Journal of Affective Disorders 178 (2015) 107–111
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research report
The bipolar II disorder personality traits, a true syndrome? Einar Gudmundsson a,b,n a b
Private practice, Reykjavik, Iceland Psychiatric Outpatient Clinic, Ludvika, Sweden
art ic l e i nf o
a b s t r a c t
Article history: Received 10 September 2014 Received in revised form 25 February 2015 Accepted 27 February 2015 Available online 9 March 2015
Background: The author was struck by the similarities and commonality of complaints, aside from mood swings, made by Bipolar II patients and started registrating these complaints. This registrational work eventually led to the development of The Bipolar II Syndome Checklist. The aim of this work was to understand how widely the Bipolar II disorder affects the personality, and what disturbing personality traits are the most common? Deliberately, no attempt was made to diagnose psychiatric comorbidities, in the hope that one would get a clearer view of what symptoms, if any, could be considered a natural part of the Bipolar II Disorder. As far as the author knows this is a novel approach. Method: 105 Bipolar II patients completed the Bipolar II Syndrome Checklist. The answers to the 44 questions on the list are presented in tables. Results: Symptoms like anxiety, low self esteem, paranoia, extreme hurtfulness, migraine, Post Partum Depression, obsessive traits, alcoholism in the family are amongst the findings which will be presented in greater detail. Limitations: No control group. Bipolar I patients excluded. The Bipolar II Syndrome Checklist has not been systematically validated. Conclusions: The results show that Bipolar II Disorder causes multiple symptoms so commonly that it may be justified to describe it as a syndrome, The Bipolar II Syndrome. Also these disturbances commonly lie in families of Bipolar II patients and are in all likelihood, greatly underdiagnosed. The clinical relevance of this study lies in increasing our knowledge and understanding of the nature of the Bipolar II Disorder, which in all probability will increase the diagnostic and treatment accuracy, since clinicians are more likely to scan for other symptoms needing treatment. & 2015 Published by Elsevier B.V.
Keywords: Bipolar II Disorder Personality Traits The Bipolar II Syndrome The Bipolar II Disorder Syndrome Checklist Mood disorders The Bipolar II Disorder
1. Introduction The scientific literature on Bipolar Disorder has largely been occupied with the nature of mood swings, and their treatment. The focus has commonly been on the duration of swings, the depth or height of swings, duration of remission between swings etc. With important exceptions (Akiskal et al., 1995; Judd et al., 2003; Akiskal et al., 2006; Rihmer et al., 2010) other symptoms have usually been categorized as a part of a co-morbidity and given another diagnose as well, sometimes many diagnoses. This approach is different from most of the literature on Schizophrenia where few researchers are scanning for co-morbidities. Rather the diagnosis has been widened to include common possible symptoms, and where symptoms of the two towers in classical psychiatry, Schizophrenia and Bipolar
n Correspondence to: Sunnuflot 20, 0210 Gardabaer, Iceland. Tel.: þ 354 896 6997/þ 354 588 8557. E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jad.2015.02.030 0165-0327/& 2015 Published by Elsevier B.V.
Disorder, merge, it merits its own diagnosis; Schizoaffective Disorder. When working simultaneously in two countries (Iceland and Norway) the author was struck by the similarities of Bipolar II Disorder patient's complaints and symptoms in both countries. Complaints that were not necessarily associated with the classical mood swings. Over several years the author registered these complaints as a curiosity to see if there was anything to be learned from them. The author deliberately avoided focusing on the diagnosis of co-morbidities to see where this registration would lead. Eventually this led to a 44 item list, The Bipolar II Syndrome Checklist. This list quickly proved valuable in clinical work, and many patients were astonished by the questions on the list: “These questions are right to the core of my problems”. “After all those years of seeking help, nobody has asked me about these symptoms” are common responses by patients. Also: “This list is very much about me”. A more systematic approach was clearly needed to follow up on the patient's symptom diversity. So this paper came about.
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E. Gudmundsson / Journal of Affective Disorders 178 (2015) 107–111
2. Method The Bipolar II Syndrome Checklist (BSC) was presented to 105 Bipolar II patients, over several years from the authors Private Practice in Reykjavik, Iceland. When the news of the authors work with Bipolar II patients spread amongst colleagues, the referral rate of Bipolar II patients increased rapidly. Also family members of Bipolar II patients increasingly sought treatment. The clinical diagnosis of a Bipolar II Disorder (DSM IV, 1994) was the only inclusion criteria. The first 105 Bipolar II patients to fully complete the BSC are the patients included in this study. The gender ratio was found to be 36% Male and 64% Female. Average Age for both sexes was found to be 32 years. All 105 patients were asked around 40 questions from the BSC and rated by the author himself and all 105 patients completed the list. The BSC was introduced during the 1–3 sessions upon admission. Usually the list was completed in one session, but sometimes it would stretch to two sessions. Questions regarding symptoms in the family were answered by the patient, but when the patient did not know the answers, he was encouraged to ask someone in the family who would know. The average time for completing the BSC was between 20–30 min. The list and answers are now part of the patient's journal. A few questions were later added during the process accounting for different (lower) numbers of patients answering these particular questions.
