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Bipolar II disorder

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Bipolar II disorder
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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 are more frequent and more intense than manic episodes.[citation needed] 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.[1] 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.[2] The hypomanic episodes associated with bipolar II disorder must last all day for a period of at least four days.[3]

Bipolar II is believed to be under-diagnosed because hypomanic behavior often presents as high-functioning behavior.[unreliable medical source?][4] Those with bipolar II are at highest risk of suicide among the bipolar spectrum.[5][6] 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.

Signs and symptoms

Hypomanic episodes

  • High energy levels
  • Grandiosity
  • Hedonistic mood
  • Unrealistic optimism
  • Mystical experiences
  • Irritability and anger
  • Automatic thoughts
  • Maladaptive assumptions
  • Dysfunctional personal schemas[7]

Depressive episodes

  • Low energy levels
  • Cessation of usual activities
  • Black and white thinking
  • Unrealistic pessimism
  • Overgeneralization
  • Automatic thoughts
  • Maladaptive assumptions
  • Dysfunctional personal schemas[7]

Relapse

In the case of a relapse, the following symptoms often occur and are considered early warning signs:[8]

  • 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.[9]

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.[8]

Diagnosis

The Diagnostic and Statistical Manual 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.[10] 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.[11]

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.[10][12]

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.[13] 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.[13] 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.[12]

Treatments

The most common treatment for reducing bipolar II disorder symptoms is medication, usually in the form of mood stabilizers. 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. SSRIs should be used as a last resort, since, 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.[citation needed] 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. Relapses can still occur, even with continued medication and therapy.[citation needed]

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.[14] 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.[15]

The management for 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.[citation needed]
  • 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%.[citation needed]
  • 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.[citation needed]

Treatment typically includes three things: the treatment of acute hypo mania, the treatment of acute depression, and the prevention of the relapse of either hypo mania or depression. The main goal is to avoid causing harm to the patient.[16]

Prognosis

There is evidence to suggest that Bipolar II Disorder has a more chronic course of illness than Bipolar I Disorder.[17] 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.[17] The natural course of Bipolar II Disorder, when left untreated, leads to patients spending the majority of their lives unwell with most of their suffering stemming from depression.[12] Their recurrent depression results in personal suffering and disability.[12] 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.[18] 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.[17] 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.[12] In order to improve a patient’s prognosis, long term therapy is most favorably recommended for controlling symptoms, maintaining remission and preventing relapses.[19] 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.[20] 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.[19]

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 mania symptoms.[18] 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.[12] 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.[21] 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.[21] This social impairment can last for years, even after treatment that has resulted in a resolution of mood symptoms.[21] 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.[21] Impaired ability in regards to executive functions is directly tied to poor psychosocial functioning, a common side-effect in patients with Bipolar II.[22] The impact on a patient’s psychosocial functioning stems from the depressive symptoms (more common in Bipolar II than Bipolar I).[18] An increase in these symptoms’ severity seems to correlate with a significant increase in psychosocial disability.[22] 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.[23] 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.[23] Bipolar II patients have also been shown to present worse cognitive functioning than those patients with Bipolar II, though they demonstrate about the same disability when it comes to occupational functioning, interpersonal relationships, and autonomy.[22] 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.[18] 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.[12] These lasting impacts further suggest that a prolonged exposure to an untreated Bipolar II disorder can lead to permanent adverse effects on functioning.[21]

Recovery and recurrence

Bipolar II Disorder has a chronic relapsing nature.[19] It has even been suggested that Bipolar II patients have a higher degree of relapse than Bipolar I patients .[17] Generally, within four years of an episode, around 60% of patients will relapse into another episode.[19] Some patients are even symptomatic half the time, either with full on episodes or symptoms that fall just below the threshold of an episode.[19] 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.[19] Even with treatment, patients do not always regain full functioning, especially in the social realm .[21] There is a very clear gap between symptomatic recovery and full functional recovery, for both Bipolar I and Bipolar II patients.[22] 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.[22] 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.[24] 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.[25] One of the treatments of choice is Lithium, which has been shown to be very beneficial in reducing the frequency and severity of depressive episodes.[20] Lithium prevents mood relapse and works especially well in Bipolar II patients who experience rapid-cycling.[20] 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.[20] 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.[24] The plan has to aim high otherwise patients will relapse into depression.[24] 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.[24]

