Bipolar II

Bipolar-II is a common type of depression.  Exact rates are not clear, but it probably affects between 2-3 in 100 people.  Unfortunately there is little public awareness of this condition, which borrows its name from the more well-known bipolar-I disorder. This similarity in names is confusing, since the word bipolar brings to mind a more extreme state called mania or manic-depression. 

People with bipolar-II never have mania; instead, they suffer from depressions that alternate with states of nervous excitation called hypomania.  Hypomania can make people feel anxious, impulsive, hyperactive, irritable and, sometimes, happy and confident. Hypomania may feel good or may feel uncomfortable, but unlike mania it never causes people to completely lose control.  

Mood swings and depression

“I was silly and giddy one minute, bursting with rage the next; running around excitedly in the afternoon but impossible to rouse out of bed in the morning.”
Gogo Lidz  (click to read her personal description of bipolar-II).

Bipolar-II affects everyone differently, but a common theme is that it causes mood to shift up and down throughout life.  The first symptoms usually appear during adolescence, and these early mood swings often shift very rapidly as in the quote above.  As people age, these shifts in mood usually slow down.  Over time, depressions tend to occur more often and the ups (or hypomanias) may fade away. 

Depression is so common in bipolar-II that it is often misdiagnosed as “major depression.”  In fact, 1 in 3 people diagnosed with major depression actually have bipolar-II.  Identifying the correct diagnosis is crucial since bipolar-II may worsen with antidepressant medication.  The chart below details the differences between major depression, bipolar-I and bipolar-II:

 

Depression?

Hypomania?

Mania?

Unipolar Major Depressive disorder

Yes

No

No

Bipolar-II disorder

Yes

Yes

No

Bipolar-I disorder

Yes

 

Yes

 

Yes

 

Because they may be rare or mild, it can be difficult to identify the times of hypomania which distinguish bipolar-II from major depression. There are other clues which can alert people with depression to look carefully for bipolar-II. Most importantly, if anyone in your family has bipolar or manic-depression it is more likely that your depression is a bipolar-II type. Depressions that come on early in life, such as before age 20, are more likely to be bipolar-II, as are those which keep returning throughout life. Depressions that come on after pregnancy (called post-partum depression) are also a sign of bipolar-II.  Sometimes people with bipolar-II find that antidepressants work at first and then wear off, leading to frequent medication changes.

Lastly, people with bipolar-II often have a highly reactive mood, and may experience mood swings even when depressed. This mood reactivity makes people feel easily hurt, rejected or irritated by others, and overwhelmed by or sensitive to stress. During depression, they may also have significant fatigue or over-eating.  Their mood may change with the seasons, with depressions in the Winter and hypomania in the Spring (read more about Light therapy for seasonal mood changes).  

 

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Other symptoms of bipolar-II

Mood impacts our thoughts as much as our emotions. People with bipolar-II are often misdiagnosed with Attention Deficit Hyperactivity disorder (ADHD) because of the difficulties it causes in concentration. During hypomania, people are easily distracted and their thoughts race quickly from topic to topic.  They may wander in daydreams while engaged in unrelated tasks, or their mind may be crowded with multiple streams of thought. 

These shifting thoughts make it difficult to set priorities. They may neglect important responsibilities while they hyperfocus on a single task, or may shift from task to task in a disorganized way.  Thoughts can be experienced very powerfully, which can be a source of inspiration or frustration.  Hypomania can make people easily annoyed and quick to react.  It becomes very hard not to “sweat the small stuff”, and conflict with other people frequently erupts.

Energy is usually elevated in hypomania.  Sometimes this heightens creativity and productivity.  Other times the surge in energy makes people feel edgy and restless, and they may use alcohol or drugs to settle down.  People in this state tend to sleep less.  They may welcome this change or lie awake in an anxious state of insomnia.

Anxiety is one of the most common symptoms of hypomania. This may be felt physically as a restless nervousness or as an uncomfortable feeling of dread, as if something bad may happen at any moment.  Usually the person cannot identify what they are afraid of.  Often the anxiety intensifies in social settings, and the intentions of other people may be seen as hostile or mean-spirited.  At its most extreme, full panic attacks occur.

