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BIPOLAR II DISORDER IN ADOLESCENTS

Diagnosis and Treatment of Bipolar II Disorder in Adolescents: A Literature Review

Ghalia T. Mahran

Wake Forest University

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BIPOLAR II DISORDER IN ADOLESCENTS

Abstract

“Adolescents with Bipolar II disorder have a higher rate of co-occurring anxiety disorders

compared with those with Bipolar I disorder, and the anxiety disorder most often predates the

bipolar disorder” (Axelson et al. 2006: Sala et al. 2010). However, because adolescents may have

similar experiences of anxiety, high highs, low lows, and risky behaviors, during puberty it is

oftentimes difficult to diagnose an adolescent with Bipolar II disorder. This manuscript will

provide an analysis and overview of the controversy and difficulties that arise when diagnosing

adolescents, as well as the differences in diagnosing adolescents with Bipolar II disorder, in

comparison with adults. This manuscript will also introduce from the literature and briefly

analyze, treatment options that may differ for adolescents than adults when facing Bipolar II

disorder symptoms. Finally, a discussion based on the literature will be shown to identify

diagnosis, therapeutic approaches and/or treatment options for adolescents with this disorder, as

well as any existing inconsistencies in the literature, and opportunities for further investigation

and research.
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BIPOLAR II DISORDER IN ADOLESCENTS

Diagnosis and Treatment of Bipolar II Disorder in Adolescents: A Literature Review

Background:

Bipolar II disorder is characterized by the Diagnostic and Statistical Manual of Mental

Disorders, fifth edition (DSM5) as “a clinical course of recurring mood episodes consisting of

one or more major depressive episodes and at least one hypomanic episode” (American

Psychiatric Association, 2000 p. 296). Hypomanic episodes within Bipolar II disorder consist of

“inflated self-esteem, decreased need for sleep, more talkative than usual or pressure to keep

talking, flight of ideas or subjective experience that thoughts are racing, distractibility, increase

in goal-directed behavior, and excessive involvement in activities that have a high potential for

painful consequences” (American Psychiatric Association, 2000 p. 296). According to the

DSM5, adolescents living with bipolar II disorder have difficulty maintaining relationships, jobs,

and consistent good grades in school (American Psychiatric Association, 2000).

Significance of Bipolar II Disorder in Adolescents

Bipolar II disorder is a high risk, debilitating disorder that often coincides with one or

more other disorders such as anxiety. Risk of suicide is quite high in bipolar II disorder,

“approximately one-third of individuals with bipolar II disorder report a lifetime history of

suicide attempt” (Novick et al. 2010). “The prevalence rates of lifetime attempted suicide in

bipolar II disorder and bipolar I disorder appear to be similar (32.4% and 36.3%, respectively).

However, “the lethality of attempts, as defined by a lower ratio of attempts to completed

suicides, may be higher in individuals with bipolar II disorder compared with individuals with

bipolar I disorder” (Tondo et al. 2007).

It is challenging to make a proper diagnosis with children and adolescents who may be

experiencing anxiety, depression or irritability periodically but do not have the rest of the
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symptoms attributed to bipolar I or bipolar II disorder. For a diagnosis to occur according to the

DSM5 “the child’s symptoms must exceed what is expected in a given environment and culture

for the child’s developmental stage” (American Psychiatric Association 2000 p. 299). Bipolar II

disorder in adolescents is, however, more common and more severe when diagnosed during

childhood or adolescents, as opposed to adult onset bipolar II disorder according to the DSM5

(American Psychiatric Association, 2000). Bipolar II disorder in adolescents is also significant

because the” prevalence rate of pediatric bipolar II disorder is difficult to establish” (American

Psychiatric Association, 2000). However, “bipolar I, bipolar II, and bipolar disorder not

otherwise specified yield a combined prevalence rate of 1.8% in the U.S. and non-U.S.

community samples, with higher rates (2.7% inclusive) in youths age years or older (Van Meter

et al. 2011). As stated before, bipolar II disorder is also highly significant because suicide risk is

high in bipolar II disorder; “approximately one-third of individuals with bipolar II disorder report

a lifetime history of suicide attempt” (Novick et al. 2010).

