Understanding Bipolar 2

Sometimes happiness and despair are two sides of the same coin. Just as depression drags people into the abyss, its opposite – mania – can propel them to unimagined heights. They feel great when they get sick and usually experience the crash into depression after some time.

Diagnosis and frequency

It’s hard to say how common bipolar affective disorder actually is. There are several reasons for this. On the one hand, the diagnostic criteria have been changed again and again, which has led overall to the fact that bipolar disorders are diagnosed more frequently today than in the past and that even milder courses meet the diagnostic criteria. (…) On the other hand, people are more likely to seek medical help in a depressive phase and are then often diagnosed as unipolar depressive. It can be assumed that about 4 percent of the population will develop bipolar affective disorder once or more during their lifetime. (…) When manic and depressive episodes alternate, one speaks of a bipolar disorder. There are two different forms of bipolar disorder (…). If both the depressive phases and the manic phases are fully developed, one speaks of a bipolar I disorder. However, there are also forms in which the depressive phases are fully developed, but the manic phases only occur in a weakened form. This is referred to as Bipolar II disorder. Common to all affective disorders is that between the depressive or manic phases of the illness, longer intervals without symptoms are usually experienced, during which the affected person feels relatively well and even professionals or relatives hardly notice any effects of the illness on them. For mania to be diagnosed, at least three of the following symptoms must be present:

  • Decreased need for sleep (…)
  • Increase in activity (…)
  • Urge to talk (…)
  • Increased self-esteem or ideas of grandeur (…)
  • Impaired judgment (…)
  • Racing thoughts or flight of ideas (…)
  • Psychotic symptoms (…)


Different models try to explain the development of bipolar disorders. It is quite obvious that an illness with such different phases cannot be traced back to a simple cause. It is assumed, as with most mental illnesses, that genetic, biological and psychosocial causes interact. Genetic predisposition appears to be more pronounced in bipolar than in unipolar disorders. Probably inherited is a certain predisposition to react to stresses with a rapid destabilization of biological rhythms and thus to a certain extent to get easily out of step. (…) Another biological explanation of mania could be a demonstrable overexcitability of the affected persons. (…) Psychological explanatory models tend to look for the cause of a bipolar disorder in the way affected persons experience and evaluate their everyday life. There is evidence that bipolar personalities fluctuate between the extremes, so to speak, even outside acute phases of illness. (…) Another psychological explanatory model (…) assumes that people with bipolar disorders are particularly concerned with fulfilling social roles and meeting the expectations of others. (…)

Help through medication

Drug therapy plays a central role in bipolar disorders. Besides antidepressants against the depressive phases, so-called phase prophylactics are often used, e.g. lithium. They help to mitigate extreme mood swings and stabilize biological rhythms. (…) However, the disease cannot be managed with medication alone. Those affected can do a great deal to cope with their illness by paying attention to its early warning signs, by taking countermeasures in good time and by adhering to fixed rhythms and temporal structures. And professionals can help sufferers find their center and thus keep a safe distance from the extremes of mania and depression.

Helpful handling

Regulated routines, regular rhythms, adequate sleep, and balanced demands can protect against derailing into mania. Yet many people, especially those with bipolar disorder, equate the realm of center, regularity and balance with boredom. In stable phases, people with bipolar disorder sometimes feel they are not really living up to their potential, not making enough of themselves and their lives. They have the impression that only in mania they really use their possibilities. In mania, they have come to know extreme resilience, being able to get an enormous amount done in a short amount of time, and needing little sleep. They find it difficult to settle for a lighter workload and to schedule sufficient time for sleep. Professionals should therefore work with the affected persons to evaluate moderate housekeeping with one’s own forces as a positive, desirable target state. If the focus is always on avoiding crises and manic episodes, this is not very desirable or motivating for the person concerned in the long term. If, on the other hand, one’s own center is associated with positive feelings such as balance, lightness, joie de vivre and confidence, it appears to be a desirable goal. One’s own center can be defined as the state in which one feels in balance. Affected people can recognize this state by the following points, among others:

  • One feels secure.
  • The state consumes less energy than mania.
  • The feelings are more pleasant, less extreme.
  • The experience is more complete: negative feelings are also perceived, not only positive ones.
  • You are more with yourself and feel an inner calm.
  • You don’t overestimate yourself so often, make fewer mistakes and don’t forget so much, but can complete things.