Mortality

Several studies have shown that the risk of suicide 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.[12] 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.[26][12] The risk of suicide for Bipolar II patients is especially high; as many as 50% of them will attempt suicide at least once.[27] Bipolar Disorders in general are the 3rd leading cause of death in 15–24 year olds.[27] Bipolar II patients were also found to employ more lethal means and have more complete suicides over all.[12] 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).[18] 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.[28] Mixed symptoms and rapid-cycling, both very common in Bipolar II, are also associated with an increased risk of suicide.[12] The tendency for Bipolar II to be misdiagnosed and treated ineffectively, or not at all in some cases, also leads to an increased risk.[26] 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.[28]

High profile cases

Catherine Zeta-Jones 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.[29]

Carrie Fisher has been diagnosed with the condition.[30]

Specifiers

  • Chronic
  • With catatonic features
  • With melancholic features
  • With psychotic features
  • With atypical 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

References

  1. ^ "Bipolar disorder".
  2. ^ "Bipolar Disorder". National Institute of Mental Health. US Department of Health and Human Services. Retrieved 30 September 2011.
  3. ^ Buskist, W. & Davis, S.F., ed. (2008). 21st Century Psychology: A Reference Handbook. Thousand Oaks, CA: Sage Publications Inc. p. 290. ISBN 978-1-4129-4968-2.{{cite book}}: CS1 maint: multiple names: editors list (link)
  4. ^ [unreliable medical source?]Glenda M. MacQueen, M.D., Ph.D. and L. Trevor Young, M.D., Ph.D. (03-2001). "Bipolar II Disorder: Symptoms, Course, and Response to Treatment". American Psychiatric Association. Retrieved 2011-05-15. {{cite web}}: Check date values in: |date= (help); Italic or bold markup not allowed in: |publisher= (help)CS1 maint: multiple names: authors list (link)
  5. ^ David L. Dunner (2004). "Correlates of Suicidal Depression" (PDF). Journal of Clinical Psychiatry. Retrieved 2011-05-15. {{cite web}}: Italic or bold markup not allowed in: |publisher= (help)
  6. ^ Z. Rihmer & P. Pestality (1999-09-22). "Bipolar II disorder and suicidal behavior". Psychiatric Clinics of North America. PMID 10550861. {{cite journal}}: Cite journal requires |journal= (help); Italic or bold markup not allowed in: |publisher= (help)
  7. ^ a b Manicavasagar, Vijaya (2008). Gordan Parker (ed.). Bipolar II Disorder: Modelling, Measuring, and Managing. Cambridge, England: Cambridge University Press.
  8. ^ a b Orum, Margo (2008). Gordan Parker (ed.). Bipolar II Disorder: Modelling, Measuring, and Managing. Cambridge, England: Cambridge University Press.
  9. ^ Smith, Meg (2008). Gordan Parker (ed.). Bipolar II Disorder: Modelling, Measuring, and Managing. Cambridge, England: Cambridge University Press. pp. 195–203.
  10. ^ a b Baek, J. H., Park, D. Y., Choi, J., Kim, J. S., Choi, J. S., Ha, K., ... Hong, K. S. (2011). Differences between bipolar I and bipolar II in clinical features, comorbidity, and family history. Journal of Affective Disorders, 131, 59–67.
  11. ^ American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR).
  12. ^ a b c d e f g h i j k Hadjipavlou, George (2008). Gordan Parker (ed.). Bipolar II Disorder: Modelling, Measuring, and Managing. Cambridge, England: Cambridge University Press. p. 65. {{cite book}}: More than one of |pages= and |page= specified (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  13. ^ a b Benazzi, F. (2007). Bipolar II disorder : epidemiology, diagnosis and management. CNS Drugs, 21(9), 727–740.
