DSM-5 bipolar 2: Criteria, symptoms, and treatments

What Is Bipolar 2 Disorder?

Bipolar 2 disorder is a type of bipolar disorder characterized by major depressive episodes and hypomanias, which are elevated moods that don’t meet the threshold for manias. While manic episodes are often severely debilitating, hypomanic episodes (sometimes called “baby” manic episodes) don’t impair daily living. They might even be welcomed. But unfortunately they are just one side of a mood swing.

Because bipolar disorder affects emotional states, it’s commonly referred to as a mood disorder. It’s a long-term, chronic mental health condition that usually shows up by the time someone is in their mid-20s. Is bipolar type 2 serious? Yes, it’s serious because it can cause functional impairments and distress. But it can also be successfully treated and managed throughout the lifespan with medication and other interventions. It affects between 0.5 and 1% of the population.

What Is a Bipolar Disorder?

All bipolar disorders are characterized by mood swings of varying intensity. There’s some controversy about why someone can be diagnosed with bipolar 2 or bipolar 1 rather than just land somewhere on a spectrum of a single disorder. In fact, bipolar 2 wasn’t formally recognized by the American Psychiatric Association (APA) until 1994. The debate has to do with the ultimate usefulness and clinical accuracy of bipolar categories. Are bipolar 1 and 2 actually different disorders, or do their symptoms just represent different dimensions of the same disorder? 

Some experts advocate for thinking of bipolar disorder in terms of predominant polarity (PP) rather than different categories (see the different types of bipolar below). For example, someone may have far more depressive episodes than manic episodes, so they would be “depression predominant.” Within this diagnosis clinicians can further specify bipolar disorder by severity and duration of symptoms.   

All Types of Bipolar Disorder

• Bipolar 1 disorder (aka bipolar I disorder or type I bipolar)
• Bipolar 2 disorder (aka bipolar II disorder or type 2 bipolar) 
• Cyclothymic disorder 
• Substance/medication-induced bipolar and related disorder
• Bipolar and related disorder due to another medical condition (like thyroid disease or multiple sclerosis)
• Other specified bipolar and related disorder
• Unspecified bipolar and related disorder

DSM 5 Bipolar 2 Criteria and Bipolar 2 Symptoms

To be diagnosed with bipolar 2 according to criteria laid out in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), someone must experience A) a hypomanic episode, and B) a major depressive episode. These can occur at any point over the course of a lifetime.

A. What qualifies as a hypomanic episode? An episode of bipolar 2 hypomania requires at least four days of elevated mood change, which might include feelings of increased energy, irritability, and expansiveness. During this time, you must have at least three of the following symptoms. If your mood has been exclusively irritable, you must have four of the following symptoms.

DSM-5 Symptoms of Hypomania

1. Exaggerated sense of well-being and self-confidence (euphoria), grandiosity
2. Decreased need for sleep
3. Unusual talkativeness
4. Rushed/scattered thinking, racing thoughts
5. Attention/focus issues, distractability
6. Psychomotor agitation, which is an increase in purposeless physical activity (e.g., restlessness, pacing, tapping fingers or feet, abruptly starting and stopping tasks, rapidly talking, and moving items around without meaning) or increase in “activity toward goals”
7. Impulsivity, poor decision-making, and risk-taking 

All of these heightened, wired feelings and behaviors can’t be attributed to a substance, and they have to be so uncharacteristic that other people notice. These symptoms don’t, however, cause enough functional impairments to qualify as mania. 

B. What qualifies as a depressive episode? A major depressive episode requires at least two weeks of major depressive disorder (MDD) symptoms.

