Many believe bipolar II is not as serious as bipolar I because symptoms of mania aren’t as severe. But bipolar II has another aspect to it that can also be serious if not treated.
Bipolar II is a chronic mental illness, defined by episodes of depression and periods of elevated or irritable mood, called hypomania. This is similar to mania but less extreme.
It’s a common misconception that bipolar II is less severe than bipolar I. Indeed, the mania is less pronounced, but this doesn’t mean the condition is any easier.
In fact, people with bipolar II often experience
We’re taking a look at how bipolar II looks and feels from the perspective of a woman living with the condition as well as the medical viewpoint of Dr. Joseph Patrick McEvoy,professor of Psychiatry and Health Behavior at Augusta University in Georgia.
Bipolar II is one of several subtypes of bipolar disorder.
According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the subtypes of bipolar disorder include:
- Bipolar I: Diagnosis requires the presence of at least one manic episode, with or without a history of depressive episodes.
- Bipolar II: Diagnosis requires at least one hypomanic and one major depressive episode.
- Cyclothymic disorder: Characterized by periods of hypomanic symptomsand periods of depressive symptomslasting for at least 2 years in adults. However, symptoms don’t meet the diagnostic criteria for a hypomanic or depressive episode.
- Other types: Drug/substance-induced bipolar disorder; bipolar disorder due to another medical condition; other specified bipolar disorder; and unspecified bipolar disorder.
Bipolar I and II are the most common subtypes.
But when it comes down to splitting hairs between the two, they seem to have more similarities than differences if someone experiences mania and depression in bipolar I.
“The symptoms and signs are the same except that only mild mania is … (by definition) in Bipolar II. … The treatments are the same. The outcomes are the same with high-quality treatment (sustained remission) and the outcomes are the same if there is no (or poor quality) treatment.”
Symptoms of bipolar disorder can begin at any age, but they typically begin between the ages of 15 and 19. Males and females from all backgrounds are equally likely to develop the condition.
“I was 15 when I was diagnosed. It was suspected since every female on my dad’s side has bipolar II rapid cycling,” says 20-year-old Ava Rose.
The hallmark symptoms of bipolar II are hypomania and depression. Let’s take a closer look at both from Rose’s perspective.
What hypomania looks and feels like: Rose’s account
According to some people with bipolar II, hypomania feels less like an illness and more like a great mood. This makes it harder to pinpoint in the early years because increased energy and confidence aren’t necessarily things you’d complain about to your doctor.
“Through the early years of my diagnosis, it was much harder to detect when I was in a hypomanic state,” recalls Rose.
“I remember feeling invincible and taking much more risks — like running in the street, starting fights and arguments, having more of a god-complex way of thinking where nothing could hurt/affect/bring me down.”
According to the DSM-5, hypomania must last at least 4 days in a row and be present most of the day, nearly every day.
During this time, 3 or more of the following symptoms must be observed or felt and be a significant change from the person’s typical behavior:
- Inflated self-esteem or grandiosity
- Reduced need for sleep
- Increased talkativeness
- Racing thoughts
- Distracted easily
- Increase in goal-directed activity (may have several projects going at once) or psychomotor agitation (pacing the room, swinging leg, fidgeting)
- Engaging in activities that could lead to long-term consequences (shopping sprees; sex not protected by condoms or other barrier methods, gambling)
In many cases, it’s friends, family and peers who notice the behavior changes first. Rose recalls how difficult it was at that time, because she felt unable to fully trust herself or her feelings.
“I remember it was so tough that it wasn’t something I could mask. I remember just talking and someone made a joke about me seeming manic, and it just destroyed my heart, since they never even knew I have bipolar disorder.”
“It felt like I could never be myself — cause being myself just felt crazy.”
What does bipolar II depression look and feel like?
Although hypomania is the core feature that defines bipolar II, the depressive episodes tend to be more frequent, long-lasting, and disabling over a person’s lifetime.
According to the DSM-5, the depressive aspect of bipolar II is defined by at least one major depressive episode resulting in depressed mood or loss of interest or pleasure in life.
Depression in bipolar II
A person must experience 5 or more of the following symptoms in 2 weeks to be diagnosed with a major depressive episode:
- Depressed mood (sad, hopeless, empty) most of the day, nearly every day (in kids or teens, this can look like irritability)
- Loss of interest or pleasure in previously favorite activities
- Significant changes in appetite or weight
- Restlessness, such as pacing the room
- Feeling tired, fatigued or low energy to complete tasks
- Sleep disturbances, such insomnia or sleeping too much
- Feelings of worthlessness or guilt
- Poor ability to think or concentrate, or indecisiveness
- Continual thoughts of death; recurrent suicidal ideation without a specific plan, or a suicide attempt
“[Depression] feels like the world is crumbling around me, like I’m 10-feet underground and can’t dig myself up,” Rose says.
