The Truth About Bipolar 2 Disorder

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It's a misconception that bipolar disorders are an up-down, up-down experience. The mood storms are more likely to be crashes into depression, and it's particularly so in bipolar II disorder.

A colleague recently lamented that a former patient with a classic type 2 bipolar profile completed suicide. He was informed that, after a period of stabilization, the deceased encountered a particularly prolonged depressive phase, during which they self-medicated with alcohol. Isolated to the point of requiring a missing person file, it was discovered that my colleague's former patient shut off all connections, drank heavily, and left this world in their mid-20s without so much as a short note.

Of the bipolar patients I've worked with over the years, it's the type 2 that stood out for self-injury and suicidal activity, and there's research backing that this isn't isolated to the people I encountered. Before looking more closely, however, a basic review of type 1 versus type 2 bipolar disorders may be helpful to readers.

The classic bipolar profiles

• Type 1: The hallmark of this condition is manic or mixed episodes that at some time cycle with major depressive episodes (MDE). Mania is not just more energy and chattiness, some inflated self-esteem, and increased productivity. While it may vary among patients, mania is generally an experience charged to the point of thoughts spinning out of control and with a grandiosity of delusional proportions; not unusually, there are psychotic features, like hallucinations, and even catatonia can happen. Mixed episodes are essentially when mania has superimposed MDE. Type 1 patients also encounter subdued manic experiences, known as hypomania.
• Type 2: Patients of this profile are "limited" to hypomania cycling with MDE. Hypomanic episodes generally don't incapacitate them, though there may be some risky behaviors, or their increased physical and mental energy could render them tiresome to be around. If a full manic or mixed episode ever occurs, the diagnosis changes to type 1.

Why type 2 doesn't translate to "less serious"

Type 2 bipolar disorder earns the spotlight for its major depression episodes. It's as if what's lost in having "only" a dampened manic phase (hypomania) is frequently made up for on the depressive end.

People with type 1 or 2 bipolar disorder both tend to experience atypical MDE (e.g., Singh & Williams, 2006; Lojoko et al., 2015; Buzuk et al., 2016). As written about in detail in this post, atypical MDE presents the following features:

• Mood reactivity: The person's mood may brighten in reaction to positive events or news.
• Leaden paralysis: An extreme form of psychomotor retardation whereby the patient feels literally weighted, especially in the extremities.
• Excessive sleep or lack of energy.
• Overeating or binge-eating and significant weight gain.

• A sense of interpersonal rejection present even when the person is not in a depressive episode.

Other than melancholic MDE, atypical MDE are generally more intense than other major depression subtypes (e.g., Singh & Williams, 2006; Brailean et al., 2019). They are also known to take the longest to remit, whether in bipolar disorders or major depressive disorder. Like any MDE, those with atypical features could also experience psychosis, which, according to some researchers (e.g., Mitchell & Malhi, 2004; Tondo et al., 2017), is not uncommon in bipolar depression.

While type 1 and 2 both tend to experience more MDE than mania/hypomania (e.g., Forte et al., 2015), those with type 2 bipolar disorder usually experience more (e.g., Vieta & Suppes, 2010; Tondo et al., 2017) and longer depressive episodes than type 1 (e.g., Tondo et al., 2017; APA, 2022). Also, according to Zananito et al. (2015), more "harm avoidance" characteristics (i.e., increased worry, pessimism, shyness, doubt, and fatigue [Ching-Yen et al., 2015]) are associated with depression in type 2 bipolar patients.

Further complicating things is that people with type 2 bipolar disorder, with age, seem to show shorter periods of remission between mood episodes (APA, 2022). Lastly, according to Weiss et al. (2015), "As the course of the disorder progresses, individuals with bipolar II may be increasingly vulnerable to relapse following lower levels of stress."

In short, type 2 sufferers are prone to more episodes of longer-lingering, more-intense MDE with superimposed anxiety symptoms. Further, in type 2, MDE episodes may occur increasingly closer together with aging, and progressive mood episodes, which are usually MDE, could be triggered with minimal stress.

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The consequences

One doesn't need to be a researcher to understand that this MDE/mood cycling package naturally lends itself to more suicidal activity. According to the APA (2022), those with bipolar type 2 have suicide attempt rates of about 36.3 percent, or 4 percent higher than type 1. Jamison (2019) also tells us that the suicide attempt rate amongst type 2 is heightened. In addition, it appears that there is elevated lethality in the attempts of those with type 2 bipolar depression (APA, 2022). Interestingly, first-degree relatives of those with bipolar 2 have a 6.5-fold increase in suicidal activity.

Clinical implications

Bipolar 2 is often misdiagnosed as MDE (e.g., Benazzi, 2006; Chang et al., 2015; APA, 2022). This is because patients are more prone to seek treatment while depressed, and hypomania, being much less severe than mania, likely won't bring someone in for intervention.

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Given the consequences of bipolar 2 depression, clinicians would do well to thoroughly review to identify historical hypomanic periods in depressed people and be vigilant for emerging episodes during therapy. This is especially true if depressed patients present with atypical MDE symptoms that are unusually prolonged and severe, considering this profile is associated with bipolar 2.

Regarding treatment, psychotherapy is essential not only for stabilizing current mood episodes but for preventing future cycling by helping patients to manage stress and especially sleep hygiene. It's no secret that stress can contribute to the onset of mood cycling in bipolar patients. The onset of mood cycling is believed to be correlated with a lack of sleep (e.g., Harvey et al., 2009; Hensch et al., 2019), which is common under stress. Even if it is a manic/hypomanic episode that initiates from lack of sleep, these can crash into MDE.

Finally, while referral to psychiatry is a wise consideration in any major affective disorder, given the genetic/biological loading amidst bipolar disorders, it's crucial for helping to interrupt mood cycling.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.