Bipolar II disorder
Encyclopedia
Bipolar II disorder is a bipolar spectrum disorder characterized by at least one hypomanic episode and at least one major depressive episode
; with this disorder, depressive episodes can be more frequent and are more intense than hypomanic episodes. People with bipolar disorder type II have never had full mania
, although they can experience periods of high energy and impulsiveness similar to but not as extreme as mania. These periods alternate between episodes of depression. Sometimes severe symptoms can make it extremely difficult or impossible to function in work, school, or at home. People with Bipolar Disorder may be depressed or irritable and violent. The hypomanic episodes associated with bipolar II disorder must last all day for a period of at least four days.
Bipolar II is believed to be under-diagnosed because hypomanic behavior often presents as high-functioning behavior. Those with bipolar II are at highest risk of suicide among the bipolar spectrum. Hypomania in bipolar II may manifest itself in disorganized racing thoughts, irritability, anxiety, insomnia, or all of the above combined. Because these agitated symptoms are negative, it may be difficult to distinguish a bipolar II hypomanic state from depression. Hypomania is often regarded as an elation of mood, however, mood may be negative in bipolar II hypomania. Mixed States and/or Rapid Cycling may also be present.
People with bipolar disorder may develop alternate identities to match each mood they experience. For some, this is done intentionally, as a means by which to escape trauma or pain from a depressive period, or simply to better organize one's life by setting boundaries for one's perceptions and behaviors.
(DSM-IV) recognizes two types of bipolar disorders—bipolar I and bipolar II. People with bipolar I disorder suffer from alterations of full manic episodes and major depressive episodes. On the contrary, as noted above, people with bipolar II disorder experience a milder form of a manic episode, known as a hypomanic episode as well as major depressive episodes. Although bipolar II is thought to be less severe than bipolar I in regards to symptom intensity, it is actually more severe and distressing with respect to episode frequency and overall course, often experiencing more frequent bouts of depressive episodes. Specific criteria defined by the DSM-IV for a bipolar II diagnosis is as follows:
When considering the possibility of bipolar II disorder, it is also important to utilize differential diagnosis
methods, or methods to identify the presence of a particular disorder when other alternatives are possible. The DSM-IV notes that in the diagnosis of bipolar II disorder, the presence of mood symptoms like hypomanic and major depressive episodes cannot be better accounted for by Schizoaffective Disorder
. Nor can it extend beyond Schizophrenia
, Schizophreniform Disorder
, Delusional Disorder
, or Psychotic Disorder Not Otherwise Specified.
Studies have identified major differences between bipolar I and bipolar II in regards to their clinical features, comorbidity rates and family histories. According Baek et al. (2011), during depressive episodes, bipolar II patients tend to show higher rates of psychomotor agitation, guilt, shame, suicide ideation, and suicide attempts. Bipolar II patients have shown higher lifetime comorbidity rates of DSM axis I diagnoses such as phobias, anxiety disorders, substance & alcohol abuse, and eating disorders and there is a higher correlation between bipolar II patients and family history of psychiatric illness including major depression and substance-related disorders. The occurrence rate of psychiatric illness in first degree relatives of bipolar II patients was 26.5%, versus 15.4% in bipolar II patients.
Although the DSM-IV reports a bipolar II lifetime prevalence rate of 0.5%, recent epidemiological studies indicate a rate closer to 5% with one in two depressed outpatients suffering from this disorder. There are several reasons for this increase in bipolar II diagnoses. New semi-structured interviews allow trained research clinicians to diagnose a patient on the bipolar spectrum more accurately, DSM-IV criteria has relaxed so that now the minimum duration of hypomania is less than four days, and history of hypomania is now focused more on over-activity, especially in regards to goal-setting activity, than mood changes. Screening instruments like the Mood Disorders Questionnaire (MDQ) are helpful tools in determining a patient's status on the bipolar spectrum and getting families involved can also improve chances of an accurate diagnosis and acknowledgment of hypomanic episodes. In addition, there are certain features that have been shown to increase the chances that depressed patients are suffering from a bipolar disorder including atypical symptoms of depression like hypersomnia
and hyperphagia, a family history of bipolar disorder, medication-induced hypomania, recurrent or psychotic depression, antidepressant refractory depression, and early or postpartum depression.
