BIPOLAR II

DISORDER
 LEARNING OBJECTIVES
1. To understand the diagnostic criteria for
Bipolar Disorder type II
2. To become familiar with demographic and
clinical findings associated with Bipolar
Disorder type II
3. To become familiar with treatment options for
Bipolar Disorder type II
 WHAT IS BIPOLAR II
DISORDER?
•Is defined by a pattern of
depressive episodes shifting back
and forth with hypomanic
episodes, but no full – blown manic
or mixed episodes.
BIPOLAR
DISORDER II
Bipolar II disorder is similar to bipolar I disorder
except that mania is absent in bipolar II
disorder.

Hypomania is the essential diagnostic finding.

Hypomania is similar to mania but less severe

 WHAT IS THE DIFFERENCE BETWEEN
BIPOLAR 1 AND BIPOLAR TYPE 2?
Bipolar 1: Bipolar 2:
• Where the individual has • Where the individual has
experienced episode(s) experienced episode(s)
of mania, with or without of both hypomania and
a history of depressive depression(and has
disorders. never an experienced
episode of mania or had
psychotic episodes).
• This is why Bipolar 2 disorder is sometimes
known as “soft” bipolar. Depression is present,
but instead of mania, the person suffers from
hypomania- a milder form of mania.
• So one way of understanding the differences
between hard and soft bipolar, or Type 1
Bipolar and Type 2 Bipolar, is to understand the
differences between MANIA and HYPOMANIA
 MANIA VS. HYPOMANIA
MANIA HYPOMANIA
• Is a high mood that is of • Comes from the Greek and
distinct severity and where means “less than mania”. It
the individual is often describes a high that is less
psychotic in the sense of severe than manic episode
having delusions and/or and without any psychotic
hallucinations. features such as
misinterpretation of events.
CLINICAL MANIFESTATIONS OF
BIPOLAR II DISORDER
Characterized by the occurrence of hypomania and
episodes of major depression in an individual who has
never met criteria for mania or a mixed state.
Hypomania is determined by the same symptom
complex as mania, but the symptoms are less severe,
cause less impairment, and usually do not require
hospitalization.
Bipolar II is cyclic
Suicide occurs in 10% to 15% of patients (same as
bipolar I)
 WHAT IS A HYPOMANIC EPISODE?
• Hypomania is the signature characteristic of
Bipolar II disorder.
• It is a state characterized by euphoria and/or
an irritable mood.
• In order for an episode to qualify as
hypomanic, the individual must also present
three or more of the below symptoms, and last
at least four consecutive days and be present
most of the day, nearly every day
• D- Distractibility thoughts
• I- Insomnia
• G- Grandiosity
• F- Fast(racing)thoughts/flights of ideas
• A- Activities(increased, goal directed)
• S- Speech ( overtalkative )
• T- Thoughtless(reckless-impulsive) behaviors
 WHAT IS MAJOR DEPRESSIVE
EPISODES?
• A period of sad mood or loss of interest in most things
all day log, nearly everyday for at least two weeks
• It is during depressive episodes that BP-II patients
often seek help. Symptoms may be syndromal or
subsyndromal.
• Depressive BP-II symptoms may include five or more
of the below symptoms (at least one of them must
be either depressed mood or loss of
interest/pleasure). In order to be diagnosed, they
need to be present only during the same two-week
period, as a change from previous hypomanic
functioning:
• S- Sleep changes( usually increased)
• I- Loss of interest
• G- Guilty feelings/ worthlessness
• E- Energy low
• C- Concentration(diminished)
• A- Appetite changes(usually increased)
• P- Psychomotor changes9usually retardation)
• S- Suicidal ideation or recurrent thoughts of death
 WHO IS AT RISK FOR
BIPOLAR II DISORDER?
• Virtually anyone can develop bipolar II disorder .
About 2.5% of the U.S. population suffers from some
form of bipolar disorder- nearly 6 million people.
• Most people are in their teens or early 20s when
symptoms of bipolar disorder first start. Nearly
everyone with bipolar II disorder develops it before
age 50. People with an immediate family member
who has bipolar are at higher risk
 DEVELOPMENT AND COURSE( APA , 2013)
• Can begin in late adolescence
• Average age of onset in mid-20s
- slightly later than bipolar 1
• Most often begins with depressive episode and not
recognized until hypomanic episode occurs
• May be preceded by anxiety, substance use, or eating
disorders
• Lifetime episodes of hypomanic and depressive episodes
greater than in bipolar 1
 FUNCTIONAL CONSEQUENCES (APA , 2013)
• Most individuals return to fully functional state between
episodes
• 15% may continue to have some inter-episode dysfunction
• 20% transition directly into another mood episode without
inter-episode recovery
• Functional recovery may be slow
• Cognitive impairments may occur
 SCREENING INSTRUMENTS
• The Mood Disorder Questionnaire (MDQ)
- Screening tool present and past episodes of mania/hypomania.
- includes 13 questions associated with the symptoms of bipolar disorder
- may be used in primary care settings
> efficient way to identify patients most likely to have a bipolar
disorder
• The Composite International Diagnostic Interview (CIDI) Bipolar Disorder
Screening Scale
-can accurately identify threshold/sub-threshold bipolar disorder
-scale detected between 67-96% of true cases in clinical studies
-compares favourably with the MDQ screening scale
 SCORING THE MOOD DISORDER
QUESTIONNAIRE (MDQ)
If the patient answers:
• 1. “Yes” to seven or more of the 13 items in question number 1;
• AND
• 2. “Yes” to question number 2;
AND
• 3. “Moderate” or “Serious” to question number 3;
you have a positive screen. All three of the criteria above should be
met. A positive screen should be followed by a comprehensive medical
evaluation for Bipolar Spectrum Disorder.
 ETIOLOGY
1. Heredity Predisposition. Heredity predisposition for bipolar II
disorder is even more than unipolar disorder. As far as
studies related to identical twins ad fraternal twins are
concerned, the concordance rate is far more for identical
twins (72%) than to fraternal twins (14%).
2. Biochemical Factors. Abnormalities in neurotransmitters is
one of the major factor causing bipolar disorders. It
includes abnormalities in the following neurotransmitters:
-norepinephrine
-serotonin
-dopamine
3. Neurophysiological factors. According to Flor and Henry et
al., 1983. The psychosis and mood disorders are the two ends
of a continuum. The individuals who have disturbances in
their left hemisphere of cerebrum, suffer from pschyosis and
those who have disturbances in their right hemisphere of
cerebrum show bipolar disorders.
Other Biological Factors
1. Abnormal sleep rhythms plays an important role in both-
Unipolar and bipolar disorder. In bipolar disorders, the
biological rhythms regarding sleep are disturbed and the
person experiences less need for sleep. This, in return,
further causes abnormalities in the rhythms, resulting
bipolar disorders. (Goodwin & Jamison,1990; Whybrow,
1997)
2. Abnormal Brain Glucose Metabolic Rates. With the modern
technology of Positron Emission Tomography (PET), its possible to
visualize the variations in brain glucose metabolism rate during
depressed and manic states, according to Whybrow, 1997, the
blood flow to the left hemisphere and prefrontal cortex is reduced
during depression; whereas, during mania, this blood flow is
reduced in the right frontal and the temporal region. During
normal mood, blood flow across two brains hemispheres is
approximately equal.

