BIPOLAR
II DISORDER
Robert J. Mignone, M.D., F.A.C.P.
Given the fact that we humans live our lives as emotional, physical
and spiritual beings, the ways that we feel and think will vary according
to biology, personality, spirituality and life experience. That having
been said, the diagnostic challenge for any person suffering a mood
disorder is to sort out the differences between normal responses to
living, versus medical/biological conditions that seem to have a life
of their own. Consider this Differential Diagnosis:
1. Understandable Upset: Expected sadness, hurt or frustration to
life events.
2. Adjustment Reaction: More intense emotional responses to
life’s
traumas and stresses. Therefore the life stressor(s) is apparent. Transient
and variable picture, moderate severity, responds to support and pleasant
experience. These may be driven by dysfunctional personality traits
of over-reaction, short fuse, etc. “Some sunny days, some cloudy
days, many rainy days.” Sleep, appetite and other health functions
may be affected, but not to the degree of Major Depression.
3. Depression: Unipolar Depression, sometimes known as “clinical
depression,” A dark place, often called a “black hole”,
feeling ill, across all aspects of life. Not responsive to pleasant
input. Many neurovegetative symptoms .“Raining all the time” “Blah,
out of gas.” Lasts weeks to months. In between depressive episodes,
feels normal, perhaps months or years.
4. Bipolar II Depression: Same dark times as Major Depression, but
with more abrupt onset and clearing. Lasts weeks to months. In between
downs, mood is normal or dysregulated, with brief wind-ups/crank-ups,
often called moody and temperamental. Weather metaphor unpredictable,
mixtures of bursts of rain storms, often rainy or cloudy, sometimes
sunny.
5. Bipolar I Depression: Depressions similar dark place, but
mood in-between either normal or flying in a manic high, loss of good
judgment, either delusions of grandeur or explosively violent, or both.
6. Substance Abuse Effects: Alcohol, tranquilizer and other
drug abuse can produce a chronic disturbance of mood, thinking and
memory. May cloud diagnosis of mood or anxiety picture.
7. ADHD/ADD: Distractible, can’t focus, scattered, disorganized,
often teased as being a “Ditz”, “spacey”, “scatterbrain,” or “absent-minded
professor”
8. Anxiety Disorder: General Anxiety Disorder (GAD) most common. “worry
wort” anxiety or apprehension with stewing, “making mountains
out of mole-hills”, not to be confused with motor agitation
or racing thoughts of Bipolar II.
Other anxiety disorders: Panic
Anxiety Disorder, Social anxiety,
Obsessive Compulsive Disorder, and PTSD.
When
a person is trying to formulate why they frequently feel sad or down
in the dumps, or why they so often are irritable and grouchy, they
must tackle the task of sorting out how much of their life experiences
have been understandable and usual, and even expected, versus how
much is so called “biological.”
Grief reactions are examples of understandable sadness. Being alone
and missing loved ones can be called understandable and normal loneliness.
Boredom describes the understandable lack of creativity and expressive
outlets in life. Becoming angry or even outraged at some kinds of behaviors
or life events is not only understandable, but called for.
The
diagnostic task is to identify whether or not one’s reactions
in life fall within such a range that one would call them normal and
non-problematic, and even expectable. Alternatively, are they overreactions
in the context of being generally “out of sorts”? In other
words, do the changes of mood and thinking pertain to situational change
in what otherwise would be normal mood, or do they appear to have a
life of their own, unrelated to the situation? The latter changes of
mood, thinking, and feeling that do not seem to correlate well with
life’s events may fall under the heading of biological conditions.
Those have a strong neuro-chemical contribution and likely a genetic
basis.
Bipolar
I, the old fashioned term for which is “Manic Depression,” should
not be confused with Bipolar II. Its swings are more extreme, especially
on the manic side. When a person with Bipolar I is wound up they are
going 150 MPH, so to speak, (thoughts, activity, energy, and speech)
and can have psychotic delusions of grandeur and can be at times dangerously
violent. People suffering those manias usually end up in hospital or
at least in acute treatment. They also may run afoul of the law. Quite
often they are involuntarily hospitalized for their own protection.
Bipolar II does
NOT include those severe swings. Therefore, the commonly used term “Bipolar” is so misleading as to be avoided.
The so-called “highs” (or, hypomanias) in Bipolar II are
actually mild in comparison. There is an uptick in energy and rapidity
of thoughts, and sometimes in mood, though more often it is more a
matter of being moody and temperamental with a sense of being wound
up and cranked up, but not over the top as is the case with Bipolar
I.
All of the above having been presented, Bipolar II Disorder,
referred to in our offices as “periodic mood disregulation,” is
an inherited biological condition. Often, it becomes manifest in
childhood as being moody, pouty, and sulky. In other instances it
waits until adolescence for a stormy, up and down, and at times even
explosive, picture with running away, alternating with periods of
depression. The disregulation can occur within a day or days. Parents
may say that they have three kids in one, (normal, down, or cranked
up.). Sometimes it will not appear until young adulthood, when it
then establishes the pattern of what at first blush looks to be recurrent
depressions.
