Overview
Bipolar II is a type of bipolar disorder that is characterized by the experience of symptoms of both major depressive disorder as well as a hypomanic episode. These episodes can often be cyclic in nature, and in some cases dysfunction may be experienced in between the transition from one stage to another as well.
Bipolar II often has serious functional implications, often in the form of cognitive impairments that can lead to occupational consequences and be cause for unemployment among individuals diagnosed with the disorder. A significant suicide risk has also been associated with the disorder.ย
Sex-based differences in the occurrence of the disorder have been reported varyingly, with most studies finding and equal distribution among males and females, while some clinical samples have shown female predominance.
The age of onset is usually in the mid-20s, and depressive symptoms mark the beginning of the onset period. Owing to this, Bipolar II is frequently misdiagnosed as Major Depressive Disorder. There is a considerable genetic risk associated with the disorder, as well as other biological, temperamental, and environmental factors.
Treatment modalities for Bipolar II combine both pharmacological and psychosocial intervention methods.
Signs and Symptoms
The signs and symptoms of Bipolar II Disorder may include:
1. Hypomanic Episode
- Period of abnormally elevated mood
- Irritability
- Inflated self-esteem
- Decreased need for sleep, such as feeling well-rested after only 3 hours
- Being talkative
- Flight of ideas and racing thoughts
- Distractibility
- Increase in goal-directed activity, being more productive
- Psychomotor agitation
- Impulsivity and risk-taking behavior
2. Major Depressive Episode
- Depressed mood
- Loss of interest of pleasure in activities
- Feelings of emptiness or hopelessness
- Crying, being tearful
- Fluctuations in weight
- Disturbances in sleeping patterns
- Feeling restless or slowed down
Risk Factors
Variations is epidemiological data have been observed with regards to the sex-based distribution of Bipolar II Disorder. While a general trend has not revealed any sex-based differences in occurrence, clinical samples in some cases have suggested a female preponderance. Sex-based differences are more likely to occur in the context of the clinical characteristics of the disorder that may be observed. The average age of onset is considered to be in the mid-20s. A major depressive episode is likely to mark the onset of the disorder.
There is a significant genetic risk involved in the occurrence of Bipolar II Disorder. Individuals with relatives diagnosed with Bipolar II are at a greater risk of presenting with symptoms. Family history of other underlying psychiatric issues, including anxiety, depression, and fatigue, is also higher among individuals presenting with Bipolar II. Genome studies have also shown shared patterns with Schizophrenia.
Bipolar II is also looked at from a biological perspective. Neurochemical imbalances, particularly monoamines serotonin and dopamine are considered. Anomalies in intracellular signaling pathways may affect neuronal functions.
Cognitive dysfunction as a result of sleep disturbance may also be associated with clinical presentation of the disorder. A stress diathesis model might highlight the interaction of biological and environmental correlates. Studies have found that in Bipolar II, the effect of negative life events was associated with a decrease in severity of hypomania.
Certain temperamental factors may also be involved in the occurrence of the disorder, with a higher emotional liability often being linked to its manifestation. Mood symptoms can be both a cause and consequence of the disorder.
Bipolar II is also associated with significant psychological comorbidity. The most common concomitance is of anxiety disorders, with approximately 75% of individuals with anxiety disorder reporting a co-occurring anxiety disorder. Approximately 60% of individuals report having three or more co-occurring mental disorders. Substance use disorders and eating disorders are also commonly reported.
Diagnosis
Bipolar II may frequently be underdiagnosed or misdiagnosed. Due to the higher likelihood of individuals presenting with depressive symptoms in the beginning of onset of Bipolar II, the disorder may be diagnosed as Major Depressive Disorder. This could lead to inappropriate treatment and further exacerbation of symptoms.
Since it is not possible to predict hypomanic episodes, it is important for clinicians to be alert and aware with regards to its possibility upon the onset of depressive symptoms. Symptoms of hypomania, such as periods of overactivity, decreased need for sleep, risk-taking, and impulsivity may be explained to the patient or their close ones beforehand, in order to facilitate prompt diagnosis.
Thorough clinical histories may point out certain factors that may be useful in alerting the clinician to the probability of a development of bipolar disorder, such as younger age at onset and a family history of bipolar disorder.
Mood disorder questionnaires have proven to be helpful in the assessment of Bipolar II disorder. Self-report mood ratings, as well as a mood diary can be used in order to assess symptoms adequately. The Bipolar Depression Rating Scale is one used for assessment.
The DSM-5 mentions the following criteria for the diagnosis of Bipolar II Disorder:
For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a current or past hypomanic episode and the following criteria for a current or past major depressive episode:
Hypomanic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable), represent a noticeable change from usual behavior, and have been present to a significant degree:
- Inflated self-esteem or grandiosity.
- Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
- More talkative than usual or pressure to keep talking.
- Flight of ideas or subjective experience that thoughts are racing.
- Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
- Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment).
Note: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis.
Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to a medical condition.
