DSM 5 Bipolar 2 Disorder Criteria
DSM 5 Bipolar 2 Disorder Criteria
Exploring the complexities of mental health can reveal conditions with confusingly similar symptoms, complicating diagnosis and treatment. Last week we explored Bipolar I Disorder, and today we dive into Bipolar II Disorder, another condition often mistaken for ADHD, Borderline Personality Disorder, or even autism. Additionally, Bipolar II's subtleties within its own classification and its frequent co-occurrence with other neurodivergences like ADHD, further blur the diagnostic lines.
To demystify this complexity, Bipolar II Disorder has been added to my "DSM in Pictures" series. This installment presents the DSM-5 criteria specifically for Bipolar II, following the structured guidance provided by the DSM-5—used widely by mental health professionals—and shares parallels with the ICD-11, which offers similar diagnostic criteria.
Understanding Bipolar II Disorder
Bipolar disorders manifest as significant mood, energy, and functional fluctuations – characterized by alternating poles or episodes – that are severe enough to profoundly impact daily life.
Classifications of Bipolar Disorder
The primary types of bipolar disorder include:
Bipolar I Disorder: Marked by at least one manic episode, which might be preceded or followed by hypomanic or major depressive episodes. Manic episodes involve extreme energy levels and euphoria, which can disrupt normal functioning.
Bipolar II Disorder: Defined by a pattern of depressive and hypomanic episodes but lacking the full manic episodes that characterize Bipolar I. Diagnosis requires the presence of at least one hypomanic episode and one major depressive episode.
Cyclothymic Disorder: Characterized by periods of depressive symptoms and periods of elevated mood symptoms for at least two years, without meeting the full criteria for major depressive, manic, or hypomanic episodes (NIMH).
The Nature of Bipolar II Episodes
Bipolar II is characterized by milder hypomanic episodes that do not reach the severe levels of mania seen in Bipolar I, often leading to its under-recognition and complicating the diagnostic process. While these hypomanic episodes are less disruptive, they impact life quality and are frequently overshadowed by major depressive episodes that typically dominate the clinical landscape. Individuals with Bipolar II often endure longer periods of depression compared to periods of hypomania.
Bipolar manifests uniquely in each person, influenced by the type and intensity of the mood episodes they experience. Research shows that while manic or hypomanic episodes tend to decrease with age, depressive episodes become increasingly prevalent. This age-related shift suggests that over time, bipolar is more likely to affect individuals through extended depressive states rather than episodes of high energy or mania (Shen, 2018).
Comparing the two forms of the disorder, Bipolar I typically presents a ratio of major depressive episodes to manic/hypomanic episodes of about 3:1. Bipolar II shows a dramatically different pattern with a ratio of major depressive episodes to hypomanic episodes of 39:1. This stark difference underscores the significant dominance of depression in Bipolar II, highlighting the substantial impact depression has on the lives of those with the disorder (Judd et al., 2002; Judd et al., 2003).
Prevalence and Impact
Bipolar spectrum disorders affect approximately 2.4% of the global population. Despite its profound impact, Bipolar II is often less recognized than Bipolar I, yet both have significant implications for overall health and quality of life. These conditions are among the most life-threatening psychiatric disorders; individuals diagnosed with bipolar disorder have a life expectancy that is 9 to 13 years less than that of the general population (Shen, 2018).
The heightened risk of early death in people with bipolar disorder stems from both preventable and natural causes, including accidents, suicide, heart disease, diabetes, lung conditions, flu, and pneumonia. Alarmingly, the suicide rate among individuals with bipolar disorder is 20 to 30 times higher than that of the general population. This alarming statistic highlights the urgent need for robust support systems and effective mental health care to support the emotional and physical challenges (Shen, 2018).
Early Signs and Diagnosis Challenges
The symptoms of bipolar disorder often first appear in the late teenage years or early adulthood, marked by subtle mood changes that can be mistaken for normal adolescent variability. It is essential for effective treatment and management to recognize these patterns as part of a broader mood disorder spectrum.
Given the diagnostic difficulties, it is common for there to be a delay between symptom onset and diagnosis. In fact, a common delay of about 10 years between the first episode of illness and a diagnosis of bipolar disorder has been reported (Hirschfeld et al., 2003).
DSM 5 Bipolar 2 Disorder Criteria
DSM-5 Criteria for Bipolar II Disorder
Bipolar II Disorder is characterized by cycles of depressive and hypomanic episodes, distinct from the full manic episodes seen in Bipolar I Disorder. To diagnose Bipolar II, the DSM-5 requires the presence of at least one hypomanic episode and one major depressive episode:
Hypomanic Episode: A distinct period of elevated, expansive, or irritable mood lasting at least four consecutive days, markedly different from the individual's usual non-depressed mood.
Major Depressive Episode: Includes symptoms such as persistent sadness, hopelessness, and a significant loss of interest in almost all activities, severely impairing daily functioning.