3. Results The BSC (Fig. 1) is here divided into 6 subcategories and the answers are presented in tables. Results are shown in Tables 1–6. The questions are presented here in somewhat abbreviated form. There were a few new questions added during the research period. Those questions are marked with n, and questions that were only relevant for female patients are marked with nn and nnn. During the last stages of this study it had come clear that the rate of completed suicides by a relative was unexpectedly high. A question about completed suicides in family was added to the BSC, but too late to be formally included in this study. Table 1 shows how great the burden of anxiety is for this group of patients (96%), especially during the morning hours (76%). It shows how common chronic thoughts of death and suicide are (59%), even though actual suicidal attempts (one, or more) are only made by one out of five (22%). It also shows how many experience worsening of symptoms between the ages of 15–20 (82%). Females who had borne children were asked if they had experienced Post Partum Depression, which turned out to be very common (63%). Almost two thirds of the females had experienced depression associated with Menstruation (64%). Table 2 shows how low the self-esteem generally is in this group of patients (95%), and many have always had low self-esteem (63%). Also they are burdened with extreme hurtfulness (97%), guilt (87%) and their eagerness to please is common (92%). Also it shows their problems with compliments in face of success (51%). Table 3 shows how common Mild Paranoia is (95%). (Here mild means to have difficulties in trusting and opening up to other people, never letting anyone really come close, often being on the guard). Also it shows how common it is to have imagined conspiracy at one time or another in one's life which is a sign of a more fulminant paranoia (80%). Distrusting compliments are very common (83%), meaning here to look for a hidden agenda behind the compliments, what is the person really after with the compliments. Childhood fear of darkness (61%) has some similarities to paranoia, and may be seen as a kind of childhood paranoia. For many patients fear of darkness seems to last well into adult life (34%).
The Bipolar II Syndrome Checklist-R: Nr............ Name........................................................ID................................. 1) Mood swings: a) Depression: No..........Probably.........Yes......... b) Hypomania: No.........Probably..........Yes.......... 2) Anxiety: No.....Considerable....Constant....Social Phobia: Yes... No..* 3) Anxiety and/or depression when waking up: No.....Seldom.....Often...... 4) Worst part of day usually: Morning........ Afternoon........Evening......... 5) Chronic thoughts of death and/or suicide: No....Yes...Attempts (nr.)...... 6) Worsening of symptoms between age 15-20: No.......Yes........ 7) Post partum depression: No.....Probably......Yes.....,family: No....Yes.... 8) Depression ass. with menstruation: No........ Yes......... 9) Mild parnoia: No...... Yes......., imagined conspiracy No....... Yes.......... 10) Childhood fear of darkness: No.....Seldom....Often.....Stopped(age)..... 11) Low selfesteem: No........ Yes.......... , always No........ Yes.......... 12) Guiltfeelings: Seldom......... Often......... Constant.......... 13) Easily hurt and sensitive to what others think: No......... Yes.......... 14) Eager to please others: No......... Yes......... 15) Difficulty accepting compliments: No........ Seldom....... Yes......... 16) Distrusts compliments No........ Yes.......... 17) Delay-compulsion (procrastination): No.......... Yes......... 18) Difficulty making decisions: No......... Yes........... 19) Difficulty forgiving yourself your own mistakes: No........ Yes......... 20) Perfectionistic: No........... Yes.......... 21) Obsessed with fat: No.......Yes.....Other bodyparts: No.......Which........ 22) Other OCD tendencies: No.....Yes/Which............................................. 23) Sleep disturbances: No.....Yes......, frequent nightmares No.....Yes...... 24) Difficulty laughing deeply: No........... Yes......... 25) Uncontrollable crying episodes: No....... Yes........ 26) Concentration problems: No........ Yes........ 27) Disturbance of memory: No........ Yes......... 28) Noise intolerance: No......... Yes.......... 29) Intolerance of smells: No.......... Yes......... 30) Touch intolerance: No......... Yes........ 31) Tics: No......... Yes........., in childhood.......... 32) Swings in threshold of physical pain experience: No......... Yes........ 33) Migraine: No.......... Probably........Yes........, family No........Yes........ 34) Bipolar I in family: No......... Probably......... Yes......... 35) Depression in family: No......... Probably........ Yes......... 36) Alcoholism in family: No.....Yes..... 37) Suicide in family: No.....Yes...... 38) ADHD in family: No.....Yes...... * Dx. Bipolar II: No....Probable.......Yes......Date...............©EG2014 * Questions added after the research period was over. Fig. 1. The Bipolar II Syndrome Checklist.
Table 4 shows how common obsessive–compulsive symptoms are (75%), and a perfectionistic character (77%), with difficulties forgiving him/her self for his/her own mistakes (87%). Also the very common problems of procrastination (84%) and difficulty in making decisions (83%). Last, the very common fear of becoming fat (61%), although few are actively doing anything about it. Less common is obsession with other body parts (20%), meaning that this obsession that has nothing to do with body parts being too fat, more a kind of dysmorfia. Table 5 lists several complaints, here categorized as Neurophysiologic. Sleep disturbances with, or without nightmares are very common (80%). Commonly this group of patients seems to lose the ability to let go in laughter (74%), and uncontrollable crying episodes are common (62%), especially among the females. This is a kind of crying that sometimes can come at an inappropriate time, is hard to stop, and gives no relief afterwards. The patients usually distinguish between a good crying and uncontrollable, bad crying. Concentration problems (87%) and disturbance of memory are common (67%). This seemed to be no less common in the young. Also noise (59%) and touch (58%) intolerance are common, but smell intolerance less so (35%). Tics in childhood are not so uncommon (32%), but less so in adult life (22%). Swings in threshold of physical pain experience are experienced by 30%. Possibly, such swings may be more common in patients that cut themselves. Finally, migraine is common in this group, at least 36%.
