Bipolar II is characterized by recurrent episodes of major depression and at least one hypomanic episode. This is the distinguishing feature between bipolar I and bipolar II. In bipolar II, the “ups” never make it to a frank mania or mixed episode. In evaluating people with recurrent depression, one of the questions clinicians must tease out is: Has there ever been a hypomanic episode? On the surface this appears to be a simple question, but many people who suffer from recurrent depression may view hypomanic episodes as times when they actually felt good.
One way to distinguish this is to evaluate whether the individual has ever had a period of time in which they found themselves needing less sleep for days on end, having greatly improved energy and/or being highly productive. If these periods have lasted at least four days, then they meet the criteria for hypomania according to the DSM-IV. But again, it’s important to remember that the DSMIV is a guideline, so if someone has had multiple hypomanic episodes that don’t make the four-day criteria, they could still receive a diagnosis of bipolar II.
It’s also helpful to ask questions specific to the person’s life circumstances and occupation. If she is a truck driver it could be finding out how long she can drive at a stretch without needing sleep (It’s important to ask whether she’s using stimulants). For students it could be habitual all-nighters and week-long cram sessions. For others, including police, firefighters, doctors, and nurses it would be important to ask about periods where they’ve picked up multiple extra shifts and have gone for days on end with little sleep.
It’s important to find out about spending patterns, bankruptcies, problems with credit cards, and gambling. The sexual history may also help elicit a period of hypomania, as many people with depression experience a loss or decrease of libido (sex drive). If someone has periods where they’ve rapidly fallen in love; impulsively gotten engaged, married, or divorced; had an extramarital affair; been uncharacteristically promiscuous; or had a different-for-them sexual liaison, this is significant. Because while this behavior may not rise to the level of symptoms characteristic of mania, it may represent a period of hypomania, and have significant ramifications when selecting what treatments might be most effective for this person.