Bipolar I vs. Bipolar II: Understanding the Similarities & Differences

Similarities Between Mania & Hypomania

Episodes of mania (Bipolar I) and hypomania (Bipolar II) share the same basic symptoms, except for psychotic features, which can only be present in mania. The common symptoms in mania and hypomania include euphoric and expansive mood; or dysphoric mood, which is marked by high levels of irritability and agitation.

These symptoms can also include:

• Grandiose self-image
• Decreased need of sleep
• Rapid thoughts
• Pressured speech
• Distractibility
• Anger
• Increased energy and goal-directed behaviors
• Severe impulsivity leading to high-risk behaviors

Differences Between Mania & Hypomania

Here is a breakdown for what makes mania and hypomania different:

Mania: Bipolar I

An episode of mania is marked by:

• At least a one-week period (unless hospitalization is necessary)
• Severe enough to cause marked occupational and social impairments, hospitalization (harm to self or others), and/or bipolar psychosis
• Patient history is sufficient for diagnosis
• Hypomanic episodes can occur in patient with existing Bipolar I

Hypomania: Bipolar II

An episode of hypomania involves:

• At least four consecutive days
• Unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic
• Must have been observed by others as uncharacteristic of the individual
• If Bipolar II shows any history mania, then diagnosis is changed to Bipolar I¹

Diagnosis of Bipolar I

Bipolar I Disorder is marked by severe manic episodes, what some people call “full-blown” mania. This is generally considered the worst form of bipolar disorder, but a better understanding of bipolar II may challenge that idea. In many cases, Bipolar I Disorder can be easier to diagnose than Bipolar II. Why? Because only one manic episode in a person’s history—current or past—is required for the diagnosis.

However, finding that manic episode in the person’s history and making sure it’s not indicative of another type of mental disorder may indeed be a challenge. But again, only one episode is needed for the diagnosis; and depression, though evident in many people with Bipolar I, is not needed for the diagnosis.

Although Bipolar I may be easier to diagnose, it’s often harder to treat over the course of the illness. Someone with Bipolar I will suffer longer or sometimes more intense episodes of manic symptoms than with Bipolar II, and therefore will experience more consequences in a shorter stretch of time.

Psychotic symptoms, such as hallucinations or delusional thinking, can only be present in Bipolar I. And because of the often wild, impulsive behaviors, mania in Bipolar I tends to get more attention than hypomania in Bipolar II. However, people with Bipolar I may avoid or be denied care for any number of reasons, despite the obvious need.

Diagnosis of Bipolar II

Bipolar II Disorder is marked by hypomanic episodes that are of shorter duration and sometimes less intensity than manic episodes. That’s why it’s known as hypomania, meaning literally “under mania.” The same manic symptoms as in Bipolar I might exist, but the hypomanic episode tends to last at least four days instead of the minimum seven days in Bipolar I. Thus, it can do somewhat less damage to the individual’s life, at least in the shorter term. Depressive episodes, however, can be just as severe—or even worse—than what occurs in Bipolar I Disorder.

Moreover, those with hypomanic episodes may be harder to diagnose. They may be viewed as symptomatic of active people who are simply stressed out by life, or people who have another kind of mental health problem such as anxiety or a personality disorder. However, because Bipolar II patients tend to be highly productive individuals, and generally more functional than Bipolar I patients, they may not consider mood regulation to their benefit.

People around the Bipolar II person may tend to disagree, however. That’s because the very definition of a hypomanic episode indicates a clear change in the person’s behavior that is uncharacteristic to that individual when not hypomanic. And, importantly, that change in behavior is easily noticed by others in that person’s daily life.

An Updated Look at Bipolar II Disorder

Bipolar II Disorder has traditionally been thought of as a lesser form of the condition compared to Bipolar I. The reason for this difference is how a manic episode, which defines Bipolar I, can be longer in duration and have more severe consequences within a particular episode. A hypomanic episode, which is a characteristic of Bipolar II, tends to be shorter in duration and generally less consequential in its effects. But the impression that Bipolar II is a lesser form of the overall condition of bipolar disorder is often misleading.

First of all, simply looking at a typical manic episode and a typical hypomanic episode in a side-by-side comparison does not tell the full story of how devastating an overall Bipolar II Disorder can be. To clarify, Bipolar I is diagnosed if at least one manic episode is in that person’s history, and the assessing clinician needs only a subjective report from that individual for the diagnosis to be appropriate. There does not need to be any history of depression.

In Bipolar II, the diagnosis fits if there is a history of one hypomanic episode and one episode of major depression, and the effects of the condition should essentially change how that person is perceived by others around him or her. In other words, at least one person close to that individual would agree that there is a noticeable shift in his or her typical characteristics during hypomania.

Because of the more objective input from family or associates around that person, the full effects of hypomania are often uncovered. And in those instances, a clearer picture of hypomanic consequences can reveal substantial impairments to occupational and social functioning.

