bipolar ii disorder bipolar ii disorder bipolar ii disorder (bp-ii) is a mood disorder on the bipolar spectrum, characterized by at least one episode of hypomania and at least one episode of major depression. diagnosis for bp-ii requires that the individual must never have experienced a full manic episode. otherwise, one manic episode meets the criteria for bipolar i disorder (bp-i). bipolar ii disorderother namesbp-ii, type two bipolar, bipolar type twospecialtypsychiatry, clinical psychologytreatmentmedicationpsychotherapymedicationmood stabilizersantipsychoticsantidepressants hypomania is a sustained state of elevated or irritable mood that is less severe than mania yet may still significantly affect the quality of life and result in permanent consequences including reckless spending, damaged relationships and poor judgment.: 1651 unlike mania, hypomania is not associated with psychosis. the hypomanic episodes associated with bp-ii must last for at least four days. commonly, depressive episodes are more frequent and more intense than hypomanic episodes. additionally, when compared to bp-i, type ii presents more frequent depressive episodes and shorter intervals of well-being. the course of bp-ii is more chronic and consists of more frequent cycling than the course of bp-i. finally, bp-ii is associated with a greater risk of suicidal thoughts and behaviors than bp-i or unipolar depression. although bp-ii is commonly perceived to be a milder form of type i, this is not the case. types i and ii present equally severe burdens. bp-ii is notoriously difficult to diagnose. patients usually seek help when they are in a depressed state, or when their hypomanic symptoms manifest themselves in unwanted effects, such as high levels of anxiety, or the seeming inability to focus on tasks. because many of the symptoms of hypomania are often mistaken for high-functioning behavior or simply attributed to personality, patients are typically not aware of their hypomanic symptoms. in addition, many people with bp-ii have periods of normal affect. as a result, when patients seek help, they are very often unable to provide their doctor with all the information needed for an accurate assessment; these individuals are often misdiagnosed with unipolar depression. bp-ii is more common than bp-i, while bp-ii and major depressive disorder have about the same rate of diagnosis. of all individuals initially diagnosed with major depressive disorder, between 40% and 50% will later be diagnosed with either bp-i or bp-ii. substance use disorders (which have high co-morbidity with bp-ii) and periods of mixed depression may also make it more difficult to accurately identify bp-ii. despite the difficulties, it is important that bp-ii individuals be correctly assessed so that they can receive the proper treatment. antidepressant use, in the absence of mood stabilizers, is correlated with worsening bp-ii symptoms. causes multiple factors contribute to the development of bipolar spectrum disorders, although there have been very few studies conducted to examine the possible causes of bp-ii specifically. while no identifiable single dysfunctions in specific neurotransmitters have been found, preliminary data has shown that calcium signal transmission, the glutamatergic system, and hormonal regulation play a role in the pathophysiology of the disease. the cause of bipolar disorder can be attributed to misfiring neurotransmitters that overstimulate the amygdala, which in turn causes the prefrontal cortex to stop working properly. the bipolar patient becomes overwhelmed with emotional stimulation with no way of understanding it, which can trigger mania and exacerbate the effects of depression. signs and symptoms bipolar disorder is characterized by marked swings in mood, activity, and behavior. bp-ii is characterized by periods of hypomania, which may occur before, after, or independently of a depressive episode. hypomania main article: hypomania hypomania is the signature characteristic of bp-ii, defined by an experience of elevated mood. a patient's mood is typically cheerful, enthusiastic, euphoric, or irritable. in addition, they can present with symptoms of inflated self-esteem or grandiosity, decreased need for sleep, talkativeness or pressured speech, flight of ideas or rapid cycling of thoughts, distractibility, increased goal-directed activity, psychomotor agitation, and/or excessive involvement in activities that have a high potential for painful consequences (engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments.) hypomania is distinct from mania. during a typical hypomanic episode, patients may present as upbeat, may show signs of poor judgment or display signs of increased energy despite lack of sleep, but do not meet the full criteria for an acute manic episode. patients may display elevated confidence, but do not express delusional thoughts as in mania. they can experience increase in goal-directed activity and creativity, but do not reach the severity of aimlessness and disorganization. speech may be rapid, but interruptible. patients with hypomania never present with psychotic symptoms and do not reach the severity to require psychiatric hospitalization. for these reasons, hypomania commonly goes unnoticed. individuals often will only seek treatment during a depressive episode, and their history of hypomania may go undiagnosed. although hypomania may increase functioning, episodes require treatment as they may indicate increasing instability and can precipitate a depressive episode. depressive episodes it is during depressive episodes that bp-ii patients often seek help. symptoms may be syndromal or subsyndromal. depressive episodes in bp-ii can present similarly to those experienced in unipolar depressive disorders. patients characteristically experience a depressed mood and may describe themselves as feeling sad, gloomy, down in the dumps, or hopeless, for most of the day, nearly every day. in children, this can present with an irritable mood. most patients report significant fatigue, loss of energy, or tiredness. patients or their family members may note diminished interest in usual activities such as sex, hobbies, or daily routines. many patients report a change in appetite along with associated weight change. sleep disturbances may be present, and can manifest as problems falling or staying asleep, frequent awakenings, excessive sleep, or difficulties getting up in the morning. around half of depressed patients develop changes in psychomotor activity, described as slowness in thinking, speaking, or movement. conversely, they may also present with agitation, with inability to sit still or wringing their hands. changes in posture, speech, facial expression, and grooming can be observed. other signs and symptoms include changes in posture and facial