Bipolar II disorder: Diagnosis, symptoms, and treatment

Bipolar I vs. bipolar II disorder

Bipolar disorder is a mood disorder involving extreme fluctuations of mood and energy levels, as well as other changes in thinking and behavior.

“It’s a disorder in which people have two different kinds of symptom episodes,” says Aimee Daramus, Psy.D., a psychologist and author of Understanding Bipolar Disorder: The Essential Family Guide. There are depressive episodes, marked by low energy, mood, and activity. And there are also manic episodes (or, a less extreme form called hypomanic episodes), marked by heightened energy, mood, and activity. “Episodes tend to last a few weeks to a few months,” Dr. Daramus says.

The emphasis and expression of these episodes is what separates a diagnosis of bipolar I from bipolar II.

Bipolar I is marked by episodes of mania and depression. “In bipolar I, typically the mania is more dominant and it’s the more problematic part,” Dr. Daramus says. “People have extraordinarily high energy and strong impulsivity.” During a manic episode, people may engage in risky behavior, go without sleep, or experience delusions. “I’ve had clients who basically stay up for a few days, or who took out new credit cards and ran them all up within a couple of hours,” Dr. Daramus says.

In bipolar II disorder, depressive episodes are the more prevalent, challenging, and high-risk component of the condition. “We’re talking about really deep depressions where maybe they can’t even go to work for a long time, maybe weeks,” Dr. Daramus says. “Or sometimes they are so depressed, they can’t even get up to make themselves a bowl of cereal.” Here, the danger comes from the extreme lows during a depressive episode, as opposed to impulsive behavior. Instead of experiencing manic episodes, people with bipolar II have hypomanic episodes, which are shorter and milder, with less severe symptoms.

Symptoms of bipolar II disorder

Bipolar II involves two kinds of episodes with very different symptoms.

Depressive episode symptoms

A depressive episode in bipolar lasts at least two weeks, though often longer, Dr. Daramus says (like weeks to months). “And that depression is going to look a lot like major depression,” Dr. Daramus says. “Fatigue, sadness, sometimes anger, you can’t get things done. People have an unusually low opinion of themselves sometimes during that time.” Symptoms can include:

• Loss of interest or pleasure in things you usually enjoy
• Loss of appetite and/or or unintentional weight loss
• Insomnia
• Excessive sleeping or daytime drowsiness
• Talking unusually slowly or less than usual
• Difficulty making decisions
• Forgetfulness
• Restlessness or agitation
• Trouble concentrating
• Feelings of worthlessness or inappropriate guilt
• Negative rumination
• Tearfulness
• Hopelessness
• Thoughts of suicide or self-harm

Hypomanic episode symptoms

A hypomanic episode, which lasts at least four consecutive days, involves an abnormally elevated, expansive, or irritable mood, plus increased energy or activity. Symptoms can include:

• Inflated self-esteem or confidence
• Decreased need for sleep
• Feelings of elation or excitement
• Irritability
• Talking more than usual
• Racing thoughts or flights of ideas
• Distractibility and difficulty focusing
• Higher energy and activity levels
• Increased goal-directed activity
• Impulsive, risky or pleasure-seeking behavior (such as overspending or sexual risk-taking)

The difference between mania and hypomania

Hypomania is essentially a lighter form of mania. “The symptoms are very similar. But it’s not as extreme in hypomania as it is in mania,” Dr. Daramus says.

Mania can be severe enough to cause serious impairment, may require hospital care, and can include psychosis or delusion, says Nakisha Rodriguez, LCMHCS, a licensed clinical mental health counselor at Thriveworks. Hypomania, on the other hand, generally presents less of a danger and doesn’t include psychosis.

During a manic episode, Dr. Daramus says, someone may experience much higher self-esteem or grandiosity, need little or no sleep for days, think and talk much faster than usual, experience delusional thinking (like thinking someone is out to get them) and be highly distractible. Marked impulsivity is also a hallmark. “If they think of something they want to do, they’re just going to do it,” Dr. Daramus says.

Then there’s hypomania, where people experience significantly milder versions of many (but not all) of the same symptoms, Dr. Daramus says. From the outside, hypomania tends to look less erratic. The deviation from somebody’s normal personality, energy, and activity is still noticeable, but less significant.

Hypomania will also feel less intense for the individual experiencing it, compared to mania. “There’s still going to be some increased self-esteem,” Dr. Daramus says. “They might be talking a lot more than usual, their thoughts might be racing, they might have trouble focusing.” But there won’t be delusions or psychosis.

How is bipolar II disorder treated?

Treatment for bipolar II is generally long-term and holistic, Rodriguez says. Treatment plans are always individualized, but typically involve a combination of medication to prevent or soften episodes, plus therapy to track moods and build coping skills. “If you put both [medication and therapy] together, they work in conjunction,” Rodriguez says. “You will get results faster, it’ll be more effective, and you’ll have a chance of longer-lasting recovery.”

The tools are largely the same as those used to treat bipolar I, but the focus shifts. In bipolar I, there’s more emphasis on managing mania and the accompanying risks. Bipolar II treatment tends to center more on preventing and managing depressive episodes, Dr. Daramus says, though hypomania also needs to be managed.

Medication

Medication is an essential part of bipolar II symptom management, Dr. Daramus says. Ideally, the right medication regimen will either mostly eliminate episodes or make it so that episodes are very light and much more manageable, she explains. That said, it doesn’t always work out that way. “There’s a lot of variability,” Dr. Daramus adds.