DSM-5 Symptoms of Bipolar 2 Depression

A major depressive episode involves depressive symptoms that last at least two weeks and are severe enough to cause significant emotional and occupational distress. An episode of depression must involve a depressed mood or loss of interest and pleasure (anhedonia) in addition to at least four of the following symptoms:

1. Significant changes in weight and/or appetite
2. Sleeping too much (hypersomnia) or too little (insomnia)
3. Restlessness or sluggishness
4. Loss of energy
5. Feeling extreme worthlessness or guilt
6. Attention difficulties, indecisiveness
7. Thinking about, planning, or attempting suicide

How Long Does a Bipolar 2 Episode Last?

For people with bipolar 2, moods can fluctuate in different rhythms. Someone with rapid-cycling bipolar 2 will swing between moods at quicker rates (at least four episodes in a year). To qualify for a bipolar 2 diagnosis, a hypomania episode must last at least four days and a major depressive cycle must last at least 14 days. If someone’s bipolar symptoms last for two years or more and they never meet the full criteria for a hypomanic episode or a major depressive episode, they may be diagnosed with cyclothymic disorder. 

What Is a Bipolar Meltdown?

A bipolar meltdown is the colloquial term for a period of intense emotion that might feel uncontrollable. It can sometimes manifest as rage or aggression.

Bipolar 1 vs Bipolar 2

The most significant contrast between bipolar 1 and bipolar 2 is that the former tends to gravitate toward mania while the latter tends to gravitate toward depression. If someone with bipolar 2 has a single manic episode, they can no longer be diagnosed with bipolar 2. They have another type of bipolar disorder.

Even though hypomanias are a milder form of mania, it’s not true that bipolar 2 is a milder version of bipolar 1. By definition, hypomanias don’t cause impairment, but the major depressions that characterize bipolar 2 can be brutal. These depressive episodes also tend to happen more frequently than in bipolar 1. And the persistent, unreliable mood swings of bipolar 2 can cause significant harm to someone’s life.

Mania vs Hypomania

Mania = at least 7 days of severe functional impairment, great excitement or euphoria, dangerous decision-making, delusions, hallucinations, suicidal thoughts/actions, or even psychosis that could lead to psychiatric hospitalization 

Hypomania = at least 4 days of “enhanced” emotion that doesn’t cause significant impairment or extreme personality changes. The DSM-5 also leaves room for a 2-day, “short-duration” hypomania.

What Bipolar Is Worse, 1 or 2?

One type of bipolar disorder is not worse than another. They all have their ups and downs, as it were. The worst type of bipolar disorder is untreated bipolar disorder, due to its potential to inflict suffering. 

What Causes Bipolar 2 Disorder?

If you have a family member with bipolar 2 disorder, you have a greater risk of having the condition due to genetic factors. Its heritability might be as high as 70%. In fact, researchers recently identified 30 places (loci) on the human genome that are associated with bipolar disorder. 

There may be physiological differences in the brains of people with bipolar disorder, but there are currently no biomarkers that can distinguish between bipolar 1 and bipolar 2.

What Can Trigger Bipolar 2?

As with many mental health disorders, symptoms of bipolar 2 can be triggered by stress, negative life events, changes in sleep patterns and seasonality (both associated with chronodisruption), substance use, and medications. Childbirth can also trigger hypomanic episodes. 

What Is the Impact of Bipolar 2 Disorder?

Unpredictable mood swings and clinical depression can both be incredibly disruptive to someone’s life. But when bipolar 2 is managed well, people with the disorder can function normally. It’s only when the disorder is left untreated that someone’s biography might take a dark turn or suffer an obstruction. Living with bipolar 2 involves adhering to a treatment plan, recognizing your triggers, and knowing how to get back on your feet if you have a relapse. You can’t cure the disorder, but you can definitely control the impact it has on your life.

Preventing Bipolar 2 Episodes

Many people with bipolar disorder find that a straighter lifestyle can also help flatten the peaks and valleys of their mood swings. This means they stick to a healthy sleep schedule, exercise regularly, eat well, avoid abusing drugs and alcohol, monitor caffeine intake, and try to minimize the stress in their lives. 

