May 2019 By PsychDB.com

Bipolar II Disorder

Bipolar II Disorder is a mental disorder characterized by a clinical course of recurring mood episodes consisting of at least one major depressive episodes and at least one hypomanic episode. The depressive episode must last at least 2 weeks, and the hypomanic episode must last at least 4 days.

Criterion A

Criteria have been met for at least 1 hypomanic episode and at least 1 major depressive episode.

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), represent a noticeable change from usual behaviour, and have been present to a significant degree:

  1. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
  2. Indiscretion and excessive involvement in activities that have a high potential for painful consequences (unrestrained buying sprees, sexual behaviours, or foolish business investments).
  3. Grandiosity or inflated self-esteem.
  4. Flight of ideas or subjective experience that thoughts are racing.
  5. Activity (goal-directed) increasing (either socially, at work or school, or sexually) or psychomotor agitation.
  6. Sleep decreased (e.g., feels rested after only 3 hours of sleep).
  7. Talkative (more than usual or pressure to keep talking)

Mnemonic

The mnemonic DIG FAST can be used to remember the criteria for bipolar I and II disorder.[1]

  • D - Distractibility
  • I - Indiscretion
  • G - Grandiosity
  • F - Flight of ideas
  • A - Activity increased
  • S - Sleep decreased
  • T - Talkativeness
Criterion C

The episode is associated with an unequivocal change in 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
  • No marked social or occupational impairment
  • There is never hospitalization.
  • No psychotic features (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 (e.g.,a drug of abuse, a medication or other treatment).

What is there is an antidepressant-induced hypomania?

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 1 or 2 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 true bipolar disorder.

Specifiers

Episode Specifier

  • Current or most recent episode manic
  • Current or most recent episode hypomanic
  • Current or most recent episode depressed
  • Current or most recent episode unspecified

Severity Specifier

  • Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning.
  • Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe.”
  • Severe: The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning.

Remission Specifier

  • In partial remission: Symptoms of the immediately previous major depressive episode are present, but full criteria are not met, or there is a period lasting less than 2 months without any significant symptoms of a major depressive episode following the end of such an episode.
  • In full remission: During the past 2 months, no significant signs or symptoms of the disturbance were present.

With anxious distress

  • At least 2 of the following symptoms during the majority of days of the current or most recent episode of mania, hypomania, or depression:
    • (1) Feeling keyed up or tense
    • (2) Feeling unusually restless
    • (3) Difficulty concentrating because of worry
    • (4) Fear that something awful may happen
    • (5) Feeling that the individual might lose control of himself or herself
  • Severity:
    • Mild: 2 symptoms
    • Moderate: 3 symptoms
    • Moderate-severe: 4 or 5 symptoms
    • Severe: 4 or 5 symptoms and with motor agitation
Note: Anxious distress has been noted as a prominent feature of both bipolar and major depressive disorder in both primary care and specialty mental health settings. High levels of anxiety have been associated with higher suicide risk, longer duration of illness, and greater likelihood of treatment nonresponse. As a result, it is clinically useful to specify accurately the presence and severity levels of anxious distress for treatment planning and monitoring of response to treatment.

With mixed features

The mixed features specifier can apply to the current manic, hypomanic, or depressive episode in bipolar I or bipolar II disorder:

Manic or hypomanic episode, with mixed features:

  • A. Full criteria are met for a manic episode or hypomanic episode, and at least 3 of the following symptoms are present during the majority of days of the current or most recent episode of mania or hypomania:
    • (1) Prominent dysphoria or depressed mood as indicated by either subjective report (e.g. - feels sad or empty) or observation made by others (e.g. - appears tearful)
    • (2) Diminished interest or pleasure in all, or almost all, activities (as indicated by either subjective account or observation made by others)
    • (3) Psychomotor retardation nearly every day (observable by others and not merely subjective feelings of being slowed down)
    • (4) Fatigue or loss of energy
    • (5) Feelings of worthlessness or excessive or inappropriate guilt (not merely self-reproach or guilt about being sick)
    • (6) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
  • B. Mixed symptoms are observable by others and represent a change from the person’s usual behavior
  • C. For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features, due to the marked impairment and clinical severity of full mania
  • D. The mixed symptoms are not attributable to the physiological effects of a substance (e.g. - a drug of abuse, a medication, other treatment)

Depressive episode, with mixed features:

  • A. Full criteria are met for a major depressive episode, and at least 3 of the following manic/hypomanic symptoms are present during the majority of days of the current or most recent episode of depression:
    • (1) Elevated, expansive mood
    • (2) Inflated self-esteem or grandiosity
    • (3) More talkative than usual or pressure to keep talking
    • (4) Flight of ideas or subjective experience that thoughts are racing.
    • (5) Increase in energy or goal-directed activity (either socially, at work or school, or sexually)
    • (6) Increased or 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)
      • (7) Decreased need for sleep (feeling rested despite sleeping less than usual; to be contrasted with insomnia)
  • B. Mixed symptoms are observable by others and represent a change from the person’s usual behavior
  • C. For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features
  • D. The mixed symptoms are not attributable to the physiological effects of a substance (e.g. - a drug of abuse, a medication, or other treatment)
Note: Mixed features associated with a major depressive episode have been found to be a significant risk factor for the development of bipolar I or bipolar II disorder. As a result, it is clinically useful to note the presence of this specifier for treatment planning and monitoring of response to treatment.