, usually in the form of mood stabilizer
s. However, treatment with mood stabilizers may produce a flat affect in the patient, which is dose dependent. Concurrent use of SSRI antidepressants may help some with bipolar II disorder, though these medications should be used with caution because it is believed that they may exacerbate manic symptoms in some people; moreover, even when used along with a mood stabilizer, SSRI antidepressants may induce rapid cycling. Lithium
is considered the "gold standard" medication and is often individually used as first line treatment for bipolar II. The combination of lithium and lamotrigine
can be prescribed when either one is not enough to either curb depression or hypomania
. The combination is well tolerated and has been shown to be effective and safe in preventing mania, due to lithium's anti-manic properties, while keeping depression at bay with lamotrigine's anti-depressive properties. Non-pharmaceutical therapies can also help those with the illness. These include psychodynamic therapy, psychoanalysis
, social rhythm therapy, interpersonal therapy, behavioral therapy, cognitive therapy
, music therapy
, psychoeducation
, light therapy
, and family-focused therapy
. Relapse
s can still occur, even with continued medication and therapy.
Treatment for bipolar disorder mostly involves lithium or carbamazepine, and the effectiveness of both treatments are similar in patients of both bipolar I and bipolar II disorder. However, since there have not been many studies on the responsiveness to treatment between disorder types, more data is needed to make a more concise finding. There is often failure to diagnose and treat bipolar disorder, more so amongst patients with type II. In a study on delayed treatment, it was found that women were given treatment much later than men were, starting lithium treatment 11 years after the onset of the disorder compared to 6.9 years for men.
The management of bipolar II disorder is controversial. Some medications used are:
Non-pharmaceutical therapies have not been well studied but include cognitive behavioral therapy (CBT) and interpersonal therapy, which seem to be effective in unipolar depression, which is believed to be able to expand to bipolar II disorder.
Treatment typically includes three things: the treatment of acute hypomania, the treatment of acute depression, and the prevention of the relapse of either hypomania or depression. The main goal is to avoid causing harm to the patient.
. This constant and pervasive course of the illness leads to an increased risk in suicide and more hypomanic and major depressive episodes with shorter periods of time between episodes than Bipolar I patients experience. The natural course of Bipolar II Disorder, when left untreated, leads to patients spending the majority of their lives unwell with much of their suffering stemming from depression
. Their recurrent depression results in personal suffering and disability. This disability can present itself in the form of psychosocial impairment, which has been suggested to be worse in Bipolar II patients than in Bipolar I patients. Another facet of this illness that is associated with a poorer prognosis is rapid cycling, which denotes the occurrence of four or more Major Depressive, Hypomanic, and/or mixed episodes in a twelve month period. Rapid cycling is actually quite common in those with Bipolar II, much more so in women than in men (70% vs. 40%), and without treatment leads to added sources of disability and an increased risk of suicide. In order to improve a patient’s prognosis, long term therapy is most favorably recommended for controlling symptoms, maintaining remission and preventing relapses. With treatment, patients have been shown to present a decreased risk of suicide (especially when treated with Lithium
) and a reduction of frequency and severity of their episodes, which in turns moves them toward a stable life and reduces the time they spend ill. In order to maintain their state of balance, therapy is often continued indefinitely, as around 50% of the patients who discontinue it relapse quickly and experience either full-blown episodes or sub-syndromal symptoms that bring significant functional impairments.
symptoms. Functional impairment has been shown to be directly linked with increasing percentages of depressive symptoms, and because sub-syndromal symptoms are more common—and frequent—in Bipolar II disorder, they have been implicated heavily as a major cause of psychosocial disability. There is evidence that shows the mild depressive symptoms, or even sub-syndromal symptoms, are responsible for the non-recovery of social functioning, which furthers the idea that residual depressive symptoms are detrimental for functional recovery in patients being treated for Bipolar II. It has been suggested that symptom interference in relation to social and interpersonal relationships in Bipolar II Disorder is worse than symptom interference in other chronic medical illnesses such as cancer. This social impairment can last for years, even after treatment that has resulted in a resolution of mood symptoms. The factors related to this persistent social impairment are residual depressive symptoms, limited illness insight (a very common occurrence in patients with Bipolar II Disorder), and impaired executive functioning. Impaired ability in regards to executive functions
is directly tied to poor psychosocial functioning, a common side-effect in patients with Bipolar II. The impact on a patient’s psychosocial functioning stems from the depressive symptoms (more common in Bipolar II than Bipolar I). An increase in these symptoms’ severity seems to correlate with a significant increase in psychosocial disability. Psychosocial disability can present itself in poor semantic memory
, which in turn effects other cognitive domains like verbal memory and (as mentioned earlier) executive functioning leading to a direct and persisting impact on psychosocial functioning. An abnormal semantic memory organization can manipulate thoughts and lead to the formation of delusions and possibly effect speech and communication problems, which can lead to interpersonal issues. Bipolar II patients have also been shown to present worse cognitive functioning than those patients with Bipolar I, though they demonstrate about the same disability when it comes to occupational functioning, interpersonal relationships, and autonomy
. This disruption in cognitive functioning takes a toll on their ability to function in the work place, which leads to high rates of work loss in Bipolar II patient populations. After treatment and while in remission, Bipolar II patients tend to report a good psychosocial functioning but they still score less in that department than normal patients without the disorder. These lasting impacts further suggest that a prolonged exposure to an untreated Bipolar II disorder can lead to permanent adverse effects on functioning.
