Bipolar II Disorder - Anatomy of Psych

What is bipolar II disorder?

Bipolar II disorder is an illness characterized by recurrent mood episodes consisting of at least one major depressive episode and at least one hypomanic episode. Hypomania is less severe than mania; however, the disability related to bipolar II disorder is similar to bipolar I disorder. Individuals with bipolar II spend as much time symptomatic as those with bipolar I, but with predominantly depressive symptoms, which causes the disorder to be four times more economically burdening.

The prevalance of bipolar II disorder is 0.8% in the United States. The average age of onset is in the mid-20s.

What does bipolar II disorder look like?

Signs & Symptoms

DSM-5 Criteria

Bipolar II Disorder Criteria

Criteria A. Criteria have been met for at least 1 hypomanic episode and at least 1 major depressive episode (see Hypomanic Episode Criteria below).

Criterion B. There has never been a manic episode.

Criterion C. 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.

Criterion D. 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.

Hypomanic Episode Criteria

Criterion 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.

Criterion B. During the period of mood disturbance and increased energy and activity, at least 3 of the following symptoms have persisted (4 symptoms if the mood is only irritable), present a noticeable change from usual behavior, and have been persistent to a significant degree:

Grandiosity or inflated self-esteem.
Sleep decreases (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 (i.e. purposeless non-goal-directed activity).
Indiscretion; 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).

Criterion C. The episode is associated with an unequivocal change in the functioning that is uncharacteristic of the individual when not symptomatic.

Criterion D. The disturbance in mood and the change in functioning are observable by others.

Criterion 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.

Criterion F. The episode is not attributable to the physiological effects of a substance. Note: A full hypomanic episode that emerges during antidepressant treatment (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.

Subtypes & Specifiers

Specifiers:

With anxious distress
With mixed features
With rapid cycling
With melancholic features
With atypical features
With psychotic features
With catatonia
With peripartum onset
With seasonal pattern
Episode specifier (current/most recent episode):
- Hypomanic
- Depressed
Severity specifier:
- Mild
- Moderate
- Severe
Remission specifier:
- In partial remission
- In full remission

Risk Factors

Family history of bipolar II disorder

Prognosis

Rapid cycling typically yields worse prognosis
Individuals who are married, have higher levels of education, and fewer years of illness have better recovery
1/3 of individuals with bipolar II report a history of suicide attempt
Lethality of suicide attempts are higher in bipolar II than in bipolar I
Many individuals may experience several depressive episodes before their first hypomanic episode
5-15% of individuals with bipolar II will eventually experience a manic episode, which will then change their diagnosis to bipolar I disorder

Differential Diagnosis

Major depressive disorder
Cyclothymic disorder
Schizophrenia and other related psychotic disorders
Panic disorder or other anxiety disorders
Substance use disorders and substance/medication-induced hypomania
Attention-deficit/hyperactivity disorder
Personality disorders, especially borderline personality disorder
Other bipolar disorders

How is bipolar II disorder investigated?

Young Mania Rating Scale (YMRS)

Clinician rater
11-item scale on the patient's subjective report over the last 48 hours plus clinical observations
Takes 15-30 minutes to complete

Mood Disorder Questionnaire (MDQ)

Client rater
13 questions to screen for bipolar spectrum disorder
55% positive predictive value

How is bipolar II disorder treated?

Bipolar II Maintenance

First-line: quetiapine, lithium, lamotrigine
Second-line: venlafaxine
Third-line: carbamazepine, divalproex, escitalopram, fluoxetine, others antidepressants, risperidone (mainly for prevention of hypomania)

Bipolar II Depression

First-line: quetiapine
Second-line: lithium, lamotrigine, sertraline, venlafaxine
Third-line: divalproex, fluoxetine, tranylcypromine, ziprasidone

Nursing Management

See nursing management for bipolar I disorder.

[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

[2] Boyd, M. A. (2019). Psychiatric & mental health nursing for Canadian practice. Wolters Kluwer.

[3] Townsend, M. C. (2015). Psychiatric mental health nursing. F.A. Davis.

[4] Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., Sharma, V., Goldstein, B. I., Rej, S., Beaulieu, S., Alda, M., MacQueen, G., Milev, R. V., Ravindran, A., O'Donovan, C., McIntosh, D., Lam, R. W., Vazquez, G., Kapczinski, F., McIntyre, R. S., Kozicky, J., Kanba, S., Lafer, B., Suppes, T., Calabrese, J. R., Vieta, E., Malhi, G., Post, R. M., & Berk, M. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar disorders, 20(2), 97–170.