Many mental health disorders are widely misunderstood, with incorrect or unclear symptoms attributed to them in the public imagination — and bipolar disorders are no exception. Bipolar disorders are not rare; a whopping 2.5 million Americans over the age of 18 are believed to be living with either bipolar I or bipolar II disorder, and that's not including the ones who haven't been diagnosed properly — a major issue, which is deeply tied to misinformation about symptoms. According to a survey conducted by the National Depressive and Manic-Depressive Association, "69 percent of patients with bipolar disorder are misdiagnosed initially and more than one-third remained misdiagnosed for 10 years or more." This is more than just a frustrating mistake for sufferers — incorrectly treating a mental health disorder can have major and far-reaching consequences.
In most people's minds, bipolar disorders are often characterized by rapidly ricocheting moods that go from deep misery to extraordinary elevated self-belief — but in reality, the experiences are far more complex. In fact, the experience of bipolar I disorder is quite different from that of bipolar II — and lack of awareness about that distinction can result in poor diagnoses, ineffective or harmful treatment, and confusion about one's own mental health. Read on to find out more about why bipolar II disorder is frequently misdiagnosed as unipolar depression — and how to know if that kind of misdiagnosis may have happened to you.
Why Bipolar II Disorder Is So Often Misdiagnosed As Depression
First off, technically, people who suffer from bipolar disorders do struggle with a form of depression — or, at least, depressive episodes. People with bipolar disorder, across both types, experience similar periodic levels of low mood.
But the specifics of how low mood plays out in bipolar II sufferers is what can get the disorder mistaken for unipolar depression; while people with bipolar II disorder typically experience more subdued manic episodes than people with bipolar I disorder, their depressive episodes tend to be relatively severe.
These periods of low mood often create misdiagnoses because of their comparative severity. While bipolar I disorder sufferers experience periods of depression and mania, bipolar II sufferers experience "hypomania" instead. We'll go more in depth into the differences between manic and hypomanic states below, but the major difference is one of degree. In other words, due to their lack of severity in comparison with manic states, hypomanic states may not necessarily raise any alarm bells — especially when compared with the severity of a bipolar II sufferer's depressive episodes. The possible result? An incorrect diagnosis of depression.
This is a problem, for one very worrying reason. Many people diagnosed with plain depression are given antidepressants; but increasing scientific evidence shows that, for those with bipolar I or II disorder, antidepressants without any additional medication may actually trigger manic episodes. In a 2013 study published by the Psychiatric Times, 100,000 subjects being treated with medication specifically for major depressive disorder were followed over 2.4 years; 8.2 percent of them demonstrated "mood-switching," and the "[c]umulative risk of mood switching increased up to 24 months of antidepressant treatment." It's now widely accepted that, in people who have unrecognized bipolar disorders, antidepressants, specifically SSRIs, can increase manic episodes. (There's some evidence that this occasionally happens in people dealing only with depression as well, but scientists have yet to figure out exactly why.)
How Is Hypomania Different From Mania?
Depictions of bipolar disorders in the media (for instance, in the worldwide hit Norwegian TV show SKAM, in which a character's new boyfriend has a manic episode and ends up getting arrested), tend to focus on bipolar I. However, the lack of widespread coverage of bipolar II and hypomania symptoms means that they can slip under the radar.
What symptoms differentiate manic and hypomanic states? Mania, the National Institute of Mental Health explains, can involve a huge catalogue of symptoms. People experiencing a manic state may:
"feel very “up,” “high,” or elated; have a lot of energy; have increased activity levels; feel “jumpy” or “wired;” have trouble sleeping; become more active than usual; talk really fast about a lot of different things; be agitated, irritable, or “touchy;” feel like their thoughts are going very fast; think they can do a lot of things at once; do risky things, like spend a lot of money or have reckless sex..."
Hypomania, by contrast, is a milder form. One of the distinctions is duration — mania lasts up to 7 days, hypomania only a few days — but mania is also distinguished from hypomania by certain other severe symptoms. While people going through a hypomanic state may also experience rapid thoughts, heightened confidence, euphoria, restlessness and risk-taking, a difference, as the mental health charity Mind explains, is that people going through a manic state experience it in much more extreme form. Individuals experiencing a manic state may believe that they're invincible or "special," may be completely unable to focus on one thing at once, and may also experience psychosis, delusions, paranoia, a lack of ability to communicate clearly, and/or a tendency to engage in uncontrolled or disastrous actions.
"What really differentiates the two episodes or states from each other," notes the specialist bipolar treatment clinic Bipolar Lab, "is the severity, duration, and from a psychological point of view the experience of each patient. The DSM-IV sets four days as the minimum duration for a hypomanic episode and states that the mood has to be 'clearly different from the usual non-depressed mood'." But, it adds, "the two most important criteria... that refer to functional impairment essentially summarize the major difference between a hypomanic and a manic episode. The hypomanic episode is associated with an 'unequivocal change in functioning that is uncharacteristic of the person when not symptomatic'... and the episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features."
In other words, people experiencing hypomanic states don't necessarily act completely different when they're experiencing an episode, can keep functioning relatively normally, and generally do not engage in behavior that leads to emergency crisis treatment.
How Can You Know If You're Experiencing A Hypomanic State?
Only a medical professional can make a formal diagnosis of bipolar I or bipolar II disorder, or unipolar depression. But if you're beginning to wonder if your depression diagnosis is not quite the whole story when it comes to your mental health, you might want to take note of a few facts about hypomanic states.
According to the Harvard Medical School's Harvard Health Publications, if you're wondering if you have bipolar II disorder, you should pay attention to the following:
"The formal DSM-IV diagnostic criteria for hypomania require at least three of the following symptoms for at least four days: inflated self-esteem or grandiosity; decreased need for sleep; increased talkativeness; racing thoughts or ideas; marked distractibility; agitation or increased activity; excessive participation in activities that are pleasurable but invite personal or fiscal harm (shopping sprees, sexual indiscretions, impulsive business investments, and the like)."
One of the key differences between a hypomanic state and a manic state is also the ability to perceive what's happening to you. People experiencing a manic state often lose the capacity to notice or understand that something is wrong or off with their behavior, while hypomanic states often leave that ability intact.
If, however, you worry that you may not be observant enough, give a list of these symptoms to people who spend quite a lot of time around you, to see whether they can provide their own observations about how you're talking and acting. They may not see any difference, though, so keep note: if you suddenly only need to sleep for 4 hours a night and are incredibly excited by 15 things at once, but don't seem to be impaired in any real way, then it's time to talk to your doctor — you may be among those 69 percent of patients who were misdiagnosed.