E. Gudmundsson / Journal of Affective Disorders 178 (2015) 107–111
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Table 1 The Bipolar II Syndrome Checklist: questions relating to anxiety and depression. 1) 2) 3) 4) 5) 6) 7) 8)
Anxiety Anxiety and/or depression when waking up Worst part of day usually Worsening of symptoms age 15–20 (n ¼95) Chronic thoughts of death and/or suicide Suicidal attempts (one or more) Post Partum Depression (n¼ 43) Depression ass. with menstruation (n¼67)
No 4% No 5% Morning 76%
Considerable 41% Seldom 25% Afternoon14% No 18% No 41% No 78% Probably 9% No 36%
No 28%
Constant 55% Often 70% Evening 10% Yes 82%n Yes 59% Yes 22% Yes 63% nn Yes 64%nnn
n
n¼ 95. This question was added during the research process. n¼ 43. This question was only for women that had borne children. nnn n¼ 67. This question was only for women. nn
Table 2 The Bipolar II Syndrome Checklist: questions relating to self-esteem. 1) 2) 3) 4) 5) 6)
Low self-esteem (LSE) Always LSE Easily hurt and sensitive to what others think Eager to please others Difficulty enjoying compliments Guilt-feelings
No 5% No37% No 3% No 8% No 44% Seldom 13%
Yes 95% Yes 63% Yes 97% Yes 92% Seldom 5% Often 53%
Yes 51% Constant 34%
Table 3 The Bipolar II Syndrome Checklist: questions relating to paranoia. 1) 2) 4) 5) 6)
Mild paranoia Imagined conspiracy Distrusts compliments Fear of darkness (FD) in childhood (n ¼87) Age FD ended
n
No 5% No 20% No 17% No 29% o 20 years 55%,
Often 61%n Still FD 34%
n¼ 87. This question was added during the research process.
Table 4 The Bipolar II Syndrome Checklist: questions relating to obsessive–compulsive symptoms. 1) 2) 3) 4) 5) 6) 7)
Yes 95% Yes 80% Yes 83% Seldom 10% 420 years 11%,
OCD symptoms Perfectionistic Difficulty forgiving yourself your own mistakes Delay-compulsion (procrastination) Difficulty making decisions Obsessed with possibility of becoming fat Obsessed with other body parts (dysmorphia)
No No No No No No No
25% 23% 13% 16% 17% 39% 80%
Yes Yes Yes Yes Yes Yes Yes
75% 77% 87% 84% 83% 61% 20%
Table 6 shows psychiatric problems in the extended families commonly reported. The rate of Bipolar I is unusually high in relatives ( 441%). Also the rate of depression is exceptionally high (93%). Post Partum Depression (PPD) is common (37%), possibly higher since many patients, especially the males, said they had little knowledge about PPD in their families, let alone extended families. Migraine was known in more than half of the families (53%). The question about Alcoholism in family was included later in the process, only 38 patients were asked this question, but almost all (97%) of those reported Alcoholism in their families. Since reports of completed suicides by relatives were common in this group, the question about completed suicides developed in the latter stages, but it was considered too late to include this question formally in this research. Many patients in this group knew of completed suicides by their relatives, although the total number of suicides in Iceland is not that high (35–40 per year). This high suicide rate in the families of Bipolar II is in accordance with the high suicide rates of Bipolar II patients reported by other authors (Rihmer and Kiss, 2002; Aksikal, 2007; Pompili et al., 2013).
4. Discussion The results show how widely the Bipolar II Disorder affects the personality in general and the many symptoms of this disorder aside from the actual mood swings. The title of this paper raises the question whether it is appropriate to define The Bipolar II Disorder as a syndrome, rather than a disorder with many possible co-morbid disorders. The definition of a syndrome is supportive of the first (Wikipedia, 2014): “A syndrome is the association of several clinically recognizable features, signs (observed by someone other than the patient), symptoms (reported by the patient), phenomena or characteristics that often occur together, so that the presence of one or more features alerts the healthcare provider to the possible presence of the others.” If the above is true for Bipolar II Disorder, one would look for symptoms of anxiety, OCD, paranoia, low self-esteem, alcohol/substance abuse in these patients. Also one would look for chronic suicidal ideations, extreme hurtfulness, concentration problems, sleep problems, procrastination, Post Partum Depression to name a few of the symptoms listed above. One would even look closely at the patient's family history since many of the symptoms seem to be heritable. On the other hand one would look especially closely for Bipolar II Disorder in patients with major depressive episodes (Akiskal and Benazzi, 2005; Benazzi, 2007), OCD, paranoia, alcohol/substance use, Post Partum Depression, low self-esteem, procrastination, concentration problems and chronic suicidal ideation to name a few. Most of the symptoms mentioned above are well known in the bipolar literature mostly though as part of different co-morbidities (Merikangas et al., 2007; Angst et al., 2005; Myrick and Brady, 2003; McElroy et al., 2001; Perugi et al., 1997).
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E. Gudmundsson / Journal of Affective Disorders 178 (2015) 107–111
Table 5 The Bipolar II Syndrome Checklist: questions related to neurophysiology. 1) Sleep disturbances 2) Frequent nightmares 3) Difficulty laughing deeply 4) Uncontrollable crying episodes 5) Concentration problems 6) Disturbance of memory 7) Noise intolerance 8) Intolerance of smells 9) Touch intolerance 10) Tics 11) Swings in threshold of physical pain experience 12) Migraine
No No No No No No No No No No No No
Table 6 The Bipolar II Syndrome Checklist: questions related to relatives. 1) 2) 3) 4) 5) 6)
Bipolar I in family No 34% Probably 25% Yes 41% Depression in family No 5% Probably 2% Yes 93% Post Partum Depression in family No 63% Yes 37% Migraine in family No 47% Yes53% Alcoholism in family (n ¼38) No 3% Yes 97%n Incidence of completed suicides amongst relatives unusually high.
n
n¼38. This question was added during the research process.