If their daily habits change, they might start noticing changes in their mood. These can serve as warning signs (aka prodromal symptoms) so the person knows they need to reset their routine or or take other steps to stabilize. This kind of self-awareness and self-monitoring can also lead someone with bipolar 2 to know when they need extra support from friends and family, or from a mental health professional. 

How Is Bipolar 2 Diagnosed?

Bipolar 2 can be diagnosed according to the DSM-5 criteria mentioned above, though different mental health professionals may have different perspectives on how to think about the disorder. Some clinicians may mark that distinct boundary between type 1 and type 2, while others may take a more dimensional approach, and think of the diagnostic boundaries as more fluid. 

Bipolar 2 is often misdiagnosed as major depressive disorder (MDD). This is because a depressive episode precedes a hypomanic episode, or multiple depressive episodes occur before a hypomanic episode. In addition, people with bipolar 2 and MDD can both have irritability as a symptom. And because hypomanic episodes aren’t extreme or functionally impairing, they may go unrecognized. 

Diagnosis can also be challenging because over half of people with bipolar 2 disorder have at least three additional disorders (aka comorbid disorders), particularly anxiety disorders, substance use disorders, personality disorders, and eating disorders. 

Is there a bipolar 2 test or a bipolar 2 checklist? Mental health professionals will have different ways of evaluating clients for bipolar disorder. A comprehensive test or screening often includes a physical assessment, a family history, a full psychiatric assessment, a mood disorder questionnaire (MDQ), and mood charting, which is when you keep a careful record of your daily emotions. 

What Is the First-Line Treatment for Bipolar 2?

The first-line treatment for bipolar 2 is medication. More specifically, the first-line medications prescribed to manage bipolar 2 are often quetiapine (Seroquel), lithium, and lamotrigine (Lamictal). They are all monotherapies, meaning you take them exclusively. The second-line monotherapy treatments for bipolar 2 disorder are often venlafaxine (Effexor), an SNRI, and fluoxetine (Prozac), an SSRI. Anyone starting a new bipolar 2 medication should be monitored closely for side effects and adverse reactions like agitation or hypomania. 

Bipolar 2 Medication

According to a comprehensive 2020 analysis, the best medication for an acute bipolar 2 depressive episode is quetiapine. This first-line treatment is followed by the second-line treatments lithium, lamotrigine, sertraline (Zoloft), venlafaxine, and, as an adjunct, buproprion (Wellbutrin). But all this medication guidance is subject to change as clinical knowledge grows. Bipolar 2 simply hasn’t been researched as extensively as bipolar 1.   

The same medications that work for mania also seem to work for hypomania (when it requires treatment), namely the mood stabilizers lithium or divalproex (Depakote) and/or atypical antipsychotics. 

Nonpharmacological Treatments for DSM-5 Bipolar 2 Disorder

• Psychoeducation and active monitoring 
• Cognitive behavioral therapy (CBT)
• Interpersonal psychotherapy
• Behavioral activation
• Family-focused therapy (FFT)
• Complementary and alternative medicine (CAM) therapies
• Interpersonal and social rhythm therapy (IPSRT) 
• Peer interventions such as support groups

Final Thoughts on Bipolar 2

Whether you think of bipolar 2 disorder as part of a bipolar spectrum or continuum, or as its own distinct disorder, it’s a serious mental health condition that can exact a high personal cost if left untreated. But people with any bipolar disorder have an excellent chance of thriving if they embrace these three ingredients as part of their experience: 

1) Consistent, compassionate, and continuous mental health care

2) Psychoeducation, which can help them monitor their moods and prevent relapse

3) Psychopharmacology (medication)

Finally, it’s important to let go of the idea that you can achieve perfect mastery over your illness. Perfectionism, self-criticism, and shaming beliefs are all associated with bipolar symptoms. You can try to protect yourself from these maladaptive feelings by practicing self-compassion. Stigma has no place in mental health care, whether it comes from the outside, or from within.