, which has been shown to be very beneficial in reducing the frequency and severity of depressive episodes. Lithium prevents mood relapse and works especially well in Bipolar II patients who experience rapid-cycling. Almost all Bipolar II patients who take Lithium have a decrease in the amount of time they spend ill and a decrease in mood episodes. Along with medication, other forms of therapy have been shown to be beneficial for Bipolar II patients. A treatment called a “wellbeing plan” serves several purposes: it informs the patients, protects them from future episodes, teaches them to add value to their life, and works toward building a strong sense of self to fend off depression and reduce the desire to succumb to the seductive hypomanic highs. The plan has to aim high otherwise patients will relapse into depression. A large part of this plan involves the patient being very aware of warning signs and stress triggers so that they take an active role in their recovery and prevention of relapse.
is higher in patients who suffer from Bipolar II than those who suffer from Bipolar I, and especially higher than patients who suffer from Major Depressive Disorder. In results of a summary of several lifetime study experiments, it was found that 24% of Bipolar II patients experienced suicidal ideation or suicide attempts compared to 17% in Bipolar I patients and 12% in Major Depressive Patients. The risk of suicide for Bipolar II patients is especially high; as many as 50% of them will attempt suicide at least once. Bipolar Disorders in general are the 3rd leading cause of death in 15–24 year olds. Bipolar II patients were also found to employ more lethal means and have more complete suicides over all. They had a higher rate of suicide attempts with a higher risk for death rather than just suicidal gestures that weren’t necessarily lethal (like self-harm). Bipolar II patients have several risk factors that increase their risk of suicide. The illness is very recurrent and results in severe disabilities, interpersonal relationship problems, barriers to academic, financial, and vocational goals, and a loss of social standing in their community, all of which increase the likelihood of suicide. Mixed symptoms and rapid-cycling, both very common in Bipolar II, are also associated with an increased risk of suicide.
The tendency for Bipolar II to be misdiagnosed and treated ineffectively, or not at all in some cases, also leads to an increased risk. As a result of the high suicide risk for this group, reducing the risk and preventing attempts remains a main part of the treatment; a combination of self-monitoring, close supervision by a therapist, and faithful adherence to their medication regimen will help to reduce the risk and prevent the likelihood of a completed suicide.
received treatment for bipolar II disorder after dealing with the stress of her husband's throat cancer. According to her publicist, Zeta Jones made a decision to check into a "mental health facility" for a brief stay.
Carrie Fisher
has been diagnosed with the condition.
Major depressive episode
A major depressive episode is the cluster of symptoms of major depressive disorder. The description has been formalised in psychiatric diagnostic criteria such as the DSM-IV and ICD-10, and is characterized by severe, highly persistent depression, and a loss of interest or pleasure in everyday...
; with this disorder, depressive episodes can be more frequent and are more intense than hypomanic episodes. People with bipolar disorder type II have never had full mania
Mania
Mania, the presence of which is a criterion for certain psychiatric diagnoses, is a state of abnormally elevated or irritable mood, arousal, and/ or energy levels. In a sense, it is the opposite of depression...
, although they can experience periods of high energy and impulsiveness similar to but not as extreme as mania. These periods alternate between episodes of depression. Sometimes severe symptoms can make it extremely difficult or impossible to function in work, school, or at home. People with Bipolar Disorder may be depressed or irritable and violent. The hypomanic episodes associated with bipolar II disorder must last all day for a period of at least four days.
Bipolar II is believed to be under-diagnosed because hypomanic behavior often presents as high-functioning behavior. Those with bipolar II are at highest risk of suicide among the bipolar spectrum. Hypomania in bipolar II may manifest itself in disorganized racing thoughts, irritability, anxiety, insomnia, or all of the above combined. Because these agitated symptoms are negative, it may be difficult to distinguish a bipolar II hypomanic state from depression. Hypomania is often regarded as an elation of mood, however, mood may be negative in bipolar II hypomania. Mixed States and/or Rapid Cycling may also be present.