The results of this study show that different symptoms may vary in commonality and intensity. The possibility of a Bipolar II Disorder being overlooked is therefore great since other “nonmood swing symptoms”, commonly referred to as co-morbidities, may be the most prominent symptoms. This also means that Bipolar II patients may present with different symptoms that may need treatment from early on, even before mood stabilization. Although mood stabilizers are usually the first step in treatment, other symptoms may be the most prominent, like anxiety and/or OCD, alcohol/substance abuse, paranoia, sleeping problems etc. and therefore need treatment first or simultaneously. A limitation to this study is that Bipolar I Disorder patients are excluded, since the there were just too few Bipolar I patients actual at the time to make a significant difference. Recent research shows however that there may be some difference in the personality traits of Bipolar I and Bipolar II (Byungsu et al., 2012). Judd et al. (2003) found important differences in clinical characteristics between Bipolar I and Bipolar II where anxiety disorders, social phobia and simple phobias were more common in Bipolar II. Akiskal et al. (2006) found Bipolar II patients to be more “mood labile”, “energy-assertive”, “sensitivitybrooding” and “socially anxious” than Bipolar I. The unusually high rate (41%) of established Bipolar I Disorder in families of Bipolar II in this study is suggestive of a continuum where Bipolar II is the more common and a few close or distant relatives are burdened with the Bipolar I Disorder. Bipolar I is a more visible disorder and empirically Bipolar II is hidden in many families. The question regarding the difference between the personalities of Bipolar I and Bipolar II is not the scope of this paper although it is an important one and needs further research. A second limitation is that the BSC has not been scientifically validated, although it has proved to be a valuable tool clinically. A third limitation is the lack of a control group. A control group is necessary to validate the BSC and would have increased the scientific power of this study. It is though evident from the above that The Bipolar II Disorder affects patients in a variety of ways. Some of the patients were positive on almost all the items in the BSC. For most of the patients, the author's impression was that the Bipolar II affects the patient's personality widely, but not necessarily heavily on all items. Sometimes patient's scored on almost all items, but low,
20% 57% 26% 38% 13% 33% 41% 65% 42% 78% 70% 40%
Yes 80% Yes 43% Yes 74% Yes 62% Yes 87% Yes 67% Yes 59% Yes 35% Yes 58% Yes 22%, Yes 30% Probably 24%
In childhood 32% Yes 36%
meaning that no symptoms were very prominent or disabling. A common theme, and often a disabling one, is the “self-mobbing” or “self-bullying” that seems to be quite constant in the patient's life, although hypomanic episodes can be a temporary relief. This means amongst other things that the patients do not allow themselves to enjoy their successes, though for some they are many. Because of the great overlapping, this paper clearly favors the syndrome line of thinking above co-morbidities for the Bipolar II Disorder. This may be more in accordance with the more recent approach in the USA called The Research Domain Criteria (RDoC) developed by The National Institute of Mental health (NIMH) and represents a break with the existing research categories in Psychiatry 〈www.nimh.nih.gov〉. This paper touches on too many aspects, symptoms, co-morbidities that the scientific literature has already covered well, making it impossible to for a short paper like this to cover all the research material available. Rather the focus here has been on the whole more than the parts. As far as the author is aware of this is a novel approach in Bipolar research and it is the authors sincere hope that this paper might inspire scientists to do more research on the Bipolar II Disorder Personality Traits a long similar lines. The author permits the free use of the BSC for interested researchers and even make changes, if necessary, to facilitate further research.
Role of funding source None.
Conflict of interest None.
Acknowledgments The author would like to thank Prof. Jules Angst M.D. for looking over the preliminary abstract and results in the early stages of this work, and for his advice, pointing out of references and encouragement in general. And the author would also like to thank Prof. Joseph Calabrese M.D., also for looking over the preliminary abstract and results in the early stages of this work and for his advice, and encouragement in general, and especially for pointing out The Journal of Affective disorder as the natural journal to approach with this kind of research. Lastly the author would like to thank Jon G. Stefansson M.D. former Ass. Professor at The National University Hospital in Iceland for reading over the manuscript in the last stages, his valuable advice, and encouragement in general.
References Akiskal, H.S., et al., 1995. Arch. Gen. Psychiatry 52, 114–123. Judd, L.L., et al., 2003. The comparative clinical phenotype and long term longitudinal episode course of bipolar I and II: a clinical spectrum or distinct disorders? J. Affect. Disord. 73, 19–32.
E. Gudmundsson / Journal of Affective Disorders 178 (2015) 107–111
Akiskal, H.S., et al., 2006. The distinct temperamental profile of bipolar I and bipolar II patients. J. Affect. Disord. 92, 19–33. American Psychiatric Association, 1994. Quick Reference to the Diagnostic and Statistical Manual of Mental Disorders, fourth ed. DSM-IV, Washington DC. Rihmer, et al., 2010. Current research on affective temperaments. Curr. Opin. Psychiatry. 23, 12–18. Rihmer, Z., Kiss, K., 2002. Bipolar disorders and suicidal behaviour. Bipolar Disord. 4 (Suppl.1), S21–S25. Aksikal, H.S., 2007. Targeting suicide prevention to modifiable risk factors: has bipolar II been overlooked? Acta Psychiatr. Scand. 116, 395–402. Pompili, M., et al., 2013. Epidemiology of suicide in bipolar disorders: a systemic review of the literature. Bipolar Disord. 9, 101–105. 〈http://en.wikipedia.org/wiki/Syndrome〉. Akiskal, H.S., Benazzi, F., 2005. Optimizing the detection of bipolar II disorder in outpatient private practice: toward a systematization of clinical diagnostic wisdom. J. Clin. Psychiatry 66, 914–921. Benazzi, F., 2007. Bipolar Disorder – focus on bipolar II disorder and mixed depression. Lancet 369, 935–945.