Bipolar II disorder also makes it quite difficult for individuals to develop and hold steady

personal and professional relationships. According to the DSM5 “although many individuals

with bipolar II disorder return to a fully functional level between mood episodes, at least 15%

continue to have some inter-episode dysfunction, and 20% transition directly into another mood

episode without inter-episode recovery” (American Psychiatric Association, 2000). This means

for every 5 people with bipolar II disorder 1 person will transition directly into another mood

episode without inter-episode recovery. Comorbidity is also highly prevalent in bipolar II

disorder, especially in adolescents causing this disorder to be all the more difficult to diagnose

and assess. This Manuscript will further explore the review of the literature on bipolar II disorder

in adolescents. It will more specifically, explore difficulties that arise in diagnosing the disorder
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in adolescents, differences between the disorder in adulthood and adolescents and finally

treatment options for individuals living with this disorder.

Method

In my research on the literature I predominantly used Psychinfo, Science direct and

ERIC. I used keywords in the Boolean mode such as “bipolar II disorder in adolescents”,

“comorbidity in bipolar II disorder”, bipolar II disorder in teens”, “bipolar II treatment in teens”,

“bipolar II treatment in adolescents,” “bipolar II in adolescents and adults”, and “bipolar II

disorder”. I predominantly tried to only use articles from 2007 and beyond however, I do have

one that is older than 2007 because I believe much of the information in that article is still

relevant today as I found in much of my more recent literature. I excluded articles that were

based mainly on just diagnoses on adults and were heavily focused only on treatments for adults,

and I also tried to exclude general articles that only based their research and/or study on adults.

However, I did use some of these in order to give a more accurate view on the differences

existing between adults and adolescents living with bipolar II disorder within the parameters of

diagnosis and treatment.

I mainly focused my research on literature that would show the differences between

adolescents and adults managing bipolar II disorder. The reason I chose to also heavily include

“comorbidity” in the databases was because I found that in much of the literature on adolescents;

I found a lot on comorbidity as a main factor of why it is difficult to diagnose bipolar II disorder.

I thought this was a crucial point to understand and touch upon for the purposes of this paper. I

also thought to include it because comorbidity in bipolar II disorder also causes for some very

different treatment plans across the board whereas other disorders that lack comorbidity might

have more basic treatment options counselors and doctors may stick to.
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Results

DSM5 Criteria:

In order to meet the criteria of Bipolar II disorder, it is necessary for a current or past

hypomanic episode and for a current or past major depressive episode to exist. A hypomanic

episode, according to the DSM5 is categorized by satisfying two criteria, being:

“A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and

abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and

present most of the day, nearly every day.

B. During the period of mood disturbance and increased energy and activity, three (or more) of

the following symptoms have persisted (four if the mood is only irritable), represent a noticeable

change from usual behavior, and have been present to a significant degree:

1. Inflated self-esteem or grandiosity

2. Decreased need for sleep (e.g., feels restless after only 3 hours of sleep)

3. More talkative than usual or pressure to keep talking

4. Flight of ideas or subjective experience that thoughts are racing

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as

reported or observed

6.Increase in goal-oriented activity (either socially, at work or school, or sexually) or

psychomotor agitation

7. Excessive involvement in activities that have a high potential for painful consequences (e.g.,

engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).”

(American Psychiatric Association, 2000 p. 296).

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A major depressive episode would include “5 or more of the following symptoms present

during the same 2-week period as a hypomanic episode and represent a change from previous

functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or

pleasure. Symptoms that can be clearly attributed to a medical condition should be excluded.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective

report (e.g., feels sad, empty or hopeless) or observation made by others (e.g., appears

tearful). (Note: In children and adolescents can be irritable mood.)

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,

nearly every day (as indicated by either subjective account or observation).

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5%

of body weight in a month) or decrease or increase in appetite nearly every day. (Note: In

children consider failure to make expected weight gain).

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by others; not merely

subjective feelings of restlessness or being slowed down).

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)

nearly every day (not merely self-reproach or guilt about being sick).

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by

subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a

specific plan, a suicide attempt, or a specific plan for committing suicide” (American

Psychiatric Association, 2000).

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Diagnosis and Treatment

Bipolar II disorder has a plethora of aspects to take into account when diagnosing an

individual, and makes specific differentiations when diagnosing children and adolescents,

making it quite difficult to diagnose, especially given the high chance of comorbidity. The

DSM5 also has an entire section on small notes on how certain other disorders may look like

bipolar II disorder but can be something else such as responses to a significant loss like

“bereavement, losses from a natural disaster, serious medical illness, and financial ruin”

(American Psychiatric Association, 2000).

