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Bipolar II disorder (recurrent major depressive episodes with hypomanic episodes)

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296.89 Bipolar II Disorder (Recurrent Major Depressive Episodes With Hypomanic Episodes)

Diagnostic Features

The essential feature of Bipolar II Disorder is a clinical course that is characterized by the occurrence of one or more Major Depressive Episodes (Criterion A) accompanied by at least one Hypomanic Episode (Criterion B). Hypomanic Episodes should not be confused with the several days of euthymia that may follow remission of a Major Depressive Episode. The presence of a Manic or Mixed Episode precludes the diagnosis of Bipolar II Disorder (Criterion C). Episodes of Substance-Induced Mood Disorder (due to the direct physiological effects of a medication, other somatic treatments for depression, drugs of abuse, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Bipolar II Disorder. In addition, the episodes must not be better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified (Criterion D). The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion E). In some cases, the Hypomanic Episodes themselves do not cause impairment. Instead, the impairment may result from the Major Depressive Episodes or from a chronic pattern of unpredictable mood episodes and fluctuating unreliable interpersonal or occupational functioning.

Individuals with Bipolar II Disorder may not view the Hypomanic Episodes as pathological, although others may be troubled by the individual's erratic behavior. Often individuals, particularly when in the midst of a Major Depressive Episode, do not recall periods of hypomania without reminders from close friends or relatives. Information from other informants is often critical in establishing the diagnosis of Bipolar II Disorder.

Specifiers

The following specifiers for Bipolar II Disorder should be used to indicate the nature of the current episode or, if the full criteria are not currently met for a Hypomanic or Major Depressive Episode, the nature of the most recent episode:

If the full criteria are currently met for a Major Depressive Episode, he following specifiers may be used to describe the current clinical status of the episode and to describe features of the current episode:

If the full criteria are not currently met for a Hypomanic or Major Depressive Episode, the following specifiers may be used to describe the current clinical status of the Bipolar II Disorder and to describe features of the most recent Major Depressive Episode (only if it is the most recent type of mood episode):

The following specifiers may be used to indicate the pattern or frequency of episodes:

Recording Procedures

The diagnostic code for Bipolar II Disorder is 296.89; none of the specifiers are codable. In recording the name of the diagnosis, terms should be listed in the following order: Bipolar II Disorder, specifiers indicating current or most recent episode (e.g., Hypomanic, Depressed), severity specifiers that apply to the current Major Depressive Episode (e.g., Moderate), as many specifiers describing features as apply to the current or most recent Major Depressive Episode (e.g., With Melancholic Features, With Postpartum Onset), and as many specifiers as apply to the course of episodes (e.g., With Seasonal Pattern); for example, 296.89 Bipolar II Disorder, Depressed, Severe With Psychotic Features, With Melancholic Features, With Seasonal Pattern.

Associated Features and Disorders

Associated descriptive features and mental disorders.

Completed suicide (usually during Major Depressive Episodes) is a significant risk, occurring in 10%-15% of persons with Bipolar II Disorder. School truancy, school failure, occupational failure, or divorce may be associated with Bipolar II Disorder. Associated mental disorders include Substance Abuse or Dependence, Anorexia Nervosa, Bulimia Nervosa, Attention-Deficit/Hyperactivity Disorder, Panic Disorder, Social Phobia, and Borderline Personality Disorder.

Associated laboratory findings.

There appear to be no laboratory features that are diagnostic of Bipolar II Disorder or that distinguish Major Depressive Episodes found in Bipolar II Disorder from those in Major Depressive Disorder or Bipolar I Disorder.

Associated physical examination findings and general medical conditions.

An age at onset for a first Hypomanic Episode after age 40 years should alert the clinician to the possibility that the symptoms may be due to a general medical condition or substance use. Current or past hypothyroidism or laboratory evidence of mild thyroid hypofunction may be associated with Rapid Cycling (see p. 427). In addition, hyperthyroidism may precipitate or worsen hypomanic symptoms in individuals with a preexisting Mood Disorder. However, hyperthyroidism in other individuals does not typically cause hypomanic symptoms.

Specific Gender Features

Bipolar II Disorder may be more common in women than in men. Gender appears to be related to the number and type of Hypomanic and Major Depressive Episodes. In men the number of Hypomanic Episodes equals or exceeds the number of Major Depressive Episodes, whereas in women Major Depressive Episodes predominate. In addition, Rapid Cycling (see p. 427) is more common in women than in men. Some evidence suggests that mixed or depressive symptoms during Hypomanic Episodes may be more common in women as well, although not all studies are in agreement. Thus, women may be at particular risk for depressive or intermixed mood symptoms. Women with Bipolar II Disorder may be at increased risk of developing subsequent episodes in the immediate postpartum period.

Prevalence

Community studies suggest a lifetime prevalence of Bipolar II Disorder of approximately 0.5%.

Course

Roughly 60%-70% of the Hypomanic Episodes in Bipolar II Disorder occur immediately before or after a Major Depressive Episode. Hypomanic Episodes often precede or follow the Major Depressive Episodes in a characteristic pattern for a particular person. The number of lifetime episodes (both Hypomanic Episodes and Major Depressive Episodes) tends to be higher for Bipolar II Disorder compared with Major Depressive Disorder, Recurrent. The interval between episodes tends to decrease as the individual ages. Approximately 5%-15% of individuals with Bipolar II Disorder have multiple (four or more) mood episodes (Hypomanic or Major Depressive) that occur within a given year. If this pattern is present, it is noted by the specifier With Rapid Cycling (see p. 427). A rapid-cycling pattern is associated with a poorer prognosis.

