Bipolar disorder 1 and bipolar disorder 2 are mental illnesses that last at least one week and for most of each day, almost every day. Diagnostic criteria require that an individual experience at least one manic episode in their lifetime. [1] Bipolar disorder causes unusual, unpredictable, and extreme changes in mood, energy and activity levels, focus, and the capacity to carry out daily tasks. Typical treatment options include prescription medications and psychotherapy. Diagnostic criteria in the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) require that the individual’s symptoms significantly impair social or occupational functioning and cannot be due to substance use or another medical condition. [1]

What is bipolar 1?

According to the DSM-5, to receive a diagnosis of bipolar I disorder, an individual must meet all criteria for a manic episode. [1]

When someone is experiencing a manic episode, their mood is frequently perceived as overly happy or can come off as having an excessive amount of random enthusiasm in personal, sexual, or work interactions. An individual may begin numerous overlapping tasks during a manic episode, and the increased activity may occur at odd times. [1]

Manic Episode

Manic episodes are unusual, unpredictable, and extreme changes in mood, energy activity levels, concentration, and the ability to carry out daily tasks, lasting for at least one week. They are present most of the day, nearly every day (or, if hospitalized, for any period of time). [1]

At least three of the following manic criteria must be present during the manic episode: [1] 

  1. Inflated self-esteem or grandiosity: an exaggerated sense of self.
  2. Decreased need to sleep,g.., feeling rested after three hours of sleep.
  3. More talkative than usual, speech may be rapid, pressured, loud, or challenging to interrupt
  4. Flight of ideas, or feeling that thoughts are racing, when their thoughts race faster than expressed as speech, with rapid shifts from topic to topic.
  5. Being distracted: Easily or drawn to the attention to unimportant or irrelevant causes in their surroundings.
  6. Increase in goal-directed activity: big or small tasks that the individual feels must be completed immediately. Or psychomotor agitation: intentional or unintentional agitated movement. Examples may include talking fast, fidgeting, or walking back and forth.
  7. Excessive involvement in risky behaviors: Activities with a high likelihood of severe consequences, such as impulse buying or risky sexual activities.

The manic episode must be severe enough to warrant hospitalization to prevent harming themselves or others, significantly impairing social or occupational functioning, or when psychotic symptoms are present. Signs cannot be due to substance use or another medical condition. [1]

What is bipolar 2?

According to the DSM-5, to receive a diagnosis of bipolar 2 disorder, an individual must meet all criteria (listed below) for a hypomanic episode.

Hypomanic Episode

A manic episode is a period of unusual, unpredictable, extreme, or irritated mood and unusual and unpredictable and extreme increase in activity or energy that lasts for at least four consecutive days and lasts for most of the day, practically every day. Symptoms are significant and represent a change from their usual behavior. [1]

During the episode and period of increased energy or activity, at least three of the following hypomanic symptoms have continued (four if the mood is only irritable) [1] and include the following:

  1. Inflated self-esteem or grandiosity: an exaggerated sense of self.
  2. Decreased need to sleep,e.g., feeling rested after three hours of sleep.
  3. More talkative than usual or feeling under pressure to keep talking.
  4. Flight of ideas, or feeling that thoughts are racing.
  5. Distractibility: easily or drawn to pay attention to unimportant or irrelevant causes in their surroundings.
  6. Increase in goal-directed activity: big or small tasks that the individual feels must be completed immediately. OrPsychomotor agitation: intentional or unintentional agitated movement. Examples may include talking fast, fidgeting, or walking back and forth.
  7. Excessive involvement in risky behaviors: Activities with a high likelihood of severe consequences, such as impulse buying or risky sexual activities.

The hypomanic episode is associated with an undeniable change in functioning and mood that is not usual for the individual when they aren’t experiencing symptoms, and is noticeable by others. [1]

The episode is not severe enough to require hospitalization or to significantly interfere with social or vocational functioning. Symptoms cannot be due to substance use or another medical condition. If psychotic features are shown, then the episode is referred to as manic. [1] 

Major Depressive Episode

Five or more of the following depressive symptoms must be present for two consecutive weeks and represent a change in the individual’s usual level of functioning. [1] At least one symptom needs to be 1) Depressed mood or 2) Loss of interest or pleasure in activities. [1] 

  1. Depressed nearly every day, most of the day (self-described or described by others as sad, empty, hopeless, or tearful). Symptoms in children and teens may manifest as an irritable mood.
  2. Noticeableloss of interest or pleasure in all or most activities nearly every day, for most of the day.
  3. Unintentional and considerable weight gain or loss,g., a 5% change in body weight in a month or a change in appetite that occurs almost daily. Children might not gain the necessary amount of weight.
  4. Insomnia:trouble sleeping, or Hypersomnia: excessive daytime sleepiness or sleeping too much nearly every day.
  5. Psychomotor agitation:intentional or unintentional agitated movement. Examples may include talking fast, fidgeting, or walking back and forth. Or Psychomotor retardation: long thoughts or activities, such as visible slowing of speech, emotions, or actions. Both should be observable by others, not just self-reported.
  6. Fatigue or loss of energy nearly every day.