The most commonly prescribed categories of medications for both bipolar I and II are mood stabilizers (such as lithium) and atypical antipsychotics (such as lumateperone), according to NIMH, which can prevent episodes or make them less severe. It’s not uncommon for antidepressants to be added to help manage the depression in bipolar II, Rodriguez says. But antidepressants aren’t used on their own, since this can trigger mania or rapid cycling, per the NIMH.

Your provider might also use other medications to help with symptoms you’re experiencing, like anxiety or sleep disturbances. For example, if someone hasn’t slept well for several days during a hypomanic or depressive episode, a temporary course of sleep meds might be prescribed, Rodriguez says.

The right medication regimen depends on the individual, Rodriguez says, and it can take some trial-and-error to find the right drug and dosage. Dr. Daramus recommends seeing a prescriber every few months to monitor effectiveness and side effects.

Therapy

If medication is doing the heavy lifting of minimizing episodes in bipolar II, “then the therapist is doing the problem-solving when the meds don’t catch or solve something,” Dr. Daramus explains. One research review of 55 studies on multiple types of bipolar disorder found that psychological interventions (typically given in conjunction with medication) can help lower the risk of relapse. Therapy can also help improve someone’s quality of life in between and during episodes.

Bipolar disorder therapy can play a few roles in helping someone live with the condition, Dr. Daramus says. One is simply “getting the person used to the fact that they’ve got a disorder like this and showing them how their life can go on.” Another is setting up a system (whether in a notebook or an app) to track mood and energy levels on a daily basis. “Tracking the moods is really one of the most essential things that a therapist can help somebody do,” Dr. Daramus says.

Mood tracking can actually help someone spot and prepare for an oncoming episode over time. “That’s not something people often recognize when they have their first episodes, but they can learn to,” Dr. Daramus says.

A therapist can also be a great partner in planning ahead for episodes, depending on the challenges that tend to arise for you. For hypomanic episodes, for example, that could look like giving your credit cards to someone you trust (if you tend to spend impulsively) or creating a written list of safe outlets for your impulsivity, Dr. Daramus says.

For depressive episodes, that might look like reaching out to trusted loved ones for support, planning some comforting entertainment, scheduling extra therapy sessions, or preparing some food to keep in reach. “One thing I like to do is have my clients write letters to themselves when they’re feeling good to their depressed self,” Dr. Daramus says. “I can remind them to read [it] when they’re feeling worthless.”

Many different types of therapy can help people with bipolar II build coping skills, improve resilience and mood, and nurture relationships, Rodriguez says. In her practice, she favors cognitive behavioral therapy (CBT), which can challenge distorted thought patterns, and dialectical behavior therapy (DBT), which can support emotional regulation and reduce impulsivity.

Lifestyle changes

Consistency is key with bipolar disorder. Keeping regular routines for eating, sleeping, and exercising can support a regulated biological rhythm and make daily life more stable, Dr. Daramus says—though this doesn’t replace medication. “Sleep and exercise won’t prevent an episode. But it can make things a little bit more predictable, a little bit healthier.”

Managing and minimizing interpersonal stress is another biggie. “That includes if your family is causing the interpersonal stress,” Dr. Daramus says. That could look like a daily meditation practice, setting boundaries, or spending time in nature, for instance.

Social connection can also be incredibly supportive. “Building bonds with other people will help keep people securely rooted,” Rodriguez says. Think of activities like gardening, yoga, music, art classes. “Whatever their thing is that creates that bond in the community in a healthy, positive way,” Rodriguez says.

Frequently asked questions (FAQs)

Is bipolar II less serious than bipolar I?

No. “That’s a myth,” Rodriguez says. “Both could be equally dangerous for the person who is suffering through it.” While hypomania doesn’t come with the same risks as mania, the severe depression that occurs in bipolar II can be debilitating and dangerous.

What does a hypomanic episode feel like?

A hypomanic episode often feels good for the person experiencing it—even great. Energy, confidence, and productivity tend to rise, so often people don’t realize anything is wrong. Mood can be euphoric—or, on the other hand, irritable.

How is bipolar II disorder diagnosed?

With a thorough intake and interview process. A clinician reviews your symptoms (currently and over the span of your life), along with family history, Rodriguez says. They’ll be looking for at least one hypomanic episode, at least one major depressive episode, and no history of mania. They’ll also rule out other conditions.

Can bipolar II turn into bipolar I?

Sometimes, but it isn’t typical, and it seems to be slightly more common in younger people. If someone with bipolar II has a manic episode, the diagnosis changes to bipolar I. Some small studies show that approximately 5% of adults and 17% of college-age individuals initially diagnosed with bipolar II will have their diagnosis change to bipolar I over the next five years.

What is the difference between bipolar II and cyclothymia?

Bipolar II involves full hypomanic and major depressive episodes. Cyclothymia is a distinct disorder that involves milder, shorter hypomanic and depressive symptoms that never reach the level of a full episode.

What medications are used for bipolar II disorder?

Mood stabilizers such as lithium and atypical antipsychotics are the most common choices. Antidepressants are sometimes added (but aren’t used alone because they can trigger mania). The choice depends on the person and what they’re experiencing, Rodriguez says.

Can bipolar II disorder be treated without medication?

For most people, medication is the core of treatment, and therapy works best alongside it. Going without medication raises the risk of another episode, experts caution.

Can you live a normal life with bipolar II disorder?

Yes. Most people can live a normal, happy, and full life as long as they stick with treatment, Rodriguez says.

Can bipolar II be mistaken for ADHD?

Yes, sometimes. “It could mimic ADHD,” Rodriguez says. Some symptoms of both hypomania and depression can look like ADHD—including distractibility, racing thoughts, and restlessness. The two conditions can also occur together.