- Hi, I'm Dr. Tracy Marks a psychiatrist,
and I make mental health education videos.
Today I'm talking about two different presentations
of bipolar disorder.
A classic or textbook presentation,
and a non classic or atypical presentation.
And these are not official subtypes of bipolar disorder
that you'll find in the diagnostic manual.
This is a clinical description of two different ways
that bipolar disorder can present or look.
This matters because the classic form of bipolar disorder
tends to respond much better to lithium
and the atypical form tends to respond better
to anticonvulsant mood stabilizers
like Depakote or Lamotrigine
and the atypical antipsychotic medications
like Abilify or Seroquel.
I use and define a lot of terms in this video.
And I think it's good for you to know the clinical terms
so if you're listening to someone else talk about this,
or you're reading about it online,
you'll understand what's being said.
And sometimes when your doctor's talking to you,
he or she can slip into these terms
without thinking about it
because it takes some extra work
to do the translation in your head
to speak using nonclinical jargon.
I'll review the terms at the end of the video.
So going back to the atypical anti-psychotics,
they're called atypical
because they blocked dopamine and serotonin.
Whereas the older anti-psychotics like Haldol
block dopamine only,
and they're considered the first generation
of anti-psychotics focused only on treating psychosis.
Then in 1990, the first
of the second generation anti-psychotic medications
started with clozapine.
And these are anti-psychotics
that are mostly used today,
and especially in treating bipolar disorder
and treatment resistant depression.
Here's a comparison between classic bipolar disorder
and atypical bipolar disorder.
When it comes to hypomania and mania
with classic bipolar disorder,
you start with euphoric or happy or grandiose mania.
As you age, though, your manias can become more irritable,
but it starts out bright.
With atypical, you predominantly get dysphoria
or dark modes.
You can also get mixed states.
A mixed state is where you get a mixture of depression
and mania occurring at the same time.
I talk about it in more detail
in this video that I did on mixed mania.
With classic bipolar, you get full recovery between episodes
and can have long stretches in between episodes.
So when you're not having an episode,
you're back to your baseline state,
and that can last for months or years
before you have another episode.
With atypical, you tend to have these leftover symptoms
of a lesser intensity in between episodes.
So it may not feel like you ever really got out
of your last depression.
Things got better, but not all the way better.
So you don't feel like you ever got back
to the way you were before you got sick the first time.
And as far as terms go, the clinical term
for the leftover symptoms is subsyndromal.
These are symptoms
that are not as severe enough to be diagnosed as an illness
or a syndrome all by themselves
if you just look at them in isolation,
but in this case,
they're remnant symptoms of your bipolar illness.
Rapid cycling is having more than four episodes in a year
and is more common with atypical bipolar disorder
and rare with the classic form.
With classic, you don't tend to have other disorders
like anxiety, addictions or OCD,
and these other illnesses are called co-morbidities
because they co-occur with other illnesses.
Morbidity or morbid is a clinical term for disease state.
So if you ever read online
or hear someone refer to your premorbid state,
it's how you were before you were ill.
And if you have several illnesses
like ADHD, anxiety, bipolar disorder, et cetera,
all of these illnesses are considered co-morbidities.
So we tend to think of classic bipolar
as being more pure and not affected by other illness.
The age of onset of classic bipolar disorder
tends to be around age 15 to 19.
And for atypical it's earlier like ages 10 to 15.
Generally psychiatric illnesses that start to take shape
in a defined way in childhood
end up taking on a more severe form and adulthood.
It's like the illness has more time to gain momentum
and become a stronger version of itself.
As for personality style,
with classic bipolar disorder, people tend to have
either a normal personality that doesn't cause much problem
or what's called a hyperthermic personality.
Hyperthermic is a term we use to describe
someone who has naturally high energy,
a people person, or tends to be a leader.
With atypical bipolar disorder,
you see more personality disorders
like borderline personality disorder
or cyclothymic temperament.
I talk about the combination of bipolar disorder
and borderline personality disorder in this video.
Cyclothymia temperament is a psychological construct
and not a diagnosis.
A construct is a concept or theory that someone develops,
your temperament refers to your hard wiring
that you're born with.
With cyclothymic temperament, you're hardwired
to be more moody and emotionally reactive.
This reactivity comes
from being more interpersonally sensitive.
The last comparison is genetics.
With classic disorder, there's a clearer history
of someone in the family having bipolar disorder.
Not everyone has a family history of bipolar disorder
but many do since it's strongly heritable, another term.
Heritable means capable of being inherited
or passed down to another generation.
And in psychiatry,
the two most heritable disorders that we have
are bipolar disorder and schizophrenia.
If you have a first degree relative with this illness,
it's not okay given that you'll get it,
but you have a higher chance
than someone who does not have a relative with it.
A first degree relative
would be someone who shares half of your DNA,
like a parent or a sibling,
not a cousin or an uncle.
So with classic bipolar, it's more common
that you have bipolar disorder in the family.
With atypical bipolar disorder,
the family history is a little murkier,
there maybe relatives who have other disorders
like depression, schizophrenia or other illnesses.
Psychiatric illnesses in general can run in families
such that if you have an uncle with schizophrenia,
you could end up having depression.
You didn't inherit the same illness as your uncle
but you have a different mental disorder.
As it turns out, the classic bipolar picture
is less common than the atypical presentation.
Even though the word atypical
makes it sound like it's not that usual,
it's called atypical
because when the German psychiatrist Emil Kraepelin
first discovered bipolar disorder
which at the time he called manic depression,
it was the classic form that he first defined.
Later on this other variation became recognized.
So it's similar to the anti-psychotic story.
The newer second generation of anti-psychotics
are called atypicals
and they're a spinoff of the older ones,
but they are the ones that are more commonly used today.
But the main significance
to recognizing in these differences
is that classic bipolar disorder
tends to be more responsive to lithium.
And lithium has a lot of benefits
including being neuroprotective,
which means it protects the nerve cells in your brain
from injury and degeneration.
Despite the fact that lithium has a lot of side effects,
making people feel
as though they're cognitively slowed or dulled,
lithium has been shown
to have benefit in preventing dementia.
But it's not always an easy drug to take
and has other significant side effects.
That said, if you have a more atypical presentation
to your bipolar disorder,
you will probably get better results
with the anticonvulsants
and the atypicals anti-psychotic medications.
So to recap, here are the terms I discussed today.
Classic bipolar, atypical bipolar,
atypical or second generation anti-psychotics,
subsyndromal, morbidity, psychological construct,
hyperthermic temperament, heritable,
first degree and neuroprotective.
That's a lot of stuff.
If you wanna get used to hearing the jargon
and understanding it, watch the video again.
For more information on taking lithium, watch this video.
See you next time.