Hypomanic episodes
- High energy levels
- Grandiosity
- Hedonistic mood
- Unrealistic optimism
- Mystical experiences
- Irritability and anger
- Automatic thoughts
- Maladaptive assumptions
- Dysfunctional personal schemas
Depressive episodes
- Low energy levels
- Cessation of usual activities
- Black and white thinking
- Unrealistic pessimism
- Overgeneralization
- Automatic thoughts
- Maladaptive assumptions
- Dysfunctional personal schemas
Relapse
In the case of a relapse, the following symptoms often occur and are considered early warning signs:- Sleep disturbance: patient requires less sleep and does not feel tired
- Racing thoughts and/or speech
- Anxiety
- Irritability
- Emotional intensity
- Spending more money than usual
- Binge behavior, including food, drugs, and alcohol
- Arguments with family members and friends
- Taking on many projects at once
People with bipolar disorder may develop alternate identities to match each mood they experience. For some, this is done intentionally, as a means by which to escape trauma or pain from a depressive period, or simply to better organize one's life by setting boundaries for one's perceptions and behaviors.
Causes
There have been very few studies conducted to examine the possible causes of Bipolar II. Those that have been done, have not considered Bipolar I and Bipolar II separately and have had inconclusive results. Researchers have found that patients with either Bipolar I or II have increased levels of blood calcium concentrations and diminished size in the prefrontal and temporal regions of the brain. But these studies could not find a significant difference between those with Bipolar I or Bipolar II. There has been a study looking at genetics and Bipolar II disorder and the results are inconclusive, however, scientists did find that relatives of people with Bipolar II are more likely to develop the same bipolar disorder or major depression rather then developing Bipolar I disorder.Diagnosis
The Diagnostic and Statistical Manual of Mental DisordersDiagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
(DSM-IV) recognizes two types of bipolar disorders—bipolar I and bipolar II. People with bipolar I disorder suffer from alterations of full manic episodes and major depressive episodes. On the contrary, as noted above, people with bipolar II disorder experience a milder form of a manic episode, known as a hypomanic episode as well as major depressive episodes. Although bipolar II is thought to be less severe than bipolar I in regards to symptom intensity, it is actually more severe and distressing with respect to episode frequency and overall course, often experiencing more frequent bouts of depressive episodes. Specific criteria defined by the DSM-IV for a bipolar II diagnosis is as follows:
- The presence of a hypomanic or major depressive episode.
- If currently in major depressive episode, history of a hypomanic episode. If currently in a hypomanic episode, history of a major depressive episode. No history of a manic episode.
- Significant stress or impairment in social, occupational, or other important areas of functioning.
When considering the possibility of bipolar II disorder, it is also important to utilize differential diagnosis
Differential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
methods, or methods to identify the presence of a particular disorder when other alternatives are possible. The DSM-IV notes that in the diagnosis of bipolar II disorder, the presence of mood symptoms like hypomanic and major depressive episodes cannot be better accounted for by Schizoaffective Disorder
Schizoaffective disorder
Schizoaffective disorder is a psychiatric diagnosis that describes a mental disorder characterized by recurring episodes of elevated or depressed mood, or of simultaneously elevated and depressed mood, that alternate with, or occur together with, distortions in perception.Schizoaffective disorder...
. Nor can it extend beyond Schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
, Schizophreniform Disorder
Schizophreniform disorder
Schizophreniform disorder is a mental disorder diagnosed when symptoms of schizophrenia are present for a significant portion of the time within a one-month period, but signs of disruption are not present for the full six months required for the diagnosis of schizophrenia.The symptoms of both...
, Delusional Disorder
Delusional disorder
Delusional disorder is an uncommon psychiatric condition in which patients present with circumscribed symptoms of non-bizarre delusions, but with the absence of prominent hallucinations and no thought disorder, mood disorder, or significant flattening of affect...
, or Psychotic Disorder Not Otherwise Specified.
Studies have identified major differences between bipolar I and bipolar II in regards to their clinical features, comorbidity rates and family histories. According Baek et al. (2011), during depressive episodes, bipolar II patients tend to show higher rates of psychomotor agitation, guilt, shame, suicide ideation, and suicide attempts. Bipolar II patients have shown higher lifetime comorbidity rates of DSM axis I diagnoses such as phobias, anxiety disorders, substance & alcohol abuse, and eating disorders and there is a higher correlation between bipolar II patients and family history of psychiatric illness including major depression and substance-related disorders. The occurrence rate of psychiatric illness in first degree relatives of bipolar II patients was 26.5%, versus 15.4% in bipolar II patients.