Without a history of depression, a person cannot be considered as having Bipolar II. Someone having occasional hypomania by itself does not qualify for Bipolar II Disorder, so it’s a moot point from a diagnostic perspective that hypomania is always a bad thing. But because the depressive episodes in Bipolar II can be very severe—even suicidal—it’s mistaken to believe that Bipolar II is a lighter form of the overall condition.

Treatment of Bipolar II

To be clear, there are no comparisons in the duration and severity of depressive episodes between Bipolar I and II, so it’s not unusual for Bipolar II depression to be quite devastating and also defy some of the more traditional forms of treatment for non-bipolar major depression.

For example, as with Bipolar I, patients with Bipolar II Disorder should not be treated with typical antidepressant medications, at least not without an additional medication to prevent hypomania. That’s because antidepressants can induce manic or hypomanic episodes in patients with either form of bipolar disorder.²
The approach must be towards overall mood stabilization, which can be more complicated from a medical standpoint.

If there is any advantage of having Bipolar II over Bipolar I, it can be somewhat easier to treat when it’s correctly identified. But because it’s generally more difficult to assess, people with Bipolar II can, on average, go many more years undiagnosed than their Bipolar I counterparts. As a result, they may suffer consequences over a longer period, again making the side-by-side comparisons of Bipolar I and II misleading. And because it may appear more subtly, hypomania can easily be misidentified as other conditions, including anxiety, ADHD, OCD, or a personality disorder, further delaying effective treatment interventions.

The Severity of Bipolar II Disorder

The cumulative effect of hypomanic episodes over time can certainly impair a person’s functioning. But what many people with Bipolar II Disorder will say is that the depressive episodes are what really drives them to seek treatment. In the depressive aspect of Bipolar II, one’s mood can become severely reduced, dark, and demoralizing. So while a person with Bipolar II Disorder may have fewer consequences in the short-term, overall life functioning usually deteriorates over the long-term as a result of untreated hypomanic and major depressive episodes.

While people with Bipolar II Disorder may appear more functional compared to their Bipolar I counterparts, all the same consequences can still prevail. People with Bipolar II can become suicidal just as those with Bipolar I. They also may suffer from addiction. One study showed that almost half of those with Bipolar II Disorder had a co-occurring substance use disorder.³

This suggests that many people who enter rehabilitation for drug or alcohol addiction may have Bipolar II Disorder and will require good assessment and treatment for mood swings to maintain a healthy sobriety moving forward in their lives.

So Bipolar II Disorder should not be simply considered as a minor version of bipolar disorder, but instead as a different form of the condition, with unique characteristics and complications. The good news about Bipolar II Disorder is when accurately diagnosed, it can be safely and effectively treated and well-managed over the individual’s lifetime.

Can Bipolar II Disorder Be Beneficial?

The concept of Bipolar II Disorder developed over time and appears to have been a response to many individuals who have demonstrated exceptional creative and leadership abilities. Some people believed to have had Bipolar II Disorder include Abraham Lincoln, Winston Churchill, and Theodore Roosevelt.⁴ Also, numerous legendary authors, actors, and inventors have presented with periods of energy and productivity, but also with episodes of depression, suicidal thoughts or actions, and related drug and alcohol abuse.

While there may be controversy about assessing people without all available data, learning about how some celebrities from past and present have suffered with mood swings can help people today in understanding their own bipolar experience. And in particular, the concept of Bipolar II Disorder as a “beneficial disorder” may lead some to avoid treatment, especially if they fear a loss of creative ability. Technically, if someone only has had hypomanic episodes and never has had mania or depression, that person does not have a bipolar disorder.

The hypomanic episodes may still cause some disruption in the person’s relationships failing from bipolar disorder and other aspects of life, but it still would not by itself rise to the level of a clinical disorder. They may well function productively and with the sort of creativity that would be the envy of others. But again, things can turn in that person’s life if an episode of major depression takes hold. At that point, a diagnosis of Bipolar II Disorder would be appropriate, and treatment would be needed to achieve mood stability.

Hypomania & Creativity

Hypomania alone can support hyper-creativity, but it’s usually associated with having more intense positive emotions, which stimulate the overall creative process. Recall for a moment that hypomania and major depression are needed in the person’s history to be diagnosed with Bipolar II Disorder. People who move in and out of the hypomanic mood zone, without ever moving into the major depression zone, can likely sustain periods of hyper-creativity during their lifetimes.

But people who suffer periods of intense negative emotions, such as in major depression, often find their superior sense of creativity unsustainable for the long haul, since various factors necessary to complete projects easily fall apart. For people who’ve suffered Bipolar I Disorder, hypercreativity in the manic zone can be grandiose and overly idealized beyond the limits of the person’s skill level or social acceptability. This is even truer in the psychotic mania zone, where the individual may be in a delusional state when talking about or acting on hyper-creative ideas.

In understanding the creativity issue in bipolar disorder, it’s important to note how people often confuse the intense rise of manic energy with a sudden surge of creative skill. But this really isn’t how creativity works. Indeed, someone flush with energy may feel creative, with boundless excitement to “get things done;” but this can also lead to a disorganized and reckless path, which the person in mania will brazenly justify through denial.