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
- Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, a suicide attempt, or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or another medical condition.
Note: Criteria A-C above constitute a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individualโs history and the cultural norms for the expression of distress in the context of loss.
Bipolar II Disorder
- Criteria have been met for at least one hypomanic episode (Criteria A-F under โHypomanic Episodeโ above) and at least one major depressive episode (Criteria A-C under โMajor Depressive Episodeโ above).
- There has never been a manic episode.
- The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
- The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specifications to the diagnosis of Bipolar II are made on the basis of whether the previous episode experienced was hypomanic or depressive, as well as whether the clinical presentation of the disorder has included anxious distress, mixed features, rapid cycling, mood-congruent psychotic features, mood-incongruent psychotic features, catatonia, peripartum onset or of a seasonal pattern. Specifications are also made on the basis of severity.
Treatment
Treatment modalities for Bipolar II Disorder are based in both pharmacological and psychosocial intervention.
Pharmacology for Bipolar II is required to target symptoms of both, hypomania as well as depressive symptoms. Antipsychotic medication has proven to be highly effective in the management of hypomanic symptoms.
The first-line of treatment is usually Lithium, and the focus of medication is to ensure that symptoms of hypomania are managed without risking a switch into a depressive state. If efficacy is demonstrated in acute treatment, the same medication may be continued for long-term use. Valproate, carbamazepine, and other atypical antipsychotics have also shown some efficacy.
Medication for depressive symptoms works on the same principle of trying to manage clinical presentation without risking a switch into hypomanic symptoms. There is also a controversy regarding what the primary outcome of treating bipolar depression should be, in terms of whether emphasis should be given to recovery from depression or to long-term mood stability.
It is important to implement a combination of psychosocial and pharmacological treatment in the management of Bipolar II Disorder. Psychodynamic therapy, family-based therapy, interpersonal therapy, as well as Cognitive Behavioral Therapy may be implemented in the management of the disorder. Psychoeducation is also an integral part of psychosocial alleviation.
Differential Diagnosis
1. Major depressive disorder: Major depressive disorder, may be accompanied by hypomanic or manic symptoms. Especially for individuals with symptoms of irritability, which may be associated with either major depressive disorder or bipolar II disorder.
2. Cyclothymic disorder: There are numerous periods of hypomania symptoms and numerous periods of depressive symptoms that do not meet symptom or duration criteria for a major depressive episode. Bipolar II disorder is distinguished from cyclothymic disorder by the presence of one or more major depressive episodes. If a major depressive episode occurs after the first 2 years of cyclothymic disorder, the additional diagnosis of bipolar II disorder is given.
3. Schizophrenia spectrum and other related psychotic disorders: Bipolar II disorder must be differentiated from psychotic disorders. Schizophrenia, schizoaffective disorder, and delusional disorder are all characterized by periods of psychotic symptoms.
4. Attention-deficit/hyperactivity disorder: Attention-deficit/hyperactivity disorder (ADHD) may be misdiagnosed as bipolar II disorder, especially in adolescents and children. Many symptoms of ADHD, such as rapid speech, racing thoughts, distractibility, and less need for sleep, overlap with the symptoms of hypomania.
5. Personality disorders: Symptoms must represent a distinct episode, and the noticeable increase over baseline required for the diagnosis of bipolar II disorder must be present. A diagnosis of a personality disorder should not be made during an untreated mood episode unless the lifetime history supports the presence of a personality disorder.
6. Other bipolar disorders: Diagnosis of bipolar II disorder should be differentiated from bipolar I disorder by carefully considering whether there have been any past episodes of mania and from other specified and unspecified bipolar and related disorders by confirming the presence of fully syndromal hypomania and depression.
Comorbidity
Anxiety and substance use disorders occur in individuals with bipolar II disorder at a higher rate than in the general population. Individuals with bipolar II disorder have at least one lifetime eating disorder, with binge-eating disorder being more common than bulimia nervosa and anorexia nervosa.
Specialist
There is a higher likelihood of individuals approaching healthcare providers or mental health practitioners upon experiencing depressive symptoms at the onset of Bipolar II Disorder. The concerned clinician must assess the risk of developing Bipolar II among patients that present with symptoms of Major Depressive Disorder and work on treatment plans accordingly. Psychiatrists must be involved in pharmacological intervention, while licensed clinical psychologists and therapists with adequate training are usually involved in psychosocial intervention.
In Conclusion
Most patients with bipolar II disorder spend far more time dealing with depressed symptoms than hypomanic ones. Bipolar disorder’s origins are not fully known. If bipolar II condition may be completely avoided, that fact is unknown.
Once bipolar disorder has manifested, it is feasible to lower the chance of acquiring upcoming episodes of hypomania or depression. In addition to medicine, regular therapy sessions with a psychologist or social worker can aid in efforts to stabilise mood, resulting in fewer hospitalizations and improved overall health. Psychotherapy can help patients better identify the precursors of an impending relapse before it manifests, as well as ensure that prescribed medications are followed as directed.
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