Psychosocial Factors:
1. Psychodynamic Viewpoint. According to this view, manic and
depressive disorders may be viewed as two different but related
defence oriented strategies for dealing with severe stress. Manic
patients try to escape their problems by a flight into reality. They
try to avoid the pain of their inner lives through outer world
distractions. Such people may involve themselves in countless
number of activities, but not necessarily with true enjoyment. They
try to deny the feelings of helplessness and hopelessness and play
their role with competency.
Other Psychosocial Factors:
1. Stressful Life Events. Studies have found a significant
association between the occurrence of high levels of stress
and the experience of manic, hypomanic or depressive
episodes. One of the studies found that patients with more
prior episodes were likely to have more episodes after the
occurrence of major stressors, than the patients with fewer
prior episodes. (Hammen & Gitbin,1997). Patients who
experienced negative vents took, on an average, three
times longer to recover from an episode, than those
without negative events( Johnson & Miller, 1997). This is
because stressful events seem to disturb the critical,
biological rhythms, which play an important role in mood
disturbances.
2. Personality characteristics. Personality and cognitive
variables may interact with stress and determine the
likelihood of relapse. For example highly introverted and
obsessional individuals are more responsive to stress and
mood disturbances, individuals with a pessimistic attribution
style and who also face negative life events show an
increase in depressive symptoms.
3. Family. If a person has lost someone or both the parents
before the age of five, or if someone has lost his father
between age of 0-14 years, then that person is predisposed
for depression. Feelings inferiority in the family, an antisocial
model in the family and excessive parental demands, also
predispose a person towards mood disturbances.
Sociocultural Factors:
In one of the earlier studies by Carothers(1947, 1951, 1959),
he found manic disorder to be fairly common among East
Africans but depressive disorder was rare. Incidence rate
found in the U.S. was opposite to the trend. The reason for this
was that in Africa individuals were not held responsible for
their failures and misfortunes. However, much has changed in
Africa since Carothers made these observations. Recent
data suggests that as societies take on the ways of western
culture , they become more prone to developing Western
style mood disorder (Marsella, 1980). Mood disorders are
found to be more in urban than rural areas and more high
than the low socio-economic class.
DSM-V DIAGNOSTIC CRITERIA FOR BIPOLAR II
DISORDER
For a diagnosis of bipolar II disorder, it is necessary to meet the following
criteria for a current or past hypomanic episode and the following criteria
for a current or past major depressive episode:
Hypomanic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or
irritable mood and abnormally and persistently increased activity or
energy, lasting at least 4 consecutive days and present most of the day,
nearly every day.
B. During the period of mood disturbance and increased energy and activity,
three (or more)of the following symptoms have persisted (four if the
mood is only irritable), represent a noticeable change from usual behavior,
and have been present to a significant degree:
1. Inflated self esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant
external stimuli), as reported or observed.
6. Increase in goal directed activity (either socially, at work or school, or
sexually) or psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments).
C. The episode is associated with an unequivocal change in functioning that is
uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by
others.
E. The episode is not severe enough to cause marked impairment in social or
occupational functioning or to necessitate hospitalization. If there are
psychotic features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication or other treatment).