expression, slowed speech, poor hygiene, unkempt appearance, feelings of guilt, shame, or helplessness, diminished ability to concentrate, nihilistic thoughts, and suicidal ideation. many experts in the field have attempted to find reliable differences between bp-i depressive episodes and episodes of major depressive disorder, but the data is inconsistent. however, some clinicians report that patients who came in with a depressive episode, but were later diagnosed as having bipolar disorder often presented with hypersomnia, increased appetite, psychomotor retardation, and a history of antidepressant-induced hypomania. evidence also suggests that bp-ii is strongly associated with atypical depression. mood episodes with mixed features a mixed episode is defined by the presence of a hypomanic or depressive episode that is accompanied by symptoms of the opposite polarity. this is commonly referred to as a mood episode with mixed features (e.g. depression with mixed features or hypomania with mixed features), but can also be referred to as mixed episodes or mixed states. for example, a patient with depression with mixed features may have a depressed mood, but has simultaneous symptoms of rapid speech, increased energy, and flight of ideas. conversely, a patient with hypomania with mixed features will present with the full criteria for a hypomanic episode, but with concurrent symptoms of decreased appetite, loss of interest, and low energy. episodes with mixed features can last up to several months. they occur more frequently in patients with an earlier onset of bipolar disorder, are associated with higher frequency of episodes, and are associated with a greater risk of substance use, anxiety disorders, and suicidality. in addition, they are associated with increased treatment resistance compared to non-mixed episodes. relapse bipolar disorder is often a lifelong condition, and patients should be followed up regularly for relapse prevention. although bp-ii is thought to be less severe than bp-i in regard to symptom intensity, bp-ii is associated with higher frequencies of rapid cycling and depressive episodes. in the case of a relapse, patients may experience new onset sleep disturbance, racing thoughts and/or speech, anxiety, irritability, and increase in emotional intensity. family and/or friends may notice that patients are arguing more frequently with them, spending more money than usual, are increasing their binging on food, drugs, or alcohol, and may suddenly start taking on many projects at once. these symptoms often occur and are considered early warning signs. psychosocial factors in a person's life can trigger a relapse in patients with bp-ii. these include stressful life events, criticism from peers or relatives, and a disrupted circadian rhythm. in addition, the addition of antidepressant medications can trigger a hypomanic episode. comorbid conditions comorbid conditions are extremely common in individuals with bp-ii. in fact, individuals are twice as likely to present a comorbid disorder than not. these include anxiety, eating, personality (cluster b), and substance use disorders. for bp-ii, the most conservative estimate of lifetime prevalence of alcohol or other substance use disorders is 20%. in patients with comorbid substance use disorder and bp-ii, episodes have a longer duration and treatment compliance decreases. preliminary studies suggest that comorbid substance use is also linked to increased risk of suicidality. diagnosis bp-ii is diagnosed according to the criteria established in the american psychiatric association's diagnostic and statistical manual of mental disorders, fifth edition (dsm-5). in addition, alternative diagnostic criteria is established in the world health organization's international classification of diseases-10th revision (icd-10). the diagnostic criteria are established from self-reported experiences from patients or their family members, the psychiatric assessment, and the mental status examination. in addition, screening instruments like the mood disorders questionnaire are helpful tools in determining a patient's status on the bipolar spectrum. in addition, certain features have been shown to increase the chances that depressed patients have 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. dsm-5 criteria according to the dsm-5, a patient diagnosed with bp-ii will have experienced at least one hypomanic episode, at least one major depressive episodes, and no manic episode. furthermore, the occurrence of the mood episodes are not better explained by schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. the final criteria that must be met is that the mood episodes cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (from the depressive symptoms or the unpredictability of cycling between periods of depression and hypomania). a hypomanic episode is established if a patient's symptoms last for most of the day each day for at least four days. furthermore, three or more of the following symptoms must be present: inflated sense of self-esteem or grandiose thoughts, feeling well rested despite getting low amounts of sleep (3 hours), talkativeness, racing thoughts, distractibility, and increase in goal-directed activity or psychomotor agitation, or excessive involvement in activities with high risk of painful consequences. per dsm-5 criteria, a major depressive episode consists of the presence of a depressed mood or loss of interest/pleasure in activities (anhedonia). in addition to the former symptoms, five out of the nine following symptoms must occur for more than two weeks (to the extent in which it impairs functioning): weight loss/gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness/inappropriate guilt, decreased concentration, or thoughts of death/suicide. specifiers: with current or most recent episode hypomanic or depressed with partial remission or full remission with mild, moderate, or severe severity with anxious distress with catatonic features with mood congruent psychotic features with peripartum onset with seasonal pattern (applies only to the pattern of major depressive episodes) with rapid cycling. icd-11 according to the icd-11, a bp-ii patient will have experienced episodic experiences of one or more hypomaniac episodes and one or more major depressive episodes, and no history of a manic episode or mixed episode. these symptoms cannot be explained by other diagnoses such as cyclothymia adhd oppositional defiant disorder schizophrenia and other primary psychotic disorders substance-use disorder personality disorders other mental illness physical issues such as a brain tumor the specifiers are the same as the dsm-5 with the exception of catatonic features and if symptoms have occurred with or without psychosis about 6 weeks after childbirth differential diagnoses the signs and symptoms