The Bipolar II depressions
themselves are day in and day out “dark
places”, sometimes lasting weeks, sometimes months and months.
Between such down times the person is either OK or is moody and temperamental,
during which times he or she is wound up or cranked up. In the depressed
phase, the degree of severity varies from moderate to severe. The person
loses energy and interests in all things, including appetites for food,
sexuality, humor, and social interaction. They tend to withdraw. They
feel blah, out of gas, and have “no motivation”. Everything
is a chore, mostly everyday. If it is dark enough, they find taking
a shower even too troublesome to bother with, and do so only every
other day, or even every three or four days. Sometimes, if the depression
is deep enough, they will not draw the blinds or answer the phone.
This dark picture does not respond to pleasant events. It is as if
it is raining all day, most every day. In these respects is like
Major Depression.
Certainly, the worst case of depression, be it Major Depression,
Bipolar I Depression, or Bipolar II Depression, is to feel useless,
worthless and hopeless, even to the point of suicidal thinking or acting.
In Bipolar II, the suicide rate is in the 15% range. In Unipolar Depression,
the rate is about half of that.
The picture of Bipolar II Disorder
includes episodes of those kinds of dark places or depressions to
varying degrees. In fact, that is usually the diagnosis given by
both patients and their physicians, because the periods of dysregulation
either are not noted, or are considered reflections of a “temperamental personality.” Indeed,
as has already been stated, that would be correct if the intervals
between such depressions are normal and free of dysregulation. In that
case the picture would be that of recurrent Major Depression, commonly
known as “clinical depression.”
However, Bipolar II means more mood disregulation than that. In addition
to times of feeling normal, and times of feeling down and depressed,
Bipolar II patients also have days of being wound
up and cranked up. Their thoughts are speedy, and their moods vary
up and down. They describe themselves as moody, temperamental,
and irritable. Sometimes, in a hypomanic swing, a person will feel
super-energized and “on a
roll,” getting lots of things done, spending excessive money.
They may like the ride, and feel somewhat elevated in mood. However,
during the wind ups they more usually are out of sorts, being cantankerous
and discombobulated. These “amped” periods usually last
several days, but can last weeks. People notice the moodiness and walk
on eggshells around them, hoping that the difficult mood will soon
pass. Please note that they are NOT the “over the top” manias
of Bipolar I.
The hypomania of Bipolar II is
so misleading as to require repetition of its definition. Otherwise,
it too often conjures up images of a person “flying high”, being “on a roll”,
getting lots accomplished, spending, talking, interacting and enjoying
the ride. While that is occasionally the case, in my experience that
has NOT been the usual picture of the hypomanic wind ups in Bipolar II.
Instead, being “amped” and “speedy” more
often describes being agitated, moody, thin skinned, and easily frustrated.
The racy thoughts and agitation (often mistakenly called anxiety)
can make for not being able to sit still or concentrate. Sleep is
interrupted or sparse.
Emotional
reactions to events and/or people are over done in a “wind
up” period (days or longer). In contrast, the same event or interaction
during a normal time or interval would produce merely a normal and
proportional reaction. That could include being hurt, annoyed or even
angry, but in a normal interval the “words and the music would
match”. That is, the reactions would be proportional, and not “off
the wall”, so to speak. This periodic variability reflects the
fact that reactions depend on mood/energy states. That’s why
family and friends find Bipolar II people to be unpredictable in their
emotionality, and why they talk about walking on eggshells at times.
The moodiness of BP II is
periodic, but when present, it cuts across all life spheres. In contrast,
personality traits of being thin skinned or “supersensitive” are
ongoing, and mostly connected to life areas like intimate relationships,
or work, etc. Unlike in BP II, they reflect day to day vulnerabilities or negative habits.
Living with BP II means
not being able to count on how one will be feeling into the future.
Therefore planning (such as vacations, meetings, etc.) for a month
or six months is done only with silently crossed fingers. They can’t
count on consistency and/or predictability of their mood states.
Therefore, at the heart of the Bipolar II picture
is a periodic disregulation of mood in which one is either wound
up and cranked up, versus feeling normal, versus down in a dark place.
Often the depressions last longer and seem more prominent to the
patient than their hypomanic temperamental phases.(which can be brief)
To repeat, the “downs” of Bipolar II, if deep enough, can strongly resemble Major Depression (or, Unipolar
Depression).
A helpful metaphor to use is that a Bipolar II person’s engine
on the freeway can be normal at 65 mph, can crank to 90 mph for days,
or slow to 30 mph for days or weeks or longer. That pertains to speed
of thoughts and speech, agitation and motor activity, and an internal
sense of being wound up. Some speak of RPM shifting from cruising for
weeks or months at 1200 RPM, increasing for days to 3000 RPM and dropping
to 500 RPM for weeks or months. In contrast, Bipolar I patients speak
of normal and down times in the same way, but their manias rev up to
5000 RPM, or more, and may “red line” RPMs (+6000). Sometimes
the Bipolar II shifts are brief. Often, the downs and windups are mixed
and may last weeks to months.