Although the DSM-IV reports a bipolar II lifetime prevalence rate of 0.5%, recent epidemiological studies indicate a rate closer to 5% with one in two depressed outpatients suffering from this disorder. There are several reasons for this increase in bipolar II diagnoses. New semi-structured interviews allow trained research clinicians to diagnose a patient on the bipolar spectrum more accurately, DSM-IV criteria has relaxed so that now the minimum duration of hypomania is less than four days, and history of hypomania is now focused more on over-activity, especially in regards to goal-setting activity, than mood changes. Screening instruments like the Mood Disorders Questionnaire (MDQ) are helpful tools in determining a patient's status on the bipolar spectrum and getting families involved can also improve chances of an accurate diagnosis and acknowledgment of hypomanic episodes. In addition, there are certain features that have been shown to increase the chances that depressed patients are suffering from a bipolar disorder including atypical symptoms of depression like hypersomnia
Hypersomnia
Hypersomnia is a disorder characterized by excessive amounts of sleepiness.There are two main categories of hypersomnia: primary hypersomnia and recurrent hypersomnia...
and hyperphagia, a family history of bipolar disorder, medication-induced hypomania, recurrent or psychotic depression, antidepressant refractory depression, and early or postpartum depression.
Treatments
The most common treatment for reducing bipolar II disorder symptoms is medicationMedication
A pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...
, usually in the form of mood stabilizer
Mood stabilizer
A mood stabilizer is a psychiatric medication used to treat mood disorders characterized by intense and sustained mood shifts, typically bipolar disorder.-Uses:...
s. However, treatment with mood stabilizers may produce a flat affect in the patient, which is dose dependent. Concurrent use of SSRI antidepressants may help some with bipolar II disorder, though these medications should be used with caution because it is believed that they may exacerbate manic symptoms in some people; moreover, even when used along with a mood stabilizer, SSRI antidepressants may induce rapid cycling. Lithium
Lithium pharmacology
Lithium pharmacology refers to use of the lithium ion, Li+, as a drug. A number of chemical salts of lithium are used medically as a mood stabilizing drug, primarily in the treatment of bipolar disorder, where they have a role in the treatment of depression and particularly of mania, both acutely...
is considered the "gold standard" medication and is often individually used as first line treatment for bipolar II. The combination of lithium and lamotrigine
Lamotrigine
Lamotrigine, marketed in the US and most of Europe as Lamictal by GlaxoSmithKline, is an anticonvulsant drug used in the treatment of epilepsy and bipolar disorder. It is also used as an adjunct in treating depression, though this is considered off-label usage...
can be prescribed when either one is not enough to either curb depression or hypomania
Hypomania
Hypomania is a mood state characterized by persistent and pervasive elevated or irritable mood, as well as thoughts and behaviors that are consistent with such a mood state...
. The combination is well tolerated and has been shown to be effective and safe in preventing mania, due to lithium's anti-manic properties, while keeping depression at bay with lamotrigine's anti-depressive properties. Non-pharmaceutical therapies can also help those with the illness. These include psychodynamic therapy, psychoanalysis
Psychoanalysis
Psychoanalysis is a psychological theory developed in the late 19th and early 20th centuries by Austrian neurologist Sigmund Freud. Psychoanalysis has expanded, been criticized and developed in different directions, mostly by some of Freud's former students, such as Alfred Adler and Carl Gustav...
, social rhythm therapy, interpersonal therapy, behavioral therapy, cognitive therapy
Cognitive therapy
Cognitive behavioral therapy is a psychotherapeutic approach: a talking therapy. CBT aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure in the present...
, music therapy
Music therapy
Music therapy is an allied health profession and one of the expressive therapies, consisting of an interpersonal process in which a trained music therapist uses music and all of its facets—physical, emotional, mental, social, aesthetic, and spiritual—to help clients to improve or maintain their...
, psychoeducation
Psychoeducation
Psychoeducation refers to the education offered to people who live with a psychological disturbance. Frequently psychoeducational training involves patients with schizophrenia, clinical depression, anxiety disorders, psychotic illnesses, eating disorders, and personality disorders, as well as...
, light therapy
Light therapy
Light therapy or phototherapy consists of exposure to daylight or to specific wavelengths of light using lasers, light-emitting diodes, fluorescent lamps, dichroic lamps or very bright, full-spectrum light, usually controlled with various devices...
, and family-focused therapy
Family therapy
Family therapy, also referred to as couple and family therapy, family systems therapy, and family counseling, is a branch of psychotherapy that works with families and couples in intimate relationships to nurture change and development. It tends to view change in terms of the systems of...
. Relapse
Relapse
Relapse, in relation to drug misuse, is resuming the use of a drug or a dependent substance after one or more periods of abstinence. The term is a landmark feature of both substance dependence and substance abuse, which are learned behaviors, and is maintained by neuronal adaptations that mediate...
s can still occur, even with continued medication and therapy.