Hypomanic Episode Criteria
A hypomanic episode involves a distinct period of persistently elevated, expansive, or irritable mood along with increased activity or energy lasting at least four days, present most of the day nearly every day. During this period, the individual must display three or more of the following symptoms (four if the mood is irritable), which represent a noticeable change from usual behavior:
Inflated self-esteem or grandiosity
Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
More talkative than usual or feeling a pressure to keep talking
Flight of ideas or subjective experience that thoughts are racing
Distractibility, easily pulled away by unimportant or irrelevant external stimuli
Increase in goal-directed activities (socially, at work, school, or sexually) or physical restlessness
Excessive involvement in activities with a high potential for painful consequences (e.g., unrestrained buying sprees, sexual indiscretions, or foolish business investments)
Importantly, a hypomanic episode does not cause as many problems in the work or personal life as a manic episode. It is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization.
Major Depressive Episode Criteria
The criteria for a major depressive episode include the presence of five or more of the following symptoms during the same two-week period, representing a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure:
Depressed mood most of the day nearly every day
Markedly diminished interest or pleasure in all, or almost all, activities most of the day nearly every day
Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation nearly every day (observable by others)
Fatigue or loss of energy nearly every day
Feelings of worthlessness or excessive or inappropriate guilt nearly every day
Diminished ability to think or concentrate, or indecisiveness, nearly every day
Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
Other Criteria: These symptoms must significantly disrupt everyday life, affecting social and work activities, and must not be due to substance use or another medical condition.
After detailing the criteria for a major depressive episode, it's important to clear up a common myth about the severity of Bipolar I compared to Bipolar II Disorder.
Dispelling Myths: Severity of Bipolar Disorders
A common myth about bipolar disorder is that Bipolar I is inherently more severe than Bipolar II. While it's true that the manic episodes in Bipolar I are more intense and disruptive, this perception overlooks critical aspects of Bipolar II.
The depressive episodes in Bipolar II can be deeply severe and long-lasting. This intensity can profoundly affect a person's daily life, making everyday tasks and enjoyment significantly more challenging. Such episodes take a real toll on well-being.
When looking at the big picture, it's important to understand that the intense depressive episodes of Bipolar II can be just as debilitating as the manic episodes in Bipolar I. Each condition affects individuals differently and requires careful, personalized treatment. This highlights why it's so important not to make broad assumptions about their comparable severity or impact.
Exclusion Criteria
The diagnosis of Bipolar II Disorder must not be better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders. There has never been a full manic episode.
Conclusion
Understanding Bipolar II Disorder is crucial, especially its less intense yet equally impactful hypomanic episodes and the significant depressive episodes specific to the disorder. This knowledge is particularly vital for those working with individuals diagnosed with ADHD or autism, given the high prevalence of burnout and periods of heightened neurodivergent energy in these populations. These factors can make it challenging to distinguish between Bipolar II and other neurodivergent conditions.
For a more in-depth and visually engaging exploration of Bipolar II, consider our "Bipolar 2 DSM in Pictures" series. This series is designed to demystify these complex diagnoses through detailed visuals and concise explanations, providing valuable insights into the subtle nuances of the disorder. The PDF is available for purchase here.
Additionally, for further reading and to better understand the relationships and distinctions between these conditions, you might find the following articles informative:
These articles are designed to help shed light on the nuances of each condition.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
Chakrabarti, S., & Singh, N. (2022). Psychotic symptoms in bipolar disorder and their impact on the illness: A systematic review. World journal of psychiatry, 12(9), 1204–1232. https://doi.org/10.5498/wjp.v12.i9.1204
Hirschfeld, R. M., Lewis, L., & Vornik, L. A. (2003). Perceptions and impact of bipolar disorder: How far have we really come? Results of the national depressive and manic-depressive association 2000 survey of individuals with bipolar disorder. Journal of Clinical Psychiatry, 64, 161-174.
Judd, L. L., Akiskal, H. S., Schettler, P. J., Endicott, J., Maser, J., Solomon, D. A., et al. (2002). The long-term natural history of the weekly symptomatic status of bipolar I disorder. Archives of General Psychiatry, 59, 530-537.
Judd, L. L., Akiskal, H. S., Schettler, P. J., Coryell, W., Endicott, J., Maser, J. D., et al. (2003). A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Archives of General Psychiatry, 60, 261-269.
Keck, P. E., Jr, McElroy, S. L., Havens, J. R., Altshuler, L. L., Nolen, W. A., Frye, M. A., Suppes, T., Denicoff, K. D., Kupka, R., Leverich, G. S., Rush, A. J., & Post, R. M. (2003). Psychosis in bipolar disorder: phenomenology and impact on morbidity and course of illness. Comprehensive psychiatry, 44(4), 263–269. https://doi.org/10.1016/S0010-440X(03)00089-0
Merikangas, K. R., Akiskal, H. S., Angst, J., Greenberg, P. E., Hirschfeld, R. M. A., Petukhova, M., & Kessler, R. C. (2007). Lifetime and 12-month prevalence of bipolar spectrum disorder in the national comorbidity survey replication. Archives of General Psychiatry, 64(5), 543. https://doi.org/10.1001/archpsyc.64.5.543
Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic Advances in Psychopharmacology, 8(9), 251–269. https://doi.org/10.1177/2045125318769235
Shen Y. C. (2018). Treatment of acute bipolar depression. Ci ji yi xue za zhi = Tzu-chi medical journal, 30(3), 141–147. https://doi.org/10.4103/tcmj.tcmj_71_18