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Two Lesser-Known Forms of Bipolar Disorder: Cyclothymia and Bipolar Disorder, Not Otherwise Specified


Please do not use the following article for self-diagnosis or the diagnosis of others. Even mental health professionals cannot diagnose themselves. It is intended instead for information and to provide useful subject matter to discuss with a psychiatrist or therapist.

The distinction between bipolar I and bipolar II is confusing enough (I have written another article on that subject), but sometimes people receive even less-known diagnoses, which are “cyclothymia” and “bipolar disorder, not otherwise specified.” When people receive these diagnoses, they are often even more confused by what is going on.

Part of what makes these types of bipolar disorder especially confusing is that they are actually defined by what they are not. In other words, they are diagnoses for people who don’t quite reach the diagnostic criteria of bipolar I and bipolar II, but obviously have symptoms that are on the same spectrum.

To quickly summarise what I will say, cyclothymia is like bipolar II, except that it never quite reaches the diagnostic criteria of a major depressive episode. Bipolar disorder, not otherwise specified, is also like bipolar II, except it never quite reaches the diagnostic criteria of hypomania or major depression, or lasts less than two years. (Someone who has major depressive episodes but doesn’t quite reach the diagnostic criteria of hypomania would be diagnosed with major depressive disorder, not bipolar disorder).

Note that, if these symptoms are the result of drugs (either legal or illegal) or another medical condition, then they will not count toward a diagnosis.

Cyclothymia or Bipolar Disorder III

Sometimes cyclothymia is also called “bipolar disorder III.” It is a type of the disorder where the episodes don’t quite reach the level of a manic episode or a major depressive episode for a period of two years, and who do not have asymptomatic periods that last more than two years. Rather, it is characterized by hypomania and episodes that are similar to depressive episodes, but lack at least one of its necessary characteristics.

Major Depressive Episodes

I’m going to quickly discuss major depressive episodes, to show what it is that cyclothymic people don’t have, when compared to other forms of bipolar disorder.

For a major depressive episode to occur, it must cause “significant distress or impairment” in functioning, and not be the result of mourning. In addition, five of the following must occur for a period of two weeks (according to the DSM-IV), including at least one of depressed mood or loss of interest in pleasure:

  • Depressed mood almost every day, most of the day. In children, this can be irritability.
  • Loss of interest in pleasure almost every day, most of the day.
  • Insomnia or extra need to sleep, almost every day.
  • Significant loss or gain of weight.
  • Psychomotor retardation (tasks feel like they require especially extra effort), almost every day.
  • Fatigue or low energy, almost every day.
  • Inappropriately low self-esteem or excessive guilt, almost every day.
  • Lack of concentration or focus, almost every day.
  • Recurrent thoughts of death or suicidal thoughts or behaviors.

Okay, but what if someone has four of these symptoms? Or if they symptoms last for ten days instead of two weeks? Or if the episodes don’t cause “significant impairment or distress?” This is where cyclothymia comes in. It is intended to account for people who have depressive episodes that do not quite match up to the criteria of a “major” depressive episode.

You Can Be Cyclothymic and Have Bipolars I or II

One curious thing is that you can have both cyclothymia and either bipolar I or bipolar II. This may seem strange, but one can have both diagnoses if that person goes two years without a manic or major depressive episode, but then has a manic or major depressive episode later. Rather than change the diagnosis from cyclothymia to bipolar I or bipolar II, the diagnosis of bipolars I or II is added to the diagnosis.

Bipolar Disorder, Not Otherwise Specified

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Bipolar Disorder, Not Otherwise Specified (often abbreviated as “Bipolar Disorder, NOS”) is basically the DSM-IV’s way of admitting that its diagnostic criteria aren’t quite complete. In other words, there are a lot of people out there who are clearly on the bipolar spectrum, but don’t quite meet the diagnostic criteria of either hypomania or major depression, or don’t meet them for a period of two years.

In order to clarify what it would mean to not quite meet the diagnostic criteria of a hypomanic episode, I will summarize them here.

To have a hypomanic episode, one must have elevated or irritable mood, and also meet at least three of the following criteria for at least four days:

  • Increased self-esteem or even grandiosity (thinking oneself capable of things one is not).
  • Insomnia.
  • Increased talkativeness or pressured speech (feeling like one can’t keep up with one’s thoughts while speaking, and therefore speaking much more quickly or loudly).
  • Racing thoughts (ideas that move very, very quickly or are significantly disjointed).
  • Being easily distracted.
  • Being very driven in tasks or psychomotor agitation (having difficulty keeping still or constantly pacing.
  • Being especially interested in pleasure, to the point of causing potential problems (like excessive spending or hypersexuality).

In addition, these symptoms must lead to “unequivocal” but not “marked” impairment of functioning (a frustrating distinction, but it basically means that the person isn’t quite as functional as usual, but it doesn’t completely paralyze them), not lead to hospitalization, and not include any psychosis.

