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.