With rapid cycling

This specifier (can be applied to bipolar I or bipolar II disorder). There is presence of at least 4 mood episodes in the previous 12 months that meet the criteria for manic, hypomanic, or major depressive episode.

Note: The essential feature of a rapid-cycling bipolar disorder is the occurrence of at least 4 mood episodes during the previous 12 months. These episodes can occur in any combination and order. The episodes must meet both the duration and symptom number criteria for a major depressive, manic, or hypomanic episode and must be demarcated by either a period of full remission or a switch to an episode of the opposite polarity. Manic and hypomanic episodes are counted as being on the same pole. Episodes are demarcated by either partial or full remissions of at least 2 months or a switch to an episode of the opposite polarity (e.g. - major depressive episode to manic episode). Except for the fact that they occur more frequently, the episodes that occur in a rapid-cycling pattern are no different from those that occur in a non-rapid cycling pattern. Mood episodes that count toward defining a rapid-cycling pattern exclude those episodes directly caused by a substance (e.g. - cocaine, corticosteroids) or another medical condition.

With melancholic features

  • A. 1 of the following is present during the most severe period of the current episode:
    • (1) Loss of pleasure in all, or almost all, activities
    • (2) Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens)
  • B. 3 or more of the following:
    • (1) A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood,
    • (2) Depression that is regularly worse in the morning
    • (3) Early-morning awakening (i.e. - at least 2 hours before usual awakening)
    • (4) Marked psychomotor agitation or retardation
    • (5) Significant anorexia or weight loss
    • (6) Excessive or inappropriate guilt

With atypical features

This specifier can be applied when these features predominate during the majority of days of the current or most recent major depressive episode.

  • A. Mood reactivity (i.e. - mood brightens in response to actual or potential positive events)
  • B. 2 or more of the following:
    • (1) Significant weight gain or increase in appetite
    • (2) Hypersomnia
    • (3) Leaden paralysis (i.e. - heavy, leaden feelings in arms or legs)
    • (4) A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment
  • C. Criteria are not met for “with melancholic features” or “with catatonia” during the same episode

With psychotic features

Delusions or hallucinations are present at any time in the episode. If psychotic features are present, specify if mood-congruent or mood-incongruent:

  • With mood-congruent psychotic features:
    • The content of all delusions and hallucinations is consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment
  • With mood-incongruent psychotic features:
    • The content of the delusions or hallucinations does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment, or the content is a mixture of mood-incongruent and mood-congruent themes

With catatonia

This specifier can apply to an episode of mania or depression if catatonic features are present during most of the episode.

With peripartum onset

This specifier can be applied to the current or, if the full criteria are not currently met for a mood episode, most recent episode of mania, hypomania, or major depression in bipolar I or bipolar II disorder if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery.

With seasonal pattern

This specifier applies to the lifetime pattern of mood episodes. The essential feature is a regular seasonal pattern of at least 1 type of episode (i.e. - mania, hypomania, or depression). The other types of episodes may not follow this pattern. For example, an individual may have seasonal manias, but his or her depressions do not regularly occur at a specific time of year.

  • A. There has been a regular temporal relationship between the onset of manic, hypomanic, or major depressive episodes and a particular time of the year (e.g. - in the fall or winter) in bipolar I or bipolar II disorder. Do not include cases in which there is an obvious effect of seasonally related psychosocial stressors (e.g. - regularly being unemployed every winter).
  • B. Full remissions (or a change from major depression to mania or hypomania or vice versa) also occur at a characteristic time of the year (e.g. - depression disappears in the spring)
  • C. In the last 2 years, the individual’s manic, hypomanic, or major depressive episodes have demonstrated a temporal seasonal relationship, as defined above, and no non-seasonal episodes of that polarity have occurred during that 2-year period.
  • D. Seasonal manias, hypomanias, or depressions (as described above) substantially outnumber any nonseasonal manias, hypomanias, or depressions that may have occurred over the individual’s lifetime.

Bipolar I versus Bipolar II

There are key differences in the diagnostic criteria between Bipolar I and Bipolar II disorder, the table below outlines these differences.

Comparison

Bipolar I Bipolar II
Diagnostic Criteria manic episode only hypomanic episode + depressive episode
Length > 7 days > 4 days
Impairment Severe Minor to none
Hospitalization Possible No
Psychosis Possible No

Borderline Personality Disorder

Bipolar II and borderline personality can often present in very similar ways. Affective instability, is repeated, rapid, and abrupt shifts in mood, and considered the core pathology in borderline personality disorder. Affective instability can be misdiagnosed as hypomania, or vice versa. A good history can often help differentiate between the two (See:Paris J. Why Psychiatrists are Reluctant to Diagnose: Borderline Personality Disorder. Psychiatry (Edgmont). 2007;4(1):35-39.)

Medication

The “Ls” for bipolar depression - lithium, lurasidone, lamotrigine

Psychotherapy

ECT