As you can see, hypomania is already partly defined in terms of its not being a manic episode. Someone with bipolar disorder, NOS, however, do not even meet the above criteria. However, they clearly have at least some of them, and therefore can be considered to be on the bipolar spectrum. Nonetheless, because they don’t quite fit the criteria, they are considered to be “not otherwise specified.”

Conclusion

As you can see, the diagnostic criteria of these two disorders can be difficult to get a handle on, precisely because they are defined by what they are not. However, knowing the criteria for the episodes that people with cyclothymia and bipolar disorder, NOS, can be helpful in understanding what criteria are being used in order to mark them off from bipolars I and II.

Note that “less severe” and “less serious” are not the same thing. While cyclothymia and bipolar disorder, NOS, are not as severe as bipolars I and II, they can still be quite distressing for the people who have them. They are psychiatry’s way of addressing people who don’t quite meet their usual criteria, but clearly have a mood disorder on the bipolar spectrum and still need assistance.

All of the above are intended to be ordinary-language versions of the diagnostic criteria. You may also wish to read the official (and more techincal) DSM-IV criteria for cyclothymia, major depressive episodes, or hypomanic episodes.

10 Responses to Two Lesser-Known Forms of Bipolar Disorder: Cyclothymia and Bipolar Disorder, Not Otherwise Specified

  • I think that another problem with the vagueness of diagnosis is that it is by nature not empirically based. Rather it relies on anecdotal evidence from the patient and family, hardly to most objective perspective. However, when I read the list of symptoms, I have them all. Well, at least according to me :).
    I have in the past asked my doctors about the possibility of suffering from cyclothymia, or even BP. They mostly ignored me. It wasn’t until my last suicide attempt that I finally was able to see a psychiatrist and her resident who diagnosed me in 75 minutes. Also there are periods of time when I have no symptoms, others when I exhibit a few, and others when the whole list is applicable (either depressive or hypomanic). Until we have some better clues about how to see this disease in the physical brain, it will always remain an imperfect diagnosis.

    • It depends somewhat on what is meant by “empirical,” though I definitely agree that we’re dealing with reports here, rather than measurements. I wrote an article about this kind of issue a month ago, which can be found here.

      • thanks…I will go look at that article. Also I would agree that empirical may not be the best term…and measurements is a better expression of the sense I was trying to convey.

    • i have this with rapiid cycling i hate it it just as crippling as bi ploar it wrecks ur life

      • Thank you for your comment, Wendy. I think a lot of people think that just because the symptoms of cyclothymia are less severe, people who are cyclothymic are suffering less. However, this isn’t necessarily true. Life with cyclothymia can be extremely difficult.

  • I am diagnosed Bipolar NOS. I believe I have this diagnosis because when I sought treatment, it was voluntary. I’m at a stable point in my life but these stable points never last. I sought treatment because I was feeling more impulsive and suicidal than usual. My family doesn’t know about a lot of my symptoms because of my job, or I’m locked in my room, or disappear for a few days when I’m hypomanic. I knew for years I was Bipolar since I read a book about it but never knew exactly what these symptoms mean. They seem a bit vague. I have had 3 major depressive episodes in the past 4 years, I have definitely been hypomanic but the time frame is fuzzy, and I have definitely had at least 3 mixed state episodes. Attempted suicide 2 times but was unsuccessful both times. So my therapist and psychologist are monitoring me and slowly trying out medicines to see what will work for me. I have suffered from all of these symptoms sometimes all at once sometimes only a few at a time. It doesn’t help that I told them about my past drug use. At first they thought maybe drugs were the causes of my mood swongs but I had my worst episodes while sober for months and used drugs mostly to cope. Either way it is all on the spectrum. Having Bipolar 1 or 2 or cyclothmia doesn’t make one less or more Bipolar its just a different kind. Thank’s for writing this article!

    • You’re welcome, Vee. That’s a great point about how people are not “more” or “less” bipolar. Each has its own forms of challenges.

  • It’s nice to see some recognition of NOS, which is my diagnosis (along with Borderline Personality Disorder). I feel like a lot of times, NOS is swept under the rug as ‘illegitimate’ Bipolar and people treat us as if it doesn’t affect our lives or cause problems. The reality is, that it does, so it’s good to see someone recognize that.

    • That’s a good point, Amberle. Bipolar NOS by definition interferes with people’s lives. The point of the diagnosis is to cover cases that do interfere, but don’t meet some of the other criteria.

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Psychotherapy from Daniel

Daniel Bader, Ph.D., RP (Qualifying), CCC

Daniel Bader, Ph.D., is a Registered Psychotherapist (Qualifying) and Canadian Certified Counsellor specializing in bipolar disorder, offering in-person psychotherapy in Kitchener, Ontario, and online and telephone psychotherapy within Canada.

To book an appointment with Daniel, please visit his Psychology Today profile.