Treatment for bipolar disorder mostly involves lithium or carbamazepine, and the effectiveness of both treatments are similar in patients of both bipolar I and bipolar II disorder. However, since there have not been many studies on the responsiveness to treatment between disorder types, more data is needed to make a more concise finding. There is often failure to diagnose and treat bipolar disorder, more so amongst patients with type II. In a study on delayed treatment, it was found that women were given treatment much later than men were, starting lithium treatment 11 years after the onset of the disorder compared to 6.9 years for men.
The management of bipolar II disorder is controversial. Some medications used are:
- Antipsychotics- there was a study done over a 6-month period that found there was a 60% response rate, however in this study there were some questions raised about whether the study actually was adequately testing the difference between the drugs being used and not being used.
- Dopamine Agonists- there was a recent study done, and it found that 60% of the patients taking the drug improved in their post-tests scores on the MADRS test by 50%.
- Antidepressants- most studies have shown that there is an association between stabilized moods and the antidepressants. They had improvements on their HDRS, MADRS, and CGI tests.
Non-pharmaceutical therapies have not been well studied but include cognitive behavioral therapy (CBT) and interpersonal therapy, which seem to be effective in unipolar depression, which is believed to be able to expand to bipolar II disorder.
Treatment typically includes three things: the treatment of acute hypomania, the treatment of acute depression, and the prevention of the relapse of either hypomania or depression. The main goal is to avoid causing harm to the patient.
Prognosis
There is evidence to suggest that Bipolar II Disorder has a more chronic course of illness than Bipolar I DisorderBipolar I disorder
Bipolar I disorder is a mood disorder that is characterized by at least one manic or mixed episode. There may be episodes of hypomania or major depression as well...
. This constant and pervasive course of the illness leads to an increased risk in suicide and more hypomanic and major depressive episodes with shorter periods of time between episodes than Bipolar I patients experience. The natural course of Bipolar II Disorder, when left untreated, leads to patients spending the majority of their lives unwell with much of their suffering stemming from depression
Depression
Depression or depress may refer to:-Medicine:* Depression , a state of low mood and aversion to activity** Mood disorder, a class of mental illnesses featuring depressed mood...
. Their recurrent depression results in personal suffering and disability. This disability can present itself in the form of psychosocial impairment, which has been suggested to be worse in Bipolar II patients than in Bipolar I patients. Another facet of this illness that is associated with a poorer prognosis is rapid cycling, which denotes the occurrence of four or more Major Depressive, Hypomanic, and/or mixed episodes in a twelve month period. Rapid cycling is actually quite common in those with Bipolar II, much more so in women than in men (70% vs. 40%), and without treatment leads to added sources of disability and an increased risk of suicide. In order to improve a patient’s prognosis, long term therapy is most favorably recommended for controlling symptoms, maintaining remission and preventing relapses. With treatment, patients have been shown to present a decreased risk of suicide (especially when treated with Lithium
Lithium pharmacology
Lithium pharmacology refers to use of the lithium ion, Li+, as a drug. A number of chemical salts of lithium are used medically as a mood stabilizing drug, primarily in the treatment of bipolar disorder, where they have a role in the treatment of depression and particularly of mania, both acutely...
) and a reduction of frequency and severity of their episodes, which in turns moves them toward a stable life and reduces the time they spend ill. In order to maintain their state of balance, therapy is often continued indefinitely, as around 50% of the patients who discontinue it relapse quickly and experience either full-blown episodes or sub-syndromal symptoms that bring significant functional impairments.
Functioning
The deficits in functioning associated with Bipolar II Disorder stem mostly from the recurrent depression that Bipolar II Patients suffer from. Depressive symptoms are much more disabling than hypomanic symptoms and are potentially as or more disabling than maniaMania
Mania, the presence of which is a criterion for certain psychiatric diagnoses, is a state of abnormally elevated or irritable mood, arousal, and/ or energy levels. In a sense, it is the opposite of depression...
symptoms. Functional impairment has been shown to be directly linked with increasing percentages of depressive symptoms, and because sub-syndromal symptoms are more common—and frequent—in Bipolar II disorder, they have been implicated heavily as a major cause of psychosocial disability. There is evidence that shows the mild depressive symptoms, or even sub-syndromal symptoms, are responsible for the non-recovery of social functioning, which furthers the idea that residual depressive symptoms are detrimental for functional recovery in patients being treated for Bipolar II. It has been suggested that symptom interference in relation to social and interpersonal relationships in Bipolar II Disorder is worse than symptom interference in other chronic medical illnesses such as cancer. This social impairment can last for years, even after treatment that has resulted in a resolution of mood symptoms. The factors related to this persistent social impairment are residual depressive symptoms, limited illness insight (a very common occurrence in patients with Bipolar II Disorder), and impaired executive functioning. Impaired ability in regards to executive functions
Executive functions
The executive system is a theorized cognitive system in psychology that controls and manages other cognitive processes. It is responsible for processes that are sometimes referred to as the executive function, executive functions, supervisory attentional system, or cognitive control...