Although the majority of individuals with Bipolar II Disorder return to a fully functional level between episodes, approximately 15% continue to display mood lability and interpersonal or occupational difficulties. Psychotic symptoms do not occur in Hypomanic Episodes, and they appear to be less frequent in the Major Depressive Episodes in Bipolar II Disorder than is the case for Bipolar I Disorder. Some evidence is consistent with the notion that marked changes in sleep-wake schedule such as occur during time zone changes or sleep deprivation may precipitate or exacerbate Hypomanic or Major Depressive Episodes. If a Manic or Mixed Episode develops in the course of Bipolar II Disorder, the diagnosis is changed to Bipolar I Disorder. Over 5 years, about 5%-15% of individuals with Bipolar II Disorder will develop a Manic Episode.

Familial Pattern

Some studies have indicated that first-degree biological relatives of individuals with Bipolar II Disorder have elevated rates of Bipolar II Disorder, Bipolar I Disorder, and Major Depressive Disorder compared with the general population.

Differential Diagnosis

Hypomanic and Major Depressive Episodes in Bipolar II Disorder must be distinguished from episodes of a Mood Disorder Due to a General Medical Condition. The diagnosis is Mood Disorder Due to a General Medical Condition for episodes that are judged to be the direct physiological consequence of a specific general medical condition (e.g., multiple sclerosis, stroke, hypothyroidism) (see p. 401). This determination is based on the history, laboratory findings, or physical examination.

A Substance-Induced Mood Disorder is distinguished from Hypomanic or Major Depressive Episodes that occur in Bipolar II Disorder by the fact that a substance (e.g., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically related to the mood disturbance (see p. 405). Symptoms like those seen in a Hypomanic Episode may be part of an intoxication with or withdrawal from a drug of abuse and should be diagnosed as a Substance-Induced Mood Disorder (e.g., a major depressive-like episode occurring only in the context of withdrawal from cocaine would be diagnosed as Cocaine-Induced Mood Disorder, With Depressive Features, With Onset During Withdrawal). Symptoms like those seen in a Hypomanic Episode may also be precipitated by antidepressant treatment such as medication, electroconvulsive therapy, or light therapy. Such episodes may be diagnosed as a Substance-Induced Mood Disorder (e.g., Amitriptyline-Induced Mood Disorder, With Manic Features; Electroconvulsive Therapy-Induced Mood Disorder, With Manic Features) and would not count toward a diagnosis of Bipolar II Disorder. However, when the substance use or medication is judged not to fully account for the episode (e.g., the episode continues for a considerable period autonomously after the substance is discontinued), the episode would count toward a diagnosis of Bipolar II Disorder.

Bipolar II Disorder is distinguished from Major Depressive Disorder by the lifetime history of at least one Hypomanic Episode. Attention during the interview to whether there is a history of euphoric or dysphoric hypomania is important in making a differential diagnosis. Bipolar II Disorder is distinguished from Bipolar I Disorder by the presence of one or more Manic or Mixed Episodes in the latter. When an individual previously diagnosed with Bipolar II Disorder develops a Manic or Mixed Episode, the diagnosis is changed to Bipolar I disorder.

In Cyclothymic Disorder, there are numerous periods of hypomanic symptoms and numerous periods of depressive symptoms that do not meet symptom or duration criteria for a Major Depressive Episode. Bipolar II Disorder is distinguished from Cyclothymic Disorder by the presence of one or more Major Depressive Episodes. If a Major Depressive Episode occurs after the first 2 years of Cyclothymic Disorder, the additional diagnosis of Bipolar II Disorder is given.

Bipolar II Disorder must be distinguished from Psychotic Disorders (e.g., Schizoaffective Disorder, Schizophrenia, and Delusional Disorder). Schizophrenia, Schizoaffective Disorder, and Delusional Disorder are all characterized by periods of psychotic symptoms that occur in the absence of prominent mood symptoms. Other helpful considerations include the accompanying symptoms, previous course, and family history.

Diagnostic criteria for 296.89 Bipolar II Disorder

  1. Presence (or history) of one or more Major Depressive Episodes (see p. 356).
  2. Presence (or history) of at least one Hypomanic Episode (see p. 368).
  3. There has never been a Manic Episode (see p. 362) or a Mixed Episode (see p. 365).
  4. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
  5. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify current or most recent episode:

If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or features:

  • Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412) Note: Fifth-digit codes specified on p. 413 cannot be used here because the code for Bipolar II Disorder already uses the fifth digit.
  • Chronic (see p. 417)
  • With Catatonic Features (see p. 417)
  • With Melancholic Features (see p. 419)
  • With Atypical Features (see p. 420)
  • With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Hypomanic or Major Depressive Episode, specify the clinical status of the Bipolar II Disorder and/or features of the most recent Major Depressive Episode (only if it is the most recent type of mood episode):

  • In Partial Remission, In Full Remission (see p. 412) Note: Fifth-digit codes specified on p. 413 cannot be used here because the code for Bipolar II Disorder already uses the fifth digit.
  • Chronic (see p. 417)
  • With Catatonic Features (see p. 417)
  • With Melancholic Features (see p. 419)
  • With Atypical Features (see p. 420)
  • With Postpartum Onset (see p. 422)
Specify:
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text RevisionTM. Copyright 2000 American Psychiatric Association. All Rights Reserved.