Sometimes the person with hypomania is not bothered by it at all and it is their relatives who are concerned.  Usually it is the impulsive and hyperactive symptoms that worry them.  These symptoms can cause people to spend too much money, jump into new relationships or start projects they can’t finish.

Hypomania also has a positive side, but I have emphasized the unpleasant aspects of it here because those are what lead people to seek help. In its sunny-side, hypomania can make people friendly, confident and outgoing. They can be very happy, or euphoric, in a way that lifts the spirits of those around them. Other people see them as inspiring, spontaneous, funny and generous.  Indeed, hypomania is often a strength!    

How is the diagnosis made?

Bipolar II can only be diagnosed by an interview with a trained professional such as a psychiatrist. There is no test for bipolar-II, although research is underway to develop genetic and brain-imaging tests to aid in the diagnosis. You can help your doctor clarify the diagnosis by describing how your mood has changed throughout your whole life. 

There are also a several screening tests for bipolar available.

How is bipolar-II disorder treated?

Bipolar-II is usually treated with a combination of mood stabilizers and antidepressants. Although antidepressants help in the short-term, there is currently not enough research to know if they cause long term worsening of mood swings in bipolar-II. Antidepressants are much safer when used with mood stabilizers, which help prevent mood swings for the long term.  Some mood stabilizers actually enhance the growth of brain cells and protect brain cells from damage.

Examples of mood stabilizers include:

Lamotrigine (lamictal), Lithium (lithobid, eskalith), Depakote (valproate), Tegretol (carbamazepine), Trileptal (oxcarbazepine).

Atypicals (aripiprazole, abilify, zyprexa, olanzapine, risperdal, risperidone, seroquel, quetiapine, geodon, ziprasidone).

One of the most important mood stabilizers for bipolar-II is Lamictal. This medicine has been used to treat seizures since the early 1990’s and was approved by the FDA for bipolar disorder in 2003. It is a major advance because it is the only mood stabilizer which treats depression more effectively than mania. Lamictal is particularly effective at preventing depression for the long-term, an important benefit for bipolar-II where the depressions can be chronic and frequent if untreated.

Although its preventive effects can change people’s lives, Lamictal may not work right away because the dose has to be raised slowly over 1-2 months to prevent a rare but serious allergic skin reaction called Stevens-Johnson Syndrome. Fortunately, once Lamictal is raised to an effective dose it is well tolerated and does not cause weight gain or drowsiness.

It is important to understand that very few medicines have been studied exclusively in bipolar-II, and most of what we know comes from studies of bipolar-I. Lamictal is one medicine that was studied in both groups.  Seroquel (quetiapine) and Mirapex (pramipexole) are two other medicines that have been studied in bipolar-II.

Psychotherapy is also very helpful for this condition, both to cope with the effects it has on your life as well as to reduce the mood swings themselves.

How long should treatment last?

Having bipolar-II means that you are at risk for depression, particularly with stressful events.  Actually, up to 30% of the general population will get depression some time in their lives, so just being human puts you at risk for depression.  Since medication works not just to treat but also to prevent depression, how long you take it will be a personal decision that is best made with an understanding of your own risk factors. 

If you are thinking about stopping a medication, talk to your doctor about what the risk would be for your symptoms returning and what the safest way is to come off the medication.  Lifestyle changes (see below) will be especially important if you are not taking medicine.

What can else can I do to help bipolar-II?

Click “Recovery Guide” at right to learn how to live more effectively with bipolar II.

Avoiding recreational drugs and moderating alcohol use is also very important. Most recreational drugs, including marijuana, XTC, mushrooms, steroids, stimulants or speed, and cocaine, will make bipolar-II worse, particularly with long-term use. Drug use can also cause mania, converting bipolar-II into bipolar-I.

Even legal drugs can cause problems. Reducing caffeine can significantly improve sleep quality and mood swings (you should lower your caffeine intake slowly to prevent withdrawal headaches).  Caffeine is concentrated not just in coffee, sodas and tea but also in chocolate. While people sometimes use alcohol to induce sleep or relieve mood swings, continued use can fragment sleep and worsen bipolar. The same is true for nicotine: the immediate effects of a cigarette may lift mood and improve concentration, but long term use causes more depression. 

To continue to the next section, click Cyclothymia.

—Updated 8/5/11 by Chris Aiken, MD