is directly tied to poor psychosocial functioning, a common side-effect in patients with Bipolar II. The impact on a patient’s psychosocial functioning stems from the depressive symptoms (more common in Bipolar II than Bipolar I). An increase in these symptoms’ severity seems to correlate with a significant increase in psychosocial disability. Psychosocial disability can present itself in poor semantic memory
Semantic memory
Semantic memory refers to the memory of meanings, understandings, and other concept-based knowledge unrelated to specific experiences. The conscious recollection of factual information and general knowledge about the world is generally thought to be independent of context and personal relevance...
, which in turn effects other cognitive domains like verbal memory and (as mentioned earlier) executive functioning leading to a direct and persisting impact on psychosocial functioning. An abnormal semantic memory organization can manipulate thoughts and lead to the formation of delusions and possibly effect speech and communication problems, which can lead to interpersonal issues. Bipolar II patients have also been shown to present worse cognitive functioning than those patients with Bipolar I, though they demonstrate about the same disability when it comes to occupational functioning, interpersonal relationships, and autonomy
Autonomy
Autonomy is a concept found in moral, political and bioethical philosophy. Within these contexts, it is the capacity of a rational individual to make an informed, un-coerced decision...
. This disruption in cognitive functioning takes a toll on their ability to function in the work place, which leads to high rates of work loss in Bipolar II patient populations. After treatment and while in remission, Bipolar II patients tend to report a good psychosocial functioning but they still score less in that department than normal patients without the disorder. These lasting impacts further suggest that a prolonged exposure to an untreated Bipolar II disorder can lead to permanent adverse effects on functioning.
Recovery and recurrence
Bipolar II Disorder has a chronic relapsing nature. It has even been suggested that Bipolar II patients have a higher degree of relapse than Bipolar I patients . Generally, within four years of an episode, around 60% of patients will relapse into another episode. Some patients are even symptomatic half the time, either with full on episodes or symptoms that fall just below the threshold of an episode. Because of the nature of the illness, long-term therapy is the best option and aims to not only control the symptoms but to maintain sustained remission and prevent relapses from occurring. Even with treatment, patients do not always regain full functioning, especially in the social realm . There is a very clear gap between symptomatic recovery and full functional recovery, for both Bipolar I and Bipolar II patients. As such, and because those with Bipolar II spend more time with depressive symptoms that don’t quite qualify as a major depressive episode, the best chance for recovery is to have therapeutic interventions that focus on the residual depressive symptoms and to aim for improvement in psychosocial and cognitive functioning. Even with treatment, a certain amount of responsibility is placed in the patient’s hands; they have to be able to assume responsibility for their illness by accepting their diagnosis, taking the required medication, and seeking help when needed to do well in the future. Treatment often lasts after remission is achieved, and the treatment that worked is continued during the continuation phase (lasting anywhere from 6–12 months) and maintenance can last 1–2 years or in some cases: indefinitely. One of the treatments of choice is LithiumLithium pharmacology
Lithium pharmacology refers to use of the lithium ion, Li+, as a drug. A number of chemical salts of lithium are used medically as a mood stabilizing drug, primarily in the treatment of bipolar disorder, where they have a role in the treatment of depression and particularly of mania, both acutely...
, which has been shown to be very beneficial in reducing the frequency and severity of depressive episodes. Lithium prevents mood relapse and works especially well in Bipolar II patients who experience rapid-cycling. Almost all Bipolar II patients who take Lithium have a decrease in the amount of time they spend ill and a decrease in mood episodes. Along with medication, other forms of therapy have been shown to be beneficial for Bipolar II patients. A treatment called a “wellbeing plan” serves several purposes: it informs the patients, protects them from future episodes, teaches them to add value to their life, and works toward building a strong sense of self to fend off depression and reduce the desire to succumb to the seductive hypomanic highs. The plan has to aim high otherwise patients will relapse into depression. A large part of this plan involves the patient being very aware of warning signs and stress triggers so that they take an active role in their recovery and prevention of relapse.