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Byungsu, K., et al., 2012. Comparative study of personality traits in patients with bipolar I and II Disorder from the five-factor model perspective. Psychiatry Investig. 9 (4), 347–353. Merikangas, K.R., et al., 2007. Lifetime and 12-month prevalence of bipolar spectrum disorder in the national comorbidity survey replication. Arch. Gen. Psychiatry 64 (5), 543–552. Angst, J., et al., 2005. Obsessive–compulsive syndromes and disorders: significance of comorbidity with bipolar and anxiety syndromes. Eur. Arch. Psychiatry Clin. Neurosci. 255, 65–71. Myrick, H, Brady, K., 2003. Current review of the comorbidity of affective, anxiety, and substance use disorders. Curr. Opin. Psychiatry 16 (3), 261–270. McElroy, S.L., et al., 2001. Axis I comorbidity and its relationship to historical illness variables in 288 patients with bipolar disorder. Am. J. Psychiatry 158, 420–426. Perugi, G., et al., 1997. The clinical impact of bipolar and unipolar affective comorbidity on obsessive–compulsive disorder. J. Affect. Disord. 46 (1), 15–23. 〈http://www.nimh.nih.gov/research-priorities/rdoc/index.shtml〉.
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research report
The bipolar II disorder personality traits, a true syndrome? Einar Gudmundsson a,b,n a b
Private practice, Reykjavik, Iceland Psychiatric Outpatient Clinic, Ludvika, Sweden
art ic l e i nf o
a b s t r a c t
Article history: Received 10 September 2014 Received in revised form 25 February 2015 Accepted 27 February 2015 Available online 9 March 2015
Background: The author was struck by the similarities and commonality of complaints, aside from mood swings, made by Bipolar II patients and started registrating these complaints. This registrational work eventually led to the development of The Bipolar II Syndome Checklist. The aim of this work was to understand how widely the Bipolar II disorder affects the personality, and what disturbing personality traits are the most common? Deliberately, no attempt was made to diagnose psychiatric comorbidities, in the hope that one would get a clearer view of what symptoms, if any, could be considered a natural part of the Bipolar II Disorder. As far as the author knows this is a novel approach. Method: 105 Bipolar II patients completed the Bipolar II Syndrome Checklist. The answers to the 44 questions on the list are presented in tables. Results: Symptoms like anxiety, low self esteem, paranoia, extreme hurtfulness, migraine, Post Partum Depression, obsessive traits, alcoholism in the family are amongst the findings which will be presented in greater detail. Limitations: No control group. Bipolar I patients excluded. The Bipolar II Syndrome Checklist has not been systematically validated. Conclusions: The results show that Bipolar II Disorder causes multiple symptoms so commonly that it may be justified to describe it as a syndrome, The Bipolar II Syndrome. Also these disturbances commonly lie in families of Bipolar II patients and are in all likelihood, greatly underdiagnosed. The clinical relevance of this study lies in increasing our knowledge and understanding of the nature of the Bipolar II Disorder, which in all probability will increase the diagnostic and treatment accuracy, since clinicians are more likely to scan for other symptoms needing treatment. & 2015 Published by Elsevier B.V.
Keywords: Bipolar II Disorder Personality Traits The Bipolar II Syndrome The Bipolar II Disorder Syndrome Checklist Mood disorders The Bipolar II Disorder
1. Introduction The scientific literature on Bipolar Disorder has largely been occupied with the nature of mood swings, and their treatment. The focus has commonly been on the duration of swings, the depth or height of swings, duration of remission between swings etc. With important exceptions (Akiskal et al., 1995; Judd et al., 2003; Akiskal et al., 2006; Rihmer et al., 2010) other symptoms have usually been categorized as a part of a co-morbidity and given another diagnose as well, sometimes many diagnoses. This approach is different from most of the literature on Schizophrenia where few researchers are scanning for co-morbidities. Rather the diagnosis has been widened to include common possible symptoms, and where symptoms of the two towers in classical psychiatry, Schizophrenia and Bipolar
n Correspondence to: Sunnuflot 20, 0210 Gardabaer, Iceland. Tel.: þ 354 896 6997/þ 354 588 8557. E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jad.2015.02.030 0165-0327/& 2015 Published by Elsevier B.V.
Disorder, merge, it merits its own diagnosis; Schizoaffective Disorder. When working simultaneously in two countries (Iceland and Norway) the author was struck by the similarities of Bipolar II Disorder patient's complaints and symptoms in both countries. Complaints that were not necessarily associated with the classical mood swings. Over several years the author registered these complaints as a curiosity to see if there was anything to be learned from them. The author deliberately avoided focusing on the diagnosis of co-morbidities to see where this registration would lead. Eventually this led to a 44 item list, The Bipolar II Syndrome Checklist. This list quickly proved valuable in clinical work, and many patients were astonished by the questions on the list: “These questions are right to the core of my problems”. “After all those years of seeking help, nobody has asked me about these symptoms” are common responses by patients. Also: “This list is very much about me”. A more systematic approach was clearly needed to follow up on the patient's symptom diversity. So this paper came about.
