosed with major depression, because nothing leaps out during a depressive episode to say there’s a B side of hypomania.

Paul Latimer, MD, PhD, developed a comprehensive evaluation form based on a range of personality disorders and mood disorders — that is, bipolar and depression), anxiety, and attention deficit and hyperactivity disorder (ADHD). A psychiatrist in clinical practice and research, Dr. Latimer ran the Okanagan Clinic in Kelowna, British Columbia, up until his retirement.

Apart from the questionnaire, Latimer looks for clues in family history and often conducts a structured interview for even greater clarity. Because symptoms overlap across different conditions, pinpointing the perfect label can be tricky — but oh-so-important.

Impulsivity and distractibility are features of both ADHD and bipolar, for example. But if someone has bipolar rather than ADHD, or both bipolar and ADHD, prescribing the right pharmacotherapy gets complicated.

“If you put someone on ADHD medication, it could make the bipolar worse,” explains Latimer. “Sometimes you have to go through a period of trying treatments and seeing how they respond.”

Latimer says mild symptoms can be easy to miss since people may not even recognize a certain emotion or behavior is symptomatic if it’s not too disruptive. Take psychosis: From the doctor’s side of the desk, it’s not always clear whether someone’s statements reflect a realistic state of affairs or a touch of paranoia or delusion.

Bipolar Specifiers and Subtypes

According to the influential textbook Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, up to 70 percent of people with bipolar have psychotic symptoms during mania and at least half experience psychosis during depression. Yet the criteria for diagnosing bipolar make no mention of it.

Instead, features that affect a significant subset of the population with a particular disorder may end up as specifiers.

The late Jan A. Fawcett, MD, retired professor of psychiatry at the University of New Mexico, said in a 2015 interview that it takes an overwhelming body of clinical evidence to alter the DSM-5 criteria for a diagnosis like bipolar, “but you can add specifiers and give the clinician more to go on in terms of what to expect and how to treat.”

Dr. Fawcett was in charge of a panel of psychiatrists who spent years considering changes for the mood disorders section of DSM-5, resulting in the addition of the specifier “with anxious features.” Research shows that people who have anxious symptoms during a depressive episode tend to have a worse course of illness, poorer response to treatment, and, with severe anxiety, higher risk of suicidal behavior.

“It’s a very important issue, but it’s not in the [essential] criteria,” Fawcett noted.

Fawcett said specifiers may actually mark a distinct subtype within a larger diagnostic category. The specifier “adds a piece of information that separates it from other forms and has significance for prognosis and treatment,” he explained.

“Do people with anxious depression respond better to a different treatment than people without anxiety? We’re just beginning to look at those things.”

In an ideal world, there would be specifiers for a range of other issues that affect the course and treatment of bipolar, such as early age of onset, the presence of chronic inflammation, and how quickly moods shift between low and high.

The Seasonal Shifts of Bipolar Disorder

Saunders would love to fine-tune the rapid-cycling specifier to recognize “that many people have more than four mood episodes in a year. If you use a simple ‘more than four, less than four,’ you lose that gradation.”

While most of the specifiers for mood disorders describe some aspect of a mood episode, like the increased appetite and sluggishness of “atypical” depression, rapid cycling tells you something about the likelihood of mood shifts recurring. Peripartum onset and seasonal pattern, meanwhile, warn of when to expect them.

“The benefit of identifying seasonal patterns is that you can be proactive in looking at treatments and at lifestyle modifications that can be beneficial to preventing those episodes,” explains Saunders.

Geneviève knows that when the days shorten and the weather worsens in southern Quebec, she’s likely to go through a drop in mood, energy, and motivation. From roughly October through April, she channels what little energy she has into her job as a pharmacist’s assistant.

“I’m like a bear. I go into hibernation mode,” she says, recalling a week’s vacation spent in bed with her cats one winter.

With the arrival of spring, she bounces in the other direction. One year, as the trees began to bud earlier than usual, she found herself at a restaurant with a friend, “talking a mile a minute, interrupting… you’re thinking so fast, and it all comes out.”

Geneviève says her long-term boyfriend takes it in stride when she can’t muster the effort to do household chores, because he knows a couple of months later she’ll be up at 6 a.m. with the vacuum running.

Her doctor, meanwhile, reminds her to keep up her light therapy during the dreary season. That approach wouldn’t be useful if her depression was triggered by stress rather than changes in daylight.

Diagnosis and Denial

For Tara, it’s all about stress. That’s what sent her into severe mania and psychosis in March 2010.

The Wisconsin mother of three had a history of depression dating to her early twenties — including two postpartum episodes — and what she now understands were unrecognized hypomanic periods when she slept less and was more productive.

“I was a typical bad mental health patient,” says Tara. “I would be on the treatment plan for a while and then I would stop, and then a major life event would happen and I would go back and see my psychologist for a while. … There was always this denial: ‘This isn’t even a real disease, and I don’t have it.’”

Thus she had weak defenses against the demands of raising two preschool boys and their “tweenage” brother while also finishing up her bachelor’s degree and commuting twice a week to a management job in Milwaukee.