Note: A full hypomanic episode that emerges during antidepressant treatment

(e.g., medication, electroconvulsive therapy) but persists at a fully
syndromal level beyond the physiological effect of that treatment is sufficient
evidence for a hypomanic episode diagnosis. However, caution
is indicated so that one or two symptoms (particularly increased irritability,
edginess, or agitation following antidepressant use) are not taken as
sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a
bipolar diathesis.
Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the
same 2 week period and represent a change from previous functioning;
at least one of the symptoms is either
(1) Depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another
medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either
subjective report (e.g., feels sad, empty, or hopeless) or observation
made by others (e.g., appears tearful).
Note: In children and adolescents, can be irritable mood.
2. Markedly diminished interest or pleasure in all, or almost all, activities most
of the day, nearly every day (as indicated by either subjective account
or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of
more than5% of body weight in a month), or decrease or increase in
appetite nearly every day.
Note: In children, consider failure to make expected weight gain.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others; not merely
subjective feelings of restlessness or being slowed
down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self reproach or guilt about
being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by
subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for
committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or another
medical condition
Bipolar II Disorder
A. Criteria have been met for at least one hypomanic episode (Criteria AF
under “Hypomanic Episode” above) and at least one major depressive
episode (Criteria AC under “Major Depressive Episode” above).
B. There has never been a manic episode.
C. The occurrence of the hypomanic episode(s) and major depressive
episode(s) is not better explained by schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional disorder, or other specified or unspecified
schizophrenia spectrum and other psychotic disorder.
D. The symptoms of depression or the unpredictability caused by frequent
alternation between periods of depression and hypomania causes clinically
significant distress or impairment in social, occupational, or other important
areas of functioning.
MANAGEMENT OF BIPOLAR
II DISORDER
The treatment is the same as for bipolar I
disorder