Help for self-help

Crisis plan and early warning signs

A crisis plan is particularly useful here, in which those affected note their early warning signs as concretely as possible, as well as relief and support options with which they can react to the first signs of crisis. (…) You can use the following criteria to distinguish a normal mood swing from an incipient mania:

  • Normal mood swings subside after some time, at the latest after several days.
  • Clear triggers can be identified for normal mood swings.
  • Normal mood swings usually disappear if care is taken to reduce stress. (…)

When early warning signs of mania appear, it is important to quickly adopt appropriate self-help strategies. (…) Here are a number of ways to establish structure and rhythm in the lives of those affected:

  • Affected persons should closely monitor their sleep and, for example, keep a sleep diary.
  • Medication should be adjusted quickly in consultation with the doctor.
  • Affected persons should record and regulate their physical condition, which means allowing themselves rest breaks, making sure that they eat and drink regularly, etc. It is helpful to protect oneself from stimuli.
  • It is helpful to protect oneself from sensory overload, e.g. by limiting television and Internet consumption, canceling appointments, withdrawing and engaging in quiet activities such as walks or relaxation exercises.
  • Planning activities well also provides support and structure. This is often achieved with a daily or weekly schedule. (…)
  • It only causes new problems when people neglect their duties. In connection with a daily or weekly plan, a so-called A/B list is helpful: Tasks are divided into duties that must be done (A) and pleasant things (B). The person concerned should try to do the A tasks first and then indulge in the B tasks. (…)
  • Impulsive actions, especially uncontrolled spending of money, can cause many problems in mania. The 24-hour rule can help against this. Affected people make a kind of agreement with themselves: If they feel a strong urge to do something, for example to buy something at all costs, they first allow 24 hours to pass before they possibly put their plan into action. It is best for the person affected to put this rule in writing.
  • Sufferers should steer clear of alcohol and drugs. If a new crisis is imminent, sufferers should not hesitate to go to the doctor or, if necessary, to a clinic.
  • For those affected, fixed rhythms and structures are a chance to avert the onset of a manic episode. It is helpful if those affected are supported by others, for example by professionals or relatives who go through the daily or weekly plan with them, remind them of the 24-hour rule or draw up the A/B list with them.


  • Download the S3 guideline on the diagnosis and treatment of bipolar disorders (long version) as a PDF file.
  • Bock, T.; Koesler, A. (2005): Bipolar disorders. Understanding and treating mania and depression. eBook, Psychiatrie Verlag.
  • Bräuning, P. (2009): Living with bipolar disorder. Manic-depressive: knowledge that does you good. Trias Verlag.
  • German Society for Bipolar Disorders (DGBS) (2016): Bipolar disorders – A disease with two faces download as PDF file.
  • German Society for Bipolar Disorders (DGBS) (2017): Mania and depression – The bipolar disorder, guidebook for affected persons and relatives download as PDF file.
  • Wolkenstein, L.; Hautzinger, M. (2014): Dealing with bipolar patients. Basic knowledge, Psychiatrie Verlag.


  • ICD code affective disorders
  • Bipolar forum of the German Society for Bipolar Disorders.
  • German Society for Bipolar Disorders (DGBS).

In bipolar disorder (formerly known as manic-depressive illness), depression and mania (or a less severe form of mania called hypomania) alternate in phases. Mania is characterized by exaggerated physical activity and extreme elation out of proportion to any preceding positive event.

  • Familial predisposition plays a role in bipolar disorder.
  • Phases of depression and mania may occur separately or together.
  • Sufferers have one or more periods of excessive sadness and lack of interest in life, and one or more periods of elation, excessive energy, and often irritability, with periods of relatively normal mood in between.
  • Doctors make the diagnosis based on the pattern of symptoms.
  • Medications that stabilize mood, such as lithium, and certain anti-seizure medications can be helpful, as can sometimes psychotherapy.

Most bipolar disorders can be classified as follows.