  14. ^ MacQueen G.M., Young L.T. (2001). Bipolar II disorder: symptoms, course and response to treatment. American Psychiatric Association. Retrieved from http://ps.psychiatryonline.org/cgi/content/full/52/3/358#R52311648
  15. ^ Baldessarini RJ, Tondo L, Hennen J. (1999). Effects of lithium treatment and its discontinuation on suicidal behavior in bipolar manic-depressive disorders. Journal of Clinical Psychiatry 60(suppl 2):77–84
  16. ^ El-Mallakh R, Weisler RH, Townsend MH, Ginsberg LD (2006). "Bipolar II disorder: current and future treatment options". Annals of Clinical Psychiatry : Official Journal of the American Academy of Clinical Psychiatrists. 18 (4): 259–66. doi:10.1080/10401230600948480. PMID 17162626.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  17. ^ a b c d Randall, Carol (2010). "1". Neuropsychological emotion processing abnormalities in bipolar disorder I and II (Ph. D thesis). University of Nevada. Retrieved 19 October 2011.
  18. ^ a b c d e Ruggero, Camilo J. (December 1, 2007). "Psychosocial impairment associated with bipolar II disorder". Journal of Affective Disorders. 104: 1–3. doi:10.1016/j.jad.2007.01.035. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: date and year (link)
  19. ^ a b c d e f McAllister-Williams, R. Hamish (January 1, 2006). "Relapse prevention in bipolar disorder: a critical review of current guidelines". Journal of Psychopharmacology. 20 (2): 12–16. doi:10.1177/1359786806063071. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: date and year (link)
  20. ^ a b c d Hadjipavlou, George (2008). Gordan Parker (ed.). Bipolar II Disorder: Modelling, Measuring, and Managing. Cambridge, England: Cambridge University Press. pp. 120–132.
  21. ^ a b c d e f Wingo, Aliza P. (May 15, 2010). "Correlates of recovery of social functioning in types I and II bipolar disorder patients". Psychiatry Research. 177: 131–134. doi:10.1016/j.psychres.2010.02.020. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: date and year (link)
  22. ^ a b c d e Rosa, A.R. (December 1, 2010). "Functional impairment in bipolar II disorder: Is it as disabling as bipolar I?". Journal of Affective Disorders. 127: 71–76. doi:10.1016/j.jad.2010.05.014. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: date and year (link)
  23. ^ a b Chang, Jae Seung (June 1, 2011). "Differential pattern of semantic memory organization between bipolar I and II disorders". Progress in Neuro-Psychopharmacology & Biological Psychiatry. 35: 1053–1058. doi:10.1016/j.pnpbp.2011.02.020. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: date and year (link)
  24. ^ a b c d Orum, Margo (2008). Gordan Parker (ed.). Bipolar II Disorder: Modelling, Measuring, and Managing. Cambridge, England: Cambridge University Press. pp. 177–194.
  25. ^ Benazzi, Franco (2008). Gordan Parker (ed.). Bipolar II Disorder: Modelling, Measuring, and Managing. Cambridge, England: Cambridge University Press. pp. 232–236.
  26. ^ a b MacQueen, Glenda M (March 2001). "Bipolar II disorder: symptoms, course, and response to treatment". Psychiatric Services. 52 (3): 358–361. ISSN 1075-2730. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: date and year (link)
  27. ^ a b Fieve, Ronald R. (2009). Bipolar Breakthrough: The Essential Guide to Going Beyond Moodswings to Harness Your Highs, Escape the Cycles of Recurrent Depression, and Thrive with Bipolar II. New York: Rodale. p. 232. ISBN 978-1-60529-645-6.
  28. ^ a b Manicavasagar, Vijaya (2008). Bipolar II Disorder: Modelling, Measuring, and Managing. Cambridge, England: Cambridge University Press. pp. 151–176.
  29. ^ http://www.bbc.co.uk/news/uk-wales-13073676
  30. ^ http://www.usatoday.com/news/health/spotlight/2002/05/29-fisher.htm
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