Hypomanic episodes do not require as

aggressive a treatment as mania.
 THE TYPES AND DOSES OF MEDICATIONS PRESCRIBED
ARE BASED ON YOUR PARTICULAR SYMPTOMS.
WHETHER YOU HAVE BIPOLAR I OR II MEDICATIONS
MAY INCLUDE:
• Mood stabilizers. To control episodes of mania or
hypomania, which is a less severe form of mania.
Examples: mood stabilizers include lithium(Lithobid),
valporic acid (Depankene), divalproex sodium
(Depakote), carbamazepine( Tegretol, Equetro) and
lamotrigine(Lamictal)
1. Lithium. This simple metal in pill form is highly effective at controlling
mood swings (particularly highs) in bipolar disorder. Lithium has been
used for more than 60 years to treat bipolar disorder. Lithium can take
weeks to work fully, making it better for long-term treatment than for
acute hypomanic episodes. Blood levels of lithium and other laboratory
tests (such as kidney and thyroid functioning) must be monitored
periodically to avoid side effects.
 2. Cabarmazepine( Tegetrol ). This anti seizure drug has been used to
treat mania since the 1970s. Its possible value for treating bipolar
depression, or preventing future highs and lows, is less well-established.
Blood tests to monitor liver functioning and white blood cell counts also
are periodically necessary.
3. Lamotrigine ( Lamictal ). This drug is approved by the FDA for the
maintenance treatment of adults with bipolar disorder. It has been
found to help delay bouts of mood episodes of depression, mania,
hypomania (a milder form of mania), and mixed episodes in people
being treated with standard therapy. It is especially helpful in
preventing lows.
4. Valproate (Depakote): This antiseizure drug also works to level out
moods. It has a more rapid onset of action than lithium, and it can also
be used "off label" for prevention of highs and lows.
Some other antiseizure medications, such as oxcarbazapine (Trileptal),
are also sometimes prescribed as "experimental" (less-proven)
treatments for mood symptoms or associated features in people with
bipolar disorder.
• Antidepressants. Your provider may add a certain
type of antidepressants to help manage depression.
Because an antidepressant can sometimes trigger a
manic episode, it needs to be prescribed along with
a mood stabilizer or antipsychotic in bipolar I
disorder.
• Antidepressant- antipsychotic. The medication
Symbyax combines the antidepressant fluoxetine
and the antipsychotic olanzapine. It works as a
depression treatmet and a mood stabilizer. Symbyax
is approved by the Food and Drug Administration
specifically for the treatment of depressive episodes
associated with bipolar I disorder.
• Mood-stabilizing antipsychotics. If symptoms
depression or mania persist in spite of treatment with
other medications, adding an antipsychotic
medications such as olanzapine(Zyprexa),
risperidone( Risperdal), quetiapine ( Seroquel),
aripiprazole (Abilify), ziprasidone(Geodon),
lurasidone(Latuda) or asenapine(Saphris) may help.
 IN ADDITION TO MEDICATIONS FOR BIPOLAR
MEDICATIONS FOR DISORDER, OTHER
TREATMENT APPROACHES INCLUDE:
• Psychotherapy. As a key part of treatment, your
psychiatric care provider may recommend
cognitive behavior therapy to identify unhealthy,
negative beliefs and behaviors and replace them
with healthy, positive ones.
• Substance abuse treatment. Many people with
bipolar disorder also have alcohol, tobacco or drug
problems. Drugs or alcohol may seem to ease
symptoms, but they can actually trigger, prolong or
worsen depression or mania.
• Treatment programs. Participation in an outpatient
treatment program for bipolar disorder can be very
beneficial. However, your provider may recommend
hospitalization if your bipolar disorder significantly
affects your functioning or safety.
• Lifestyle issues. In addition to medications and other
types of treatment, successful management of your
bipolar disorder includes living a healthy lifestyle,
such as getting enough sleep, eating healthy and
getting enough physical activity. If you need advice
in these areas, talk with your provider.
Catherine Zeta-Jones
Catherine Zeta-Jones has bipolar II disorder, a form
that has longer down periods, following a difficult
time in her personal life. Zeta-Jones went through a
period of mood swings following an intense period of
stress when her husband, Michael Douglas, battled
stage IV throat cancer. Adding to the stress was a
fight with Douglas' first wife over royalties from the
actor's movie, "Wall Street: Money Never Sleeps."
Stress is often a trigger for the disorder.
Zeta-Jones has been public about being bipolar and
has been an advocate for de-stigmatizing mental
illness, hoping she can inspire people to seek
treatment.
Jean-Claude Van Damme
Jean-Claude Van Damme, star of "Bloodsport" and
"Timecop," had four failed marriages, suffered from
cocaine addiction, was arrested for drunk driving
and was charged at one time with spousal abuse. He
was eventually diagnosed with rapid-cycling bipolar
disorder after hitting bottom.
In hindsight, he says he coped with an undiagnosed
manic-depressive disease by training.
Carrie Fisher
Carrie Fisher, who made an indelible mark
playing Princess Leia in "Star Wars," struggled with
drug and alcohol problems. It is difficult to
diagnose bipolar in someone with substance
abuse. After being a sober a year, she was
diagnosed with bipolar at age 29.

Her father, Eddie Fisher, was also bipolar. The

disorder can run in families.
 REFERENCES:
• https://symbiosisonlinepublishing.com/psychology/psychology31.pdf
• http://seancostellofund.org/documents/BeautifulMinds_BipolarDisorderTypeII.pdf
• https://www.slideshare.net/ClaireTait/hypomania-and-maniatenille2011-3
• http://slideplayer.com/slide/4584717/
• https://en.wikipedia.org/wiki/Bipolar_II_disorder
• https://www.webmd.com/bipolar-disorder/guide/bipolar-2-disorder#3
• https://www.slideshare.net/donnapetko/petko-bipolar-disordersiii
• http://www.sadag.org/images/pdf/mdq.pdf
 In God’s Mercy,
We Serve with Joy!
 REPORTED BY:
Baclea-an, Mary Jean
Bantaculo, Dhanica Mae
Cabadsan, Rogildo Mark
Dumduma, Jalishia Mae
Gacgacao, Hillary
Lamoste, Rhealyn
Maraya, Maritonie
Patiga, Mary jean
Villaruel, Ma. Cherry
Villena, Chanley
Vinas, Jenny Ann