  • Bipolar I disorder: Individuals have had at least one marked manic episode (making normal daily life nearly impossible or accompanied by delusions) and usually depressive episodes.
  • Bipolar II disorder: Affected individuals had major depressive episodes, at least one less severe manic (hypomanic) episode, but no marked manic episodes.

The exact cause of bipolar disorder is not known. Familial predisposition probably plays a role in the development of bipolar disorder. It is also possible that the regulation of certain substances produced by the body, such as the neurotransmitters norepinephrine or serotonin, does not function properly. (Neurotransmitters are substances needed for nerve cell communication). Bipolar disorder sometimes begins after a stressful event or a new phase is triggered by such an event. However, no cause-and-effect relationship has been demonstrated. In bipolar disorders, symptomatic phases alternate with virtually symptom-free phases (remissions). The phases last from a few weeks to 3 to 6 months. The cycles-the time from the onset of one phase to the onset of the next-vary in length. Some people have phases less frequently, perhaps only a few during their lifetime, whereas others experience four or more phases per year ( called “rapid cycling”). Despite this wide variation, cycle length is relatively constant among individuals. The phases are composed of depression, mania, or the less severe hypomania. Very few people fluctuate back and forth between mania and depression during each cycle. For most, one of the two predominates to some degree. The phases of mania end more abruptly than the phases of depression and are typically shorter, usually a week or longer. Sufferers are exuberant, markedly more energetic, and joyfully excited or irritable. Some are overly self-conscious, act or dress extravagantly, sleep little and talk more than usual. Their thoughts race. They are easily distracted and continually switch from one topic or undertaking to another. They pursue one activity (e.g., risky business ventures, gambling, or dangerous sexual behavior) after another without thinking of the consequences (e.g., loss of money or injury). However, the sufferers often think that they enjoy the best mental health. They themselves have no insight into their condition. This lack of insight plus the high potential for activity can make them impatient, intrusive, pushy, and easily agitated when contradicted. Consequently, they may have problems with social relationships and feelings of being treated unfairly or persecuted. Some sufferers have hallucinations and hear and see things that are not there. A manic psychosis Is an extreme form of mania. Sufferers have symptoms of psychosis similar to those seen in schizophrenia Schizophrenia is a mental disorder characterized by a loss of grip on reality (psychosis), hallucinations (usually hearing voices), delusions, thought disorders, and… Learn more occur. They may suffer from delusions of grandeur, such as believing they are Jesus. Others feel persecuted, for example, by the FBI. There is a marked increase in activity. Sufferers may run around, scream, curse, or chant. Physical and mental activity can be so feverish that coherent thinking and behavior can be completely lost (delirious mania), leading to extreme exhaustion. Those affected in this way require immediate treatment. Hypomania is not as severe as mania. Sufferers feel cheerful, need little sleep, and are mentally and physically active. For some people, hypomania is a very productive period. They have a lot of energy, feel creative and confident, and often function well in social situations. They may want to remain in this pleasant state. Other individuals with hypomania, however, are easily distracted and excitable, which occasionally leads to outbursts of anger. They often make commitments they can’t keep or start projects they can’t finish. Their mood changes very quickly. They may be able to recognize such effects and feel bothered by them, as do those around them. When depression and mania or hypomania occur in the same phase, sufferers may become tearful in the midst of a high, or their thoughts may begin to race in the midst of depression. Often, sufferers go to bed in the evening with depression and feel joyfully excited and energized upon awakening. The risk of suicide is particularly high during mixed episodes.

  • Examination by the doctor
  • Occasional blood and urine tests to rule out other conditions

Diagnosis of bipolar disorder is based on the particular list of symptoms (criteria). However, people with mania may not be able to describe their symptoms because they think there is nothing wrong with them. Therefore, doctors often need to interview other family members. People with mania and their family members can use a short questionnaire to help assess their risk for bipolar disorder (see Affective Disorder Questionnaire). Patients are also asked if they are thinking about suicide in any way. Doctors will determine if they are currently in a phase of mania or depression so that proper treatment can be given.

