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 as such episodes can sometimes make a person feel productive or experience emotional highs. 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.  It affects between 0.5 and 1% of the population.

Is Bipolar Type 2 Serious? 

While the manic episodes in bipolar 2 are milder than those in bipolar 1, bipolar 2 is still a serious condition that requires professional diagnosis, treatment, and ongoing management. The depressive episodes associated with it cause functional impairments and distress. Without proper care, the disorder can lead to major disruptions in a person’s life and cause considerable emotional strain for both the individual and their loved ones. Bipolar 2 can be successfully treated and managed with medication and other interventions.

Bipolar 1 vs. Bipolar 2

The main difference between bipolar 1 and bipolar 2 is the intensity of the mood episodes. Bipolar 1 is characterized by more extreme manic episodes, where individuals may experience elevated energy, impulsivity, and sometimes psychosis. Depressive episodes may or may not occur. In contrast, bipolar 2 involves hypomania and is always accompanied by episodes of depression. People with bipolar 1 are more likely to require hospitalization during manic episodes, while those with bipolar 2 might face hospitalization during severe depressive phases. While there may be physiological differences in the brains of people with bipolar disorder, there are currently no biomarkers that can distinguish between bipolar 1 and bipolar 2.

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. Some experts advocate for thinking of bipolar disorder in terms of predominant polarity (PP) rather than different categories. 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.   

Bipolar 2 Disorder Causes

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%, and researchers recently identified 30 places (loci) on the human genome that are associated with bipolar disorder. 

As with many mental health disorders, symptoms of bipolar 2 can also 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. 

Bipolar 2 Disorder 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 hypomanic episode and a major depressive episode. These can occur at any point over the course of a lifetime. Here are the symptoms of bipolar 2 disorder.

DSM-5 Symptoms of Hypomania

To qualify as a hypomanic episode of bipolar 2, one must experience at least four days of elevated mood change, which might include feelings of increased energy, irritability, and expansiveness. During this time, one must have at least three of the following symptoms. If your mood has been exclusively irritable, you must have four of the following symptoms.

• Exaggerated sense of well-being and self-confidence (euphoria), grandiosity
• Decreased need for sleep
• Unusual talkativeness
• Rushed/scattered thinking, racing thoughts
• Attention/focus issues, distractibility
• 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 an increase in “activity toward goals”
• Impulsivity, poor decision-making, and risk-taking 

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

Hypomania vs. Mania

Hypomania is at least four 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. This is typical of bipolar disorder 2. 

Mania, on the other hand, is classified as at least seven 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. This is typical of bipolar disorder 1. 

DSM-5 Symptoms of Bipolar 2 Depression

To qualify as a depressive episode, one must experience at least two weeks of major depressive disorder (MDD) symptoms that 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:

• Significant changes in weight and/or appetite
• Sleeping too much (hypersomnia) or too little (insomnia)
• Restlessness or sluggishness
• Loss of energy
• Feeling extreme worthlessness or guilt
• Attention difficulties, indecisiveness
• Thinking about, planning, or attempting suicide

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) if 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 more than half of people with bipolar 2 disorder have at least three additional disorders (known as comorbid disorders), particularly anxiety disorders, substance use disorders, personality disorders, and eating disorders. 

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. If you meet the criteria set in a bipolar 2 checklist, a mental health professional will give you a diagnosis and then help you with a treatment plan. 

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 a colloquial term for a period of intense emotion that might feel uncontrollable. During a meltdown, a person may experience overwhelming emotions such as rage, frustration, or sadness, leading to impulsive or erratic behavior, verbal outbursts, or even aggression. These episodes can be triggered by stress or frustration and can be distressing for both the individual and those around them. Because a person typically experiences a loss of control over their emotions during a bipolar meltdown, they may require professional intervention or support to manage and prevent future episodes.

Bipolar 2 Treatments

Treatment for bipolar 2 disorder often involves medication or a non-pharmacological approach, like changing one’s lifestyle and practicing certain therapeutic modalities. Most often, preventing and managing bipolar 2 episodes requires a combination of both these methods.  

Bipolar 2 Medication

Both antipsychotic medications and mood stabilizers are commonly used in the treatment of bipolar 2 disorder. Medications most often prescribed to manage bipolar 2 are quetiapine (Seroquel), lithium, and lamotrigine (Lamictal). These 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. 

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, bupropion (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. Anyone starting a new bipolar 2 medication should be monitored closely for side effects and adverse reactions like agitation or hypomania. 

Non-pharmacological Treatments for DSM-5 Bipolar 2 Disorder

For some, it’s possible to prevent bipolar 2 episodes with lifestyle alterations. Many people with bipolar disorder find that a straighter lifestyle can 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 stress. 

If daily habits change, they might start noticing changes in their mood. These can serve as warning signs (or prodromal symptoms) so the person knows to reset their routine 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 a mental health professional. Here are additional non-pharmacological treatments for 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

Unpredictable mood swings and clinical depression can both be disruptive to someone’s life. But when bipolar 2 is managed well, people with the disorder can function normally. 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 control the impact it has on your life. A large part of bipolar 2 management and treatment may be seeking the help of a qualified mental health professional.