108
E. Gudmundsson / Journal of Affective Disorders 178 (2015) 107–111
2. Method The Bipolar II Syndrome Checklist (BSC) was presented to 105 Bipolar II patients, over several years from the authors Private Practice in Reykjavik, Iceland. When the news of the authors work with Bipolar II patients spread amongst colleagues, the referral rate of Bipolar II patients increased rapidly. Also family members of Bipolar II patients increasingly sought treatment. The clinical diagnosis of a Bipolar II Disorder (DSM IV, 1994) was the only inclusion criteria. The first 105 Bipolar II patients to fully complete the BSC are the patients included in this study. The gender ratio was found to be 36% Male and 64% Female. Average Age for both sexes was found to be 32 years. All 105 patients were asked around 40 questions from the BSC and rated by the author himself and all 105 patients completed the list. The BSC was introduced during the 1–3 sessions upon admission. Usually the list was completed in one session, but sometimes it would stretch to two sessions. Questions regarding symptoms in the family were answered by the patient, but when the patient did not know the answers, he was encouraged to ask someone in the family who would know. The average time for completing the BSC was between 20–30 min. The list and answers are now part of the patient's journal. A few questions were later added during the process accounting for different (lower) numbers of patients answering these particular questions.
3. Results The BSC (Fig. 1) is here divided into 6 subcategories and the answers are presented in tables. Results are shown in Tables 1–6. The questions are presented here in somewhat abbreviated form. There were a few new questions added during the research period. Those questions are marked with n, and questions that were only relevant for female patients are marked with nn and nnn. During the last stages of this study it had come clear that the rate of completed suicides by a relative was unexpectedly high. A question about completed suicides in family was added to the BSC, but too late to be formally included in this study. Table 1 shows how great the burden of anxiety is for this group of patients (96%), especially during the morning hours (76%). It shows how common chronic thoughts of death and suicide are (59%), even though actual suicidal attempts (one, or more) are only made by one out of five (22%). It also shows how many experience worsening of symptoms between the ages of 15–20 (82%). Females who had borne children were asked if they had experienced Post Partum Depression, which turned out to be very common (63%). Almost two thirds of the females had experienced depression associated with Menstruation (64%). Table 2 shows how low the self-esteem generally is in this group of patients (95%), and many have always had low self-esteem (63%). Also they are burdened with extreme hurtfulness (97%), guilt (87%) and their eagerness to please is common (92%). Also it shows their problems with compliments in face of success (51%). Table 3 shows how common Mild Paranoia is (95%). (Here mild means to have difficulties in trusting and opening up to other people, never letting anyone really come close, often being on the guard). Also it shows how common it is to have imagined conspiracy at one time or another in one's life which is a sign of a more fulminant paranoia (80%). Distrusting compliments are very common (83%), meaning here to look for a hidden agenda behind the compliments, what is the person really after with the compliments. Childhood fear of darkness (61%) has some similarities to paranoia, and may be seen as a kind of childhood paranoia. For many patients fear of darkness seems to last well into adult life (34%).
The Bipolar II Syndrome Checklist-R: Nr............ Name........................................................ID................................. 1) Mood swings: a) Depression: No..........Probably.........Yes......... b) Hypomania: No.........Probably..........Yes.......... 2) Anxiety: No.....Considerable....Constant....Social Phobia: Yes... No..* 3) Anxiety and/or depression when waking up: No.....Seldom.....Often...... 4) Worst part of day usually: Morning........ Afternoon........Evening......... 5) Chronic thoughts of death and/or suicide: No....Yes...Attempts (nr.)...... 6) Worsening of symptoms between age 15-20: No.......Yes........ 7) Post partum depression: No.....Probably......Yes.....,family: No....Yes.... 8) Depression ass. with menstruation: No........ Yes......... 9) Mild parnoia: No...... Yes......., imagined conspiracy No....... Yes.......... 10) Childhood fear of darkness: No.....Seldom....Often.....Stopped(age)..... 11) Low selfesteem: No........ Yes.......... , always No........ Yes.......... 12) Guiltfeelings: Seldom......... Often......... Constant.......... 13) Easily hurt and sensitive to what others think: No......... Yes.......... 14) Eager to please others: No......... Yes......... 15) Difficulty accepting compliments: No........ Seldom....... Yes......... 16) Distrusts compliments No........ Yes.......... 17) Delay-compulsion (procrastination): No.......... Yes......... 18) Difficulty making decisions: No......... Yes........... 19) Difficulty forgiving yourself your own mistakes: No........ Yes......... 20) Perfectionistic: No........... Yes.......... 21) Obsessed with fat: No.......Yes.....Other bodyparts: No.......Which........ 22) Other OCD tendencies: No.....Yes/Which............................................. 23) Sleep disturbances: No.....Yes......, frequent nightmares No.....Yes...... 24) Difficulty laughing deeply: No........... Yes......... 25) Uncontrollable crying episodes: No....... Yes........ 26) Concentration problems: No........ Yes........ 27) Disturbance of memory: No........ Yes......... 28) Noise intolerance: No......... Yes.......... 29) Intolerance of smells: No.......... Yes......... 30) Touch intolerance: No......... Yes........ 31) Tics: No......... Yes........., in childhood.......... 32) Swings in threshold of physical pain experience: No......... Yes........ 33) Migraine: No.......... Probably........Yes........, family No........Yes........ 34) Bipolar I in family: No......... Probably......... Yes......... 35) Depression in family: No......... Probably........ Yes......... 36) Alcoholism in family: No.....Yes..... 37) Suicide in family: No.....Yes...... 38) ADHD in family: No.....Yes...... * Dx. Bipolar II: No....Probable.......Yes......Date...............©EG2014 * Questions added after the research period was over. Fig. 1. The Bipolar II Syndrome Checklist.