Mortality
Several studies have shown that the risk of suicideSuicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...
is higher in patients who suffer from Bipolar II than those who suffer from Bipolar I, and especially higher than patients who suffer from Major Depressive Disorder. In results of a summary of several lifetime study experiments, it was found that 24% of Bipolar II patients experienced suicidal ideation or suicide attempts compared to 17% in Bipolar I patients and 12% in Major Depressive Patients. The risk of suicide for Bipolar II patients is especially high; as many as 50% of them will attempt suicide at least once. Bipolar Disorders in general are the 3rd leading cause of death in 15–24 year olds. Bipolar II patients were also found to employ more lethal means and have more complete suicides over all. They had a higher rate of suicide attempts with a higher risk for death rather than just suicidal gestures that weren’t necessarily lethal (like self-harm). Bipolar II patients have several risk factors that increase their risk of suicide. The illness is very recurrent and results in severe disabilities, interpersonal relationship problems, barriers to academic, financial, and vocational goals, and a loss of social standing in their community, all of which increase the likelihood of suicide. Mixed symptoms and rapid-cycling, both very common in Bipolar II, are also associated with an increased risk of suicide.
The tendency for Bipolar II to be misdiagnosed and treated ineffectively, or not at all in some cases, also leads to an increased risk. As a result of the high suicide risk for this group, reducing the risk and preventing attempts remains a main part of the treatment; a combination of self-monitoring, close supervision by a therapist, and faithful adherence to their medication regimen will help to reduce the risk and prevent the likelihood of a completed suicide.
Society and culture
Catherine Zeta-JonesCatherine Zeta-Jones
Catherine Zeta-Jones, CBE, is a British actress. She began her career on stage at an early age. After starring in a number of United Kingdom and United States television films and small roles in films, she came to prominence with roles in Hollywood movies such as the 1998 action film The Mask of...
received treatment for bipolar II disorder after dealing with the stress of her husband's throat cancer. According to her publicist, Zeta Jones made a decision to check into a "mental health facility" for a brief stay.
Carrie Fisher
Carrie Fisher
Carrie Frances Fisher is an American actress, novelist, screenwriter, and lecturer. She is most famous for her portrayal of Princess Leia in the original Star Wars trilogy, her bestselling novel Postcards from the Edge, for which she wrote the screenplay to the film of the same name, and her...
has been diagnosed with the condition.
Specifiers
- Chronic
- With catatonic features
- With melancholic features
- With psychotic features
- With atypicalAtypical depressionAtypical depression is a subtype of dysthymia and major depression, sharing many of the symptoms of both, but also being characterized by mood reactivity—being able to experience improved mood in response to positive events. In contrast, sufferers of "melancholic" depression generally cannot...
features - With postpartum onset
- Longitudinal course specifiers (with and without inter-episode recovery)
- With seasonal pattern (applies only to the pattern of major depressive episodes)
- With rapid cycling
See also
- Bipolar disorderBipolar disorderBipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
- Bipolar I disorderBipolar I disorderBipolar I disorder is a mood disorder that is characterized by at least one manic or mixed episode. There may be episodes of hypomania or major depression as well...
- Detailed listing of DSM-IV-TR bipolar disorder diagnostics codes
- Bipolar spectrumBipolar spectrumThe bipolar spectrum refers to a category of mood disorders that feature abnormally elevated or depressed mood. These disorders range from bipolar I disorder, featuring full-blown manic episodes, to cyclothymia, featuring less prominent hypomanic episodes, to "subsyndromal" conditions where only...
- CyclothymiaCyclothymiaCyclothymia is a mood and mental disorder in the bipolar spectrum that causes both hypomanic and depressive episodes. It is defined medically within the bipolar spectrum and consists of recurrent disturbances between sudden hypomania and dysthymic episodes. The diagnosis of cyclothymic disorder is...
- Emotional dysregulationEmotional dysregulationEmotional dysregulation is a term used in the mental health community to refer to an emotional response that is poorly modulated, and does not fall within the conventionally accepted range of emotive response...
- Creativity and bipolar disorderCreativity and bipolar disorderMental disorders and creativity are often considered to be related, particularly in pop psychology.There is anecdotal evidence for a relationship between creativity and psychosis, particularly schizophrenia. James Joyce had a daughter with schizophrenia and had many schizotypal traits. Albert...
- Bipolar disorders researchBipolar disorders research-Heritability or inheritance of the illness:More than two-thirds of people with bipolar disorder have at least one close relative with the disorder or with unipolar major depression, indicating that the disease has a genetic component. Studies seeking to identify the genetic basis of bipolar...
- Temporal lobe epilepsyTemporal lobe epilepsyTemporal lobe epilepsy a.k.a. Psychomotor epilepsy, is a form of focal epilepsy, a chronic neurological condition characterized by recurrent seizures. Over 40 types of epilepsies are known. They fall into two main categories: partial-onset epilepsies and generalized-onset epilepsies...
External links
- Latest bipolar news and research via MedWorm
- Bipolar Test Online
- http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=426