But as different as the hypomanic and depressive states have felt, Rose reveals that they were similar in one way: They both felt like they would never end.
Other bipolar II experiences
Bipolar II is a different experience for every individual living with it.
In clinical terms, the disorder can include extra “specifiers” that further clarify the condition and the type of bipolar disorder.
Bipolar disorder specifiers
These may include the following:
- With anxious distress
- With rapid cycling: 4 or more episodes of mania or depression in one year
- With mixed features: mania and depression occurring at the same time
- With seasonal pattern: depressive episodes tend to start at the same time every year
- With catatonia: peculiar movement difficulties which may include unresponsiveness
- With mood-congruent psychotic features: hallucinations and/or delusions related to depressive themes like feeling worthless, etc.
- With peripartum onset (postpartum depression)
In this example Rose would be bipolar II, rapid cycling.
For Rose, one of the most difficult symptoms was the rapid cycling aspect of her disorder. While rapid cycling can occur in any subtype of bipolar disorder, it’s most often seen in bipolar II.
“It felt impossible to control any other aspect of my life while being flooded with such rapid changes in my mental state,” says Rose.
She describes how disorienting it could be: “Imagine walking in a straight line, but gravity is changing so rapidly, that… right after one step it was like the switch flipped, and I was thrown against the ceiling, then abruptly back on the floor, then up and down all over again. Making it impossible to actually function.”
Rose also had significant difficulties with irritation and frustration, symptoms she feels aren’t talked about enough in bipolar disorder.
“Something that should trigger a [particular] reaction in others, would affect me to a much larger degree, and it felt like there was nothing in my power to control my reactions to make them appropriate.”
“I had an awful temper and reacted with anger much more abruptly and more often than now.
“The hardest part was this all happened in the span of middle and high school; and school quickly became on the bottom of my priority list.
“Also, the relationships with my friends and family were heavily affected, it created a lot of conflict in every aspect of my life, making me constantly feel like I was drowning,” says Rose.
Because of the challenges of correctly diagnosing hypomania, bipolar II is often initially misdiagnosed as major depressive disorder (MDD). Misdiagnosis is perpetuated because people are more likely to seek help during a depressive episode rather than a hypomanic state.
In fact, hypomania occurs in
Unfortunately, misdiagnosis usually leads to inappropriate treatment. Antidepressant therapy in people with bipolar depression is tied to greater rates of mood shift to mania.
This very thing happened to Rose.
“I remember going to the pediatrician,” she says. “She asked me many questions related to only depression. This led her to diagnose me with major depressive disorder and prescribed me Prozac, I believe — it was an SSRI (selective serotonin reuptake inhibitors) for sure.”
A month later, Rose showed up for her follow-up appointment in a clearly hypomanic state.
“When I walked in I told her about how great my life was, was talking a mile a minute, and was clearly a bit delirious and very unaware of how unstable I was presenting. I was having more psychotic symptoms as well.
“She very quickly realized she was mistaken, and that it was very clear I [in fact, had] bipolar [disorder] and was having a negative reaction with the SSRI for this reason.
“In the long run, it led me to the worst depressive episode and 8-12 months of a much more unstable state with much faster cycling and a lot less control. I was very disconnected with reality.”
Bipolar II is considered a chronic illness, and therefore, treatment might include a mood stabilizer, atypical antipsychotics, and therapy.
“Clinicians need to take the long, and broad, view — bipolar disorder is a chronic biological illness with most patients going through multiple phases (mania, depression, euthymia, hypomania) every year,” McEvoy explains.
“The chronic care model teaches us to manage chronic biological illnesses with the simple goal of sustained remission through assured medication and lifestyle management… We want no phases except euthymia.” Euthymia is a typical, tranquil mental state (without any mood disturbances).
Many people with bipolar II find that psychotherapy is another helpful way to manage their thoughts and feelings.
Rose has found great success with dialectical behavior therapy (DBT). This type of therapy provides people with the skills to manage painful emotions and reduce relationship conflicts.
“Now, after 7 years of DBT therapy and medication, I am able to detect subconscious patterns of thinking that indicate I’m in a hypomanic state,” says Rose.
Rose feels she has a much better handle on the situation these days. She no longer gets stuck in a mood state thinking it will never end.
“Once I understood from a logical point — that bipolar disorder is the cycling of phases — no matter how I was feeling… [I knew] it would eventually switch.”