According to Wilkinson, Taylor and Holt (2002), “Bipolar disorder was rarely diagnosed

in adolescence due to developmental issues and overlapping symptoms with other disorders,

diagnosing bipolar disorder is often a confusing and complex process” (p. 348). The American

Academy of Child and Adolescent Psychiatry reports that up to one third of the children and

adolescents with depression in the United States may actually be suffering from the onset of

bipolar II disorder. One third of the children and adolescence diagnosed with attention deficit

hyperactive disorder may be suffering from an onset of bipolar disorder because of the

prevalence bipolar I and II disorder have with coexisting with one or more disorders, especially

for bipolar II disorder. “School absenteeism, poor academic performance, impaired social

functioning, and a greater risk of substance abuse are associated with bipolar disorder in

adolescence” (Axelson et. al 2003).

Bipolar disorder is a serious disorder that if not noticed or left untreated can lead to

suicide attempts, suicide, hospitalizations and a plethora of problems within the home and school

of the individual. According to Wilkinson, Taylor and Holt (2002), “treatment of the bipolar

adolescent is best accompanied by utilizing a team approach that includes the services of a
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mental health counselor and a board-certified child psychiatrist. Unfortunately, medications do

not cure the underlying disorder, but can contribute to improvements in behavior and emotional

stability” (p.354). Psychotherapy is important for adolescence with bipolar disorder along with

extremely cautious and careful administration of drugs, as certain anti-depressants can contribute

to or invoke a manic episode. Cognitive behavioral therapy is also thought to work well because

of the implications it has with carrying daily mood and thought patterns keeping the client

accountable.

Yet another reason bipolar II disorder is so difficult to diagnose is because bipolar II

disorder is not just genetic, an individual can adopt bipolar II disorder even later on in life due to

a traumatic experience, or from just being more susceptible to having an unstable mood.

Adolescents often have unstable moods due to going through puberty and changes in their

hormones and in their lives, making it difficult to differentiate whether there is a disorder coming

about and whether it is bipolar II disorder or not. “Mood instability is the experience of intense,

rapidly shifting emotional states during mood episodes as well as during remission” (Henry et.

al., 2008). “Examining mood instability is especially relevant among children and adolescents

with mood disorders. Childhood on-set bipolar disorder is associated with a more severe course

of illness than adult-onset bipolar disorder, including more polarity switches, longer periods with

subthreshold symptoms, more mixed symptoms and increased suicidal behaviors” (Birmaher and

Axelson, 2006).

Bipolar II disorder is also more often than not “associated with one or more co-occurring

mental disorders, with anxiety disorders being the most common. Approximately 60% of

individuals with bipolar II disorder have three or more co-occurring mental disorders; 75% have

an anxiety disorder; and 37% have a substance use disorder” (Angst et al. 2010). As mentioned
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earlier anxiety disorder in adolescents also often predates the onset of bipolar II disorder but

often goes unnoticed for much time as just another symptom of anxiety. Identifying bipolar II

disorder is difficult and the DSM5 makes many notes to try to cover all the gaps where it can

possibly be something else especially for adolescents, who can sometimes just be irritable or in a

mood because of age or other factors. In much of the literature the best form of treatment was

tied for adults and adolescents being cognitive behavioral therapy and psychotherapy but

unfortunately oftentimes this only serves to manage symptoms as bipolar and bipolar II disorder

do not currently have any cure.

Discussion

This manuscript attempted to show the challenges in diagnosing children and adolescents

with bipolar II disorder as opposed to adults. It also attempted to show the different sorts of

counseling available for individuals living with bipolar II disorder. However, this manuscript can

only cover so much being that bipolar II disorder is such a broad and still highly researched

disorder with new information coming about every day. Much of the literature covered was quite

specific and only covered bits and pieces of this disorder presumably because of the broad array

of aspects it has. Bipolar II disorder as stated above is a very dangerous disorder that effects

many adults, adolescents, and their families because of high suicide rates, difficulties with

treatment and diagnosis and expensive and lengthy hospital stays. Some gaps in the literature are

that there wasn’t much of a different, criteria on diagnosing a child or adolescent rather than an

adult, other than the DSM5’s attempt to make small notes in order to differentiate adults and

adolescents. It would be interesting and worthwhile research to see a new, criteria come about

for children and also for adolescents.

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