Table 4 shows how common obsessive–compulsive symptoms are (75%), and a perfectionistic character (77%), with difficulties forgiving him/her self for his/her own mistakes (87%). Also the very common problems of procrastination (84%) and difficulty in making decisions (83%). Last, the very common fear of becoming fat (61%), although few are actively doing anything about it. Less common is obsession with other body parts (20%), meaning that this obsession that has nothing to do with body parts being too fat, more a kind of dysmorfia. Table 5 lists several complaints, here categorized as Neurophysiologic. Sleep disturbances with, or without nightmares are very common (80%). Commonly this group of patients seems to lose the ability to let go in laughter (74%), and uncontrollable crying episodes are common (62%), especially among the females. This is a kind of crying that sometimes can come at an inappropriate time, is hard to stop, and gives no relief afterwards. The patients usually distinguish between a good crying and uncontrollable, bad crying. Concentration problems (87%) and disturbance of memory are common (67%). This seemed to be no less common in the young. Also noise (59%) and touch (58%) intolerance are common, but smell intolerance less so (35%). Tics in childhood are not so uncommon (32%), but less so in adult life (22%). Swings in threshold of physical pain experience are experienced by 30%. Possibly, such swings may be more common in patients that cut themselves. Finally, migraine is common in this group, at least 36%.
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Table 1 The Bipolar II Syndrome Checklist: questions relating to anxiety and depression. 1) 2) 3) 4) 5) 6) 7) 8)
Anxiety Anxiety and/or depression when waking up Worst part of day usually Worsening of symptoms age 15–20 (n ¼95) Chronic thoughts of death and/or suicide Suicidal attempts (one or more) Post Partum Depression (n¼ 43) Depression ass. with menstruation (n¼67)
No 4% No 5% Morning 76%
Considerable 41% Seldom 25% Afternoon14% No 18% No 41% No 78% Probably 9% No 36%
No 28%
Constant 55% Often 70% Evening 10% Yes 82%n Yes 59% Yes 22% Yes 63% nn Yes 64%nnn
n
n¼ 95. This question was added during the research process. n¼ 43. This question was only for women that had borne children. nnn n¼ 67. This question was only for women. nn
Table 2 The Bipolar II Syndrome Checklist: questions relating to self-esteem. 1) 2) 3) 4) 5) 6)
Low self-esteem (LSE) Always LSE Easily hurt and sensitive to what others think Eager to please others Difficulty enjoying compliments Guilt-feelings
No 5% No37% No 3% No 8% No 44% Seldom 13%
Yes 95% Yes 63% Yes 97% Yes 92% Seldom 5% Often 53%
Yes 51% Constant 34%
Table 3 The Bipolar II Syndrome Checklist: questions relating to paranoia. 1) 2) 4) 5) 6)
Mild paranoia Imagined conspiracy Distrusts compliments Fear of darkness (FD) in childhood (n ¼87) Age FD ended
n
No 5% No 20% No 17% No 29% o 20 years 55%,
Often 61%n Still FD 34%
n¼ 87. This question was added during the research process.
Table 4 The Bipolar II Syndrome Checklist: questions relating to obsessive–compulsive symptoms. 1) 2) 3) 4) 5) 6) 7)
Yes 95% Yes 80% Yes 83% Seldom 10% 420 years 11%,
OCD symptoms Perfectionistic Difficulty forgiving yourself your own mistakes Delay-compulsion (procrastination) Difficulty making decisions Obsessed with possibility of becoming fat Obsessed with other body parts (dysmorphia)
No No No No No No No
25% 23% 13% 16% 17% 39% 80%
Yes Yes Yes Yes Yes Yes Yes
75% 77% 87% 84% 83% 61% 20%
Table 6 shows psychiatric problems in the extended families commonly reported. The rate of Bipolar I is unusually high in relatives ( 441%). Also the rate of depression is exceptionally high (93%). Post Partum Depression (PPD) is common (37%), possibly higher since many patients, especially the males, said they had little knowledge about PPD in their families, let alone extended families. Migraine was known in more than half of the families (53%). The question about Alcoholism in family was included later in the process, only 38 patients were asked this question, but almost all (97%) of those reported Alcoholism in their families. Since reports of completed suicides by relatives were common in this group, the question about completed suicides developed in the latter stages, but it was considered too late to include this question formally in this research. Many patients in this group knew of completed suicides by their relatives, although the total number of suicides in Iceland is not that high (35–40 per year). This high suicide rate in the families of Bipolar II is in accordance with the high suicide rates of Bipolar II patients reported by other authors (Rihmer and Kiss, 2002; Aksikal, 2007; Pompili et al., 2013).
4. Discussion The results show how widely the Bipolar II Disorder affects the personality in general and the many symptoms of this disorder aside from the actual mood swings. The title of this paper raises the question whether it is appropriate to define The Bipolar II Disorder as a syndrome, rather than a disorder with many possible co-morbid disorders. The definition of a syndrome is supportive of the first (Wikipedia, 2014): “A syndrome is the association of several clinically recognizable features, signs (observed by someone other than the patient), symptoms (reported by the patient), phenomena or characteristics that often occur together, so that the presence of one or more features alerts the healthcare provider to the possible presence of the others.” If the above is true for Bipolar II Disorder, one would look for symptoms of anxiety, OCD, paranoia, low self-esteem, alcohol/substance abuse in these patients. Also one would look for chronic suicidal ideations, extreme hurtfulness, concentration problems, sleep problems, procrastination, Post Partum Depression to name a few of the symptoms listed above. One would even look closely at the patient's family history since many of the symptoms seem to be heritable. On the other hand one would look especially closely for Bipolar II Disorder in patients with major depressive episodes (Akiskal and Benazzi, 2005; Benazzi, 2007), OCD, paranoia, alcohol/substance use, Post Partum Depression, low self-esteem, procrastination, concentration problems and chronic suicidal ideation to name a few. Most of the symptoms mentioned above are well known in the bipolar literature mostly though as part of different co-morbidities (Merikangas et al., 2007; Angst et al., 2005; Myrick and Brady, 2003; McElroy et al., 2001; Perugi et al., 1997).