  1. Feeling worthless or excessive or inappropriate guilt: may be delusional (not based on facts or reality). It needs to be experienced nearly every day and not due to feeling regret or guilt about being sick.
  2. Decreased ability to think, focus, or indecisiveness nearly every day, may be self-reported or observed by others.
  3. Repeated thoughts of death(not just fear of dying), continued suicidal ideation without a specific plan (thoughts, ideas, or obsessions about the possibility of ending their life), attempted suicide, or a particular intent to commit suicide. [1]

Symptoms cause significant distress or damage in social, occupational, or other important areas of functioning. [1] The episode cannot be attributed to the effects of a substance or another medical condition. [1]

What causes bipolar 1 and 2?

People usually experience their first manic, hypomanic, or major depressive episode around 18 bipolar I disorder, but it can happen at other times throughout life. [1] 

There are environmental, genetic, and physiological factors:

Environmental

High-income countries have higher rates of bipolar vs. low-income countries (1.4% vs. 0.7%). Separated, divorced, or widowed people have higher rates than married people. [1]

Genetic and physiological

The most significant and reliable risk factor for bipolar disorder is recognized to be people with a family history of the mental health condition. Adult relatives with bipolar I and bipolar II disorders are at approximately 10-fold greater risk. [1]

Bipolar 1 vs. 2 – What is the difference?

The main difference between bipolar 1 and bipolar 2 is that the former does not require a depressive episode, and bipolar 2 requires at least one episode of hypomania and one or more episodes of major depression. [1]

What other types of bipolar disorder are there?

Cyclothymic disorder: Adults with hypomanic and depressive episodes lasting at least two years (or a full year in children) without ever having mania, hypomania, or a major depressive episode are diagnosed with cyclothymic disorder. [1] 

Mixed States: Mixed states depressive episodes with at least three manic symptoms. [2]

Rapid cycling: Individuals with bipolar I disorder who have four or more (multiple) major depressive, manic, or hypomanic episodes within 1 year receive the specifier of “with rapid cycling.” [3]

How is bipolar disorder treated?

There is no cure, and bipolar disorder is a lifelong disorder. Several medications treat bipolar disorder. Your health provider will determine the dose and medicine based on your symptoms, and long-term, continuous treatment can help people manage symptoms. [3] 

Talk therapy

Psychotherapy: Psychotherapy can be an effective component of a treatment plan. Psychotherapy, also referred to as “talk therapy”, assists individuals in recognizing and modifying distressing feelings, ideas, and behaviors. Psychotherapy offers assistance, knowledge, and direction to those who have bipolar disorder, as well as to their families. [3]

Cognitive Behavioral Therapy (CBT): CBT is an effective treatment for depression and bipolar depression. [3]

Medication

Atypical antipsychotics and mood stabilizers are common medications. Lithium and valproate are mood stabilizers and can help prevent and reduce mood episodes and their severity. [3] Lithium can reduce suicide risk. Treatment plans often include sleep and anxiety medications, along with mood stabilizers. [3]

Antidepressants are commonly prescribed to treat bipolar depression but should be taken with a mood stabilizer. Taking an antidepressant alone can trigger manic episodes and rapid cycling. [3]

Other treatment options

Electroconvulsive Therapy (ECT): ECT works by stimulating the brain and can help treat bipolar disorder’s severe symptoms. Typically, ECT is only considered after other therapies like medication or psychotherapy have failed to improve a patient’s condition, or when an immediate response is necessary, such as suicidal patients or catatonic (a state of unresponsiveness) patients. [3]

Transcranial Magnetic Stimulation (TMS): TMS stimulates the brain using magnetic waves to treat depression over several sessions. TMS is not as effective as ET but is less dangerous, does not involve general anesthesia, and has fewer potential memory or cognitive side effects. [3]

Light Therapy: Although people with seasonal affective disorder (SAD) are the primary users of light therapy, people with bipolar disorder experience more depression in the winter, often having SAD. For milder seasonal bipolar depression symptoms, light therapy may also be an option. [3]

Resources:

  1. American Psychiatric Association. (2013). Bipolar and Related Disorders. In Diagnostic and Statistical Manual of Mental Disorders(5th ed.).
  2. Moreno, D. & Moreno, R. (2004). Mixed states and rapid cycling in bipolar disorder. Revista de Psiquiatria Clínica. 32. 56-62. 
  3. National Institute of Mental Health (2022). Bipolar Disorder. Retrieved from https://www.nimh.nih.gov/health/topics/bipolar-disorder#part_2264.