  • Medication
  • Psychotherapy
  • Education and support

Severe mania or depression often requires inpatient treatment. Even if the mania is less severe, individuals need to be hospitalized if they are suicidal, have attempted to harm themselves or others, are unable to care for themselves, or have other severe problems (e.g., alcohol consumption Alcohol (ethanol) makes people depressed. Rapid or regular consumption of large amounts of alcohol can lead to health problems such as organ damage, coma, and death. Genetic and personal… Learn More or Other Substance Use Disorders Substance Use Disorders Substance Use Disorders are generally associated with patterns of behavior in which individuals continue to use a substance even though it causes them problems. These substance… Learn More ). Most patients with hypomania can be treated as outpatients. Treating people with rapid cycling is more difficult. Without treatment, bipolar disorder recurs in most people with the disorder. Treatment may include the following:

  • Medications to stabilize mood (mood stabilizers) such as lithium and some antiepileptic drugs.
  • Antipsychotic
  • Certain antidepressants
  • Psychotherapy
  • Education and support

Lithium can relieve symptoms of mania and depression. Lithium can prevent mood swings in many people with bipolar disorder. Because lithium takes 4 to 10 days to work, a faster-acting medication such as an antiepileptic or a newer antipsychotic (second generation) is often given to control agitated thoughts and activities. People with a family history of typical bipolar disorder respond better to lithium. Lithium can cause side effects. It can cause drowsiness, confusion, involuntary tremors, muscle twitching, nausea, vomiting, diarrhea, thirst, frequent urination, and weight gain. It often worsens acne or psoriasis. However, these side effects are usually short-lived and often subside when the doctor adjusts the dose. Sometimes it is necessary to stop taking lithium because of side effects that subsequently disappear. When the level of lithium in the blood is very high, there is Lithium toxicity. Very high levels of lithium in the blood may cause persistent headaches, mental confusion, drowsiness, seizures, and cardiac arrhythmias. Toxicity is more likely to occur in the following people:

  • Elderly people
  • People with impaired kidney function
  • People who have lost a lot of sodium through vomiting, diarrhea, or use of diuretics (which stimulate the kidneys to excrete more sodium and water in the urine)

Women who want to become pregnant must stop taking lithium because lithium can cause heart defects in a developing fetus in rare cases. Antiepileptic drugs, Valproate and Carbamazepine, act as mood stabilizers. They can be used at the first onset of mania or when depression and mania occur together (mixed state). Unlike lithium, these medications do not damage the kidneys. However, carbamazepine can greatly reduce red and white blood cell counts. In rare cases, valproic acid damages the liver (especially in children) or causes severe damage to the pancreas. With careful monitoring by a doctor, these problems can be prevented in time. Valproic acid is not usually prescribed to women with bipolar disorder who are pregnant or of childbearing age because the drug increases the risk for malformations of the brain or spinal cord of the fetus (neural tube defects Neural tube defects and spina bifida Neural tube defects are certain birth defects of the brain, spine, and/or spinal cord. Neural tube defects can lead to nerve damage, learning disabilities, paralysis, and death…. Learn more ), for Attention Deficit/Hyperactivity Disorder Attention Deficit/Hyperactivity Disorder (ADHD) Attention Deficit/Hyperactivity Disorder (ADHD) is characterized by difficulty concentrating or a short attention span and/or excessive activity and not following the… Learn More as well as for Autism Autism Spectrum Disorders A person suffering from Autism Spectrum Disorders (ASD) has difficulty establishing normal social relationships, does not use language normally or at all, and exhibits an obsessive… Learn more seems to increase. Valproic acid and carbamazepine may be especially helpful when patients have not responded to other treatments. Lamotrigine is sometimes used to control mood swings and during depressive episodes. Lamotrigine can cause severe skin rash. In rare cases, the rash develops into life-threatening Stevens-Johnson syndrome Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) Stevens-Johnson syndrome and toxic epidermal necrolysis are two forms of the same life-threatening skin condition that cause rash, skin peeling, and sores on mucous membranes…. Learn more . People taking lamotrigine should watch for the following symptoms: Skin rash (especially in the rectal and genital areas), fever, swollen glands, blistering, sores in the mouth or eyes, and swelling of the lips or tongue. These symptoms should be reported to the doctor. To reduce the risk of these symptoms occurring, physicians carefully follow the