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Table 5 The Bipolar II Syndrome Checklist: questions related to neurophysiology. 1) Sleep disturbances 2) Frequent nightmares 3) Difficulty laughing deeply 4) Uncontrollable crying episodes 5) Concentration problems 6) Disturbance of memory 7) Noise intolerance 8) Intolerance of smells 9) Touch intolerance 10) Tics 11) Swings in threshold of physical pain experience 12) Migraine
No No No No No No No No No No No No
Table 6 The Bipolar II Syndrome Checklist: questions related to relatives. 1) 2) 3) 4) 5) 6)
Bipolar I in family No 34% Probably 25% Yes 41% Depression in family No 5% Probably 2% Yes 93% Post Partum Depression in family No 63% Yes 37% Migraine in family No 47% Yes53% Alcoholism in family (n ¼38) No 3% Yes 97%n Incidence of completed suicides amongst relatives unusually high.
n
n¼38. This question was added during the research process.
The results of this study show that different symptoms may vary in commonality and intensity. The possibility of a Bipolar II Disorder being overlooked is therefore great since other “nonmood swing symptoms”, commonly referred to as co-morbidities, may be the most prominent symptoms. This also means that Bipolar II patients may present with different symptoms that may need treatment from early on, even before mood stabilization. Although mood stabilizers are usually the first step in treatment, other symptoms may be the most prominent, like anxiety and/or OCD, alcohol/substance abuse, paranoia, sleeping problems etc. and therefore need treatment first or simultaneously. A limitation to this study is that Bipolar I Disorder patients are excluded, since the there were just too few Bipolar I patients actual at the time to make a significant difference. Recent research shows however that there may be some difference in the personality traits of Bipolar I and Bipolar II (Byungsu et al., 2012). Judd et al. (2003) found important differences in clinical characteristics between Bipolar I and Bipolar II where anxiety disorders, social phobia and simple phobias were more common in Bipolar II. Akiskal et al. (2006) found Bipolar II patients to be more “mood labile”, “energy-assertive”, “sensitivitybrooding” and “socially anxious” than Bipolar I. The unusually high rate (41%) of established Bipolar I Disorder in families of Bipolar II in this study is suggestive of a continuum where Bipolar II is the more common and a few close or distant relatives are burdened with the Bipolar I Disorder. Bipolar I is a more visible disorder and empirically Bipolar II is hidden in many families. The question regarding the difference between the personalities of Bipolar I and Bipolar II is not the scope of this paper although it is an important one and needs further research. A second limitation is that the BSC has not been scientifically validated, although it has proved to be a valuable tool clinically. A third limitation is the lack of a control group. A control group is necessary to validate the BSC and would have increased the scientific power of this study. It is though evident from the above that The Bipolar II Disorder affects patients in a variety of ways. Some of the patients were positive on almost all the items in the BSC. For most of the patients, the author's impression was that the Bipolar II affects the patient's personality widely, but not necessarily heavily on all items. Sometimes patient's scored on almost all items, but low,
20% 57% 26% 38% 13% 33% 41% 65% 42% 78% 70% 40%
Yes 80% Yes 43% Yes 74% Yes 62% Yes 87% Yes 67% Yes 59% Yes 35% Yes 58% Yes 22%, Yes 30% Probably 24%
In childhood 32% Yes 36%
meaning that no symptoms were very prominent or disabling. A common theme, and often a disabling one, is the “self-mobbing” or “self-bullying” that seems to be quite constant in the patient's life, although hypomanic episodes can be a temporary relief. This means amongst other things that the patients do not allow themselves to enjoy their successes, though for some they are many. Because of the great overlapping, this paper clearly favors the syndrome line of thinking above co-morbidities for the Bipolar II Disorder. This may be more in accordance with the more recent approach in the USA called The Research Domain Criteria (RDoC) developed by The National Institute of Mental health (NIMH) and represents a break with the existing research categories in Psychiatry 〈www.nimh.nih.gov〉. This paper touches on too many aspects, symptoms, co-morbidities that the scientific literature has already covered well, making it impossible to for a short paper like this to cover all the research material available. Rather the focus here has been on the whole more than the parts. As far as the author is aware of this is a novel approach in Bipolar research and it is the authors sincere hope that this paper might inspire scientists to do more research on the Bipolar II Disorder Personality Traits a long similar lines. The author permits the free use of the BSC for interested researchers and even make changes, if necessary, to facilitate further research.
Role of funding source None.
Conflict of interest None.
Acknowledgments The author would like to thank Prof. Jules Angst M.D. for looking over the preliminary abstract and results in the early stages of this work, and for his advice, pointing out of references and encouragement in general. And the author would also like to thank Prof. Joseph Calabrese M.D., also for looking over the preliminary abstract and results in the early stages of this work and for his advice, and encouragement in general, and especially for pointing out The Journal of Affective disorder as the natural journal to approach with this kind of research. Lastly the author would like to thank Jon G. Stefansson M.D. former Ass. Professor at The National University Hospital in Iceland for reading over the manuscript in the last stages, his valuable advice, and encouragement in general.
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