It’s necessary to assess one’s own talents that may be seen as raw or innate. Essentially, they are possible desires or pursuits that have some genuine attachment to that person’s life and experience. An honest appraisal of one’s own abilities, with the support necessary to execute real effort towards achievement, is best accomplished through treatment. This way a person with bipolar disorder can steadily harness innate abilities following mood stabilization, and without the delusion or excessive strain of mania.

After understanding talents and desires in the creative pursuit, it’s necessary to develop an organized strategy. Energy alone is not creativity. It’s simply the body’s fuel that’s being used up at an accelerated pace. The concept of the creative process acknowledges the need for a developing skill set and a formulated plan using the plotting of time as an essential ingredient. It also requires ongoing learning and skill-refinement towards an appropriate level of success. This is best achieved through bipolar therapy in the post-stabilization phase when medications and overall treatment is set for long-term maintenance.⁵

Treatment for Bipolar I & Bipolar II Disorders

Many different fears can hold people back from seeking proper treatment. These include concerns about medications and difficulty accepting a lifelong mental illness. Many people with bipolar often fear giving up the great feelings that accompany a manic or hypomanic episode. As a result, the defense of denial is an expected aspect of bipolar disorder. It’s especially important for people with bipolar to feel in control of the energetic and hyper-creative parts of mania as an offset to the desperate, hopeless feelings of their depressive episodes.

For these reasons, it can be helpful to understand the treatment choices available and what to expect under the different circumstances in each individual situation.

Bipolar disorder treatment can take place in a variety of settings depending on the needs of the individual, especially when considering the possible imminent threat of harm or extent of any co-occurring substance abuse. Although hypomania in Bipolar II Disorder doesn’t usually require hospitalization, the level of depression in Bipolar II can certainly create the need for intensive psychiatric care. And for that matter, neither Bipolar I or II is automatically safe from suicidal feelings or actions that require a higher level of professional supervision.

With or without hospitalization or residential treatment, bipolar disorder can often be managed well in the outpatient setting. This is especially true of those whose mood is more stable, and in the case of co-occurring substance abuse, sobriety is also adequately managed.

Medication for Treating Bipolar Disorder

Overall treatment decisions can vary depending on the type of bipolar disorder presented. When it comes to medications, any of the typical bipolar meds can be used for either Bipolar I or II.

These medications can include:

• Lithium
• Anticonvulsants / antiseizures / antiepileptics
• Antipsychotics
• Antidepressants*
• Anti-anxiety medications

*Remember that antidepressants alone can induce a manic or hypomanic episode. When it comes to bipolar treatment, these meds are typically paired with another medication that would prevent a manic or hypomanic episode.

Antipsychotic medications can be appropriate for Bipolar I Disorder, especially if psychotic symptoms are present. However, some people with Bipolar II Disorder may be prescribed an antipsychotic as well.

For example, a doctor may prescribe a more sedating antipsychotic if sleep was impaired in a Bipolar II patient. Or perhaps someone with Bipolar II has an exceedingly difficult case of major depression, and the treating doctor prescribes an antipsychotic to make sure medications won’t make the depression worse or trigger a hypomanic episode. These meds can be weighted more towards depression relief and management for bipolar disorder, especially for Bipolar II, when depression is particularly resistant.

Medications prescribed for either type of bipolar disorder follow a patient’s current or most recent mood episode.⁶
If the current or most recent episode is manic or hypomanic, the medications may be more weighted towards reducing the manic symptoms. If depression is current or more recent, something more antidepressive might be prescribed. As mood becomes more stable, medications are usually set for long-term maintenance.

Therapy for Treating Bipolar Disorder

While medications are used to stabilize mood from a medical perspective, psychotherapy is important in the treatment of bipolar disorder both during and following stabilization. It’s not simply, “Take your meds and you’ll be fine.” Instead, therapy for either type of bipolar disorder assists in repairing the damage caused by the consequences of the disorder and adapting to a new emotional life without extreme mood events. Cognitive behavioral therapy for bipolar disorder is the most widely used talk therapy for treating the disorder.

Long Term Treatment & Outlook for Bipolar

Living in a post-stabilization existence is not always easy. Take, for example, the loss of the perceived benefits of mania or hypomania in creative output.For many bipolar patients, it’s understandable that medications may seem to blunt their energy and motivation in the early stabilization phase.

Yet, a complete and sustainable creative process can emerge through post-stabilization treatment objectives. Long-term bipolar therapy is usually geared to prevent depression, which impairs creativity, no matter the situation of any individual. It’s important to remember that bipolar medications have neuroprotective effects from the potential damage of untreated mood swings.⁷ Over time, these mood swings can cause neurological impairments, which would deteriorate the creative process. So, to maintain and enhance the creative process, full participation in bipolar treatment can keep the brain in good shape for a long, productive lifetime.

Family therapy, education, and support is also beneficial for long-term treatment success in any expression of bipolar disorder. Since Bipolar II is often less noticeable, there can be negative effects in relationships and social functioning that have taken a long time to manifest. It’s important for loved ones to be a part of the treatment process where appropriate to heal the various consequences brought on by bipolar disorder.