These descriptions make clear that Bipolar II (4% of the population)
should not be confused with the less common Bipolar I (1% of the population).
Bipolar I has similar same dark times, but as has been described, the
windups are more severe and are called manic (not hypomanic as in Bipolar II.)
That person is “flying”, at times delusional, and
even violent and unmanageable. RPMs are “redline,” so
to speak. Or, BP I and BP II Depressions can be profound.
Hospital or jail is not unusual. This frightening picture is one
source of fears generated by the non-specific term, “Bipolar”. For that
reason the term “Bipolar” should be avoided. Instead,
be specific Bipolar I or Bipolar II.
There are some characteristic features of Bipolar II Disorder that
also stand out, such as 1.) positive family history of someone who
has been moody, temperamental, (and perhaps even explosive) as well
as depressed. Diagnosis was probably not made, especially if the reference
is to 1990 and earlier. 2.) For a given individual, the picture will
often start in childhood as mentioned above, but it does not have to.
3.) When the picture does establish itself in young adulthood and goes
forward, the mood shifts are sudden. In Bipolar II Disorder
one tends to almost “drop” into a depression and suddenly
come out of it. In contrast, in Major Depression (not Bipolar II) one typically
slides into a depression and emerges from it. Also, in Bipolar II the
moodiness and changeability of mood can sometimes be fairly rapid,
from almost day to day, or days to days. That is the norm for children,
but can be the case for some adults. Formal definitions suggest that
depressive episodes in Bipolar II must last at least two weeks or more,
but our experience has found that the ups and downs of mood can be
brief and more quixotic.
Too often, people with Bipolar II Disorder are diagnosed as Depressed,
leading to attempts with many anti-depressants. They fail either after
a while, or right off the mark, because anti-depressants do not treat
Bipolar Disorder I or II. Instead, mood stabilizers do, all of which
(except Lithium) are anti-convulsants. The list includes Depakote,
Lamictal, Trileptal, Tegretol, Keppra, Gabitril, and Topamax.
Suicide is certainly a risk for Major Depressive Disorder, being
one of the most common causes of death worldwide in persons under 40
years of age (approximately 10% suicide rate). In Bipolar II Disorder,
suicide is even more frequent, on the order of 15% to 20% .
Bipolar II Disorder may co-exist with Attention
Deficit Disorder,
or any one of the Anxiety Disorders (General Anxiety Disorder,
Panic Disorder, Obsessive Compulsive Disorder, or Social Anxiety
Disorder) If so, those Anxiety Disorders deserve specific treatment with a serotonin
reuptake inhibitor anti-depressant. ADHD can be treated with one of
the stimulants or a norepinephrine reuptake inhibitor. In those cases,
the Bipolar I or II Disorder must be treated first. Otherwise, one
runs the risk of aggravating the dysregulation by beginning with a
stimulant for Attention Deficit or by starting with an SSRI for one
of the Anxiety Disorders or for Major Depression.
Therefore, someone presenting with Bipolar II Disorder first should
be started on a mood stabilizer and or neuroleptic. Then, when the
dose has achieved a therapeutic response, treatment of the Anxiety
Disorders and/or ADHD can follow with an anti-depressant and/or stimulant.
Sometimes a single mood stabilizer does not suffice. It may be necessary
to use two in combination, or to add one of the neuroleptics to any
of the mood stabilizers. These neuroleptics include Abilify, Risperdal,
Geodon, Zyprexa and Seroquel. They differ in side effects of weight
gain, drowsiness, movement disorder, metabolic disruption. A given
individual may experience none, one, or a few.
In summary, the tips for thinking about Bipolar II Disorder:
Clinical presentation with:
- Positive family history of a relative being moody, temperamental,
explosive and depressed;
- Early onset of mood dysregulation;
- Sudden shifts or changes of mood;
- Failure of several anti-depressants to work, or even made worse
by anti-depressants;
- The actual identification of years of periodic dysregulation
of mood, with wind ups and dark downs.
Specifics of the various mood stabilizers and neuroleptics need to
be discussed with your Physician or Nurse Practitioner. Be sure that
you give only informed consent, which means that you have been educated
about the differential diagnosis, concomitant disorders, and the different
treatment options, including sequence of instituting different kinds
of medications.
Feedback from a spouse, a dear friend, or someone who has known you
for many years is often very helpful in adding information to create
the long term picture. Remember, Bipolar II Disorder,
like so many psychiatric disorders, is made with a view towards clinical
course over time. It is not made on a snapshot of today’s set
of symptoms. Any input that helps with the construction of the long
term picture is therefore most helpful.
All the disorders discussed herein are quite treatable with proper
medication(s) and counseling. Proper diagnosis, however is first and
foremost as a premise upon which to design the therapeutic approach.