Ultimately the race to keep up shifted into overdrive. Tara, a former journalist, became convinced she was going to write the great American novel. She needed less and less rest, ultimately staying awake for three days straight. She heard Jesus Christ speaking to her and believed heaven had arrived on earth.

“I couldn’t count to 10, I didn’t know where I was, I didn’t know who the president was,” she recalls. After several sleepless nights, “I thought I was at my birthday party and Ellen [DeGeneres] was throwing it for me. She loves me, apparently, in my dreams.”

Tara says it took nearly a year to regain her well-being after she was hospitalized and diagnosed with other specified bipolar with psychotic features. (The terms “unspecified” and “other specified” mean symptoms mostly meet DSM-5 criteria, but aren’t a perfect fit.) She received her BA cum laude and works part-time at her local library, fitting in some freelance writing and editing on the side.

In her memoir Stress Fracture, Tara documents her journey through psychosis to acceptance that she has a chronic condition demanding careful management.

“It was pretty clear a crisis had occurred and it was psychosis. What took longer to accept was that it wasn’t a fluke, it was symptomatic of this larger illness,” she admits.

Wrestling through the issue with her psychologist, plus seeing that her medications made things better, turned Tara’s thinking around. It helps her to see that episode of psychosis as “a brain injury caused by repeated stress. It’s like an athlete with an injured ankle. You keep playing until at a certain point you can’t. But it heals.”

Staying healthy involves a good family support system, quarterly visits to her physician and psychiatrist to monitor her meds, staying alert to red flags like changes in her sleep patterns, and watching her stress levels.

“I have a hard time saying no when people want me to help with the baby shower or the bake sale or whatever, but I have to watch my stress. I even have to say no to things I do want to do. I know it would be fun to chaperone more field trips, to join a book club… but that would be dangerous for me to always go, go, go.”

No matter what the diagnosis, “when you’re healthy, life is just easier.”

Of note, it is not uncommon to leave a hospital stay or to get an initial diagnosis with a new outpatient provider that is unspecified or less specified. Sometimes it takes time for a provider to get to know you and your symptoms, and sometimes, symptoms can change over time or new symptoms can emerge. This may mean your precise diagnosis or specifiers may also shift over time.

9 Descriptions for Bipolar Disorder (According to the DSM-5)

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists these add-on descriptions for bipolar disorder.

1. With Anxious Distress

During the most recent or current mood episode (depressive, hypomanic, or manic), at least two of the following symptoms are present: feeling keyed up or tense, feeling unusually restless, difficulty concentrating because of worry, fearful something bad will happen, or feeling on the edge of self-control. Anxious symptoms improve as the underlying mood episode resolves.

2. With Mixed Features

Denotes the presence of depressive symptoms during a manic or hypomanic episode, or hypo/manic symptoms during a depressive episode. This replaces the separate category for “mixed state” episodes, which required meeting full criteria for both poles at the same time.

3. With Rapid Cycling

Technically, this simply means four or more mood episodes of any kind within a 12-month period — although people whose moods fluctuate quickly, sometimes within the course of a single day, often use “rapid cycling” to describe those mood gyrations. (The correct term for many ups and downs in a day is “ultradian cycling.”)

4. With Catatonic Features

Used when certain extremes of physical activity and speech occur during a mood episode, including lack of response to stimuli, not moving or speaking, repeating words or movements of another person, or frantic movement with no purpose.

5. With Psychotic Features

Noted when paranoia, delusions, or hallucinations — auditory (hearing voices), visual (seeing things) or sensory (feeling something that isn’t there) — occur at any point during a mood episode. Religious delusions are common, such as believing you’ve been given a special mission or special message from God.

6. With Melancholy Features

Describes a depressive episode characterized by an almost complete lack of ability to feel pleasure even when something good happens. Typically, there is also insomnia and significant slowing of speech and activity.

7. With Atypical Features

Applies to a depressive episode in which the person sleeps and eats more than usual, often gaining weight. Other traits: Feeling sluggish and “leaden,” and being abnormally affected by rejection. If there is low mood, spirits may lift in reaction to a positive experience.

8. With Seasonal Pattern

This is also used for depressions that recur during certain seasons — typically in fall or winter — that can’t be attributed to events like school starting or seasonal unemployment. More rarely, people experience a pattern of summertime depressions.

9. With Peripartum Onset

Indicates mood episodes that begin during pregnancy or in the months after giving birth. This replaces “postpartum onset,” the term used in previous DSM editions, to reflect the fact that many women have mood symptoms that pre-date delivery.

Editorial Sources and Fact-Checking

Zimmerman M et al. DSM-5 Anxious Distress Specifier in Patients With Bipolar Depression. Annals of Clinical Psychiatry. August 2020.

Jain A et al. Bipolar Disorder. StatPearls. February 20, 2023.

Bipolar Disorder. National Institute of Mental Health. February, 2023.

Carvalho AF et al. Rapid Cycling in Bipolar Disorder: A Systematic Review. Journal of Clinical Psychiatry. June 2014.

UPDATED: Printed as “Your particular slice of bipolar”, Summer 2015