Demystifying the DSM: Bipolar II

Dr. B here with our series on demystifying the DSM and today I'm going to be talking about Bipolar 2 which is significantly harder to diagnose and I'm very cautious and conservative in giving this diagnosis. I feel like, sometimes people have been told that they're moody, that they're bipolar by their friends or their significant other because they have extreme fluctuations in mood. But depression can cause extreme fluctuations in mood. Anxiety can cause that, and PTSD is known for causing significant mood fluctuations. So, I'm very careful. I always tell my clients I'm considering bipolar for you, but I'd like to get to know you better. I would like to see how you respond to certain medications before I tell you for sure that I think Bipolar 2 is your diagnosis. And this is very important because people get diagnosed and then own it and I want to be very diligent, specifically with this one, that I'm not over diagnosing. Someone who maybe has depression, PTSD and they are presenting with fluctuating mood and we give them a bipolar diagnosis and they own that. So, I am always very conservative in giving this diagnosis. But when you're looking at the DSM you have to have one, at least, hypomanic episode in your lifetime. And these are periods of time where you have elated mood or elated self-esteem, maybe shopping sprees, but you feel like you're in control. So, hypomania: hypo means lower. So this is kind of a softer mania, one that looks functional. Most people with bipolar 2 are functioning. They go on a shopping spree and then they feel guilty. Then they budget their money and they pay off their bills so there's some compensation type behaviors. And it impedes function, because that's a DSM criteria, but not to the point of severity that mania does. And so, this is very hidden. I mean, many people with hypomania do not seek treatment during this time. This is when they're super productive. But the depressive episodes become so debilitating that they must begin to treat it like bipolar, because, unfortunately, in bipolar, although oftentimes they're only seeking treatment during the depressive episode, they feel like they want to keep that hypomania. They don't want to let that go. They only want to treat the depression, but the depression, when we try to treat it like major depressive disorder, it doesn't work, or it could cause problems of what we call activating. So, you could give someone with bipolar 2 an antidepressant and it would actually cause a hypomania. And they would think, this antidepressant is working so great because they got to their hypomania, but the crash will likely be quick and a significant crash back into the depression. So, watching for those kinds of things over time. It's not clinically appropriate to give antidepressants when we think it's bipolar 2. We used to do that 20-30 years ago, but we need to be watching very closely. If there's any indication of this bipolar 2 that we're looking more for mood stabilizing agents rather than just antidepressants. In both bipolar one and bipolar 2, you are likely seeing them for the first, second, third time in their depressive episode. Sometimes in that bipolar one they are hospitalized or arrested or something severe but typically in bipolar 2 you do not see them in their hypomanic state because this is productivity. For them, they feel very good and happy, and so it's very important to watch your client over time, to make sure that we have that right diagnosis, but that we don't do it right off the bat either, right? At Mentally STRONG we do frequent follow ups and we coordinate the counseling with the medication follow up so that we can begin to really look at those patterns and treat it accordingly. Because if we're just trying to treat the depression, we will not actually be successful long term. Again, bipolar 2 is significantly harder to diagnose. But much higher functioning people can typically be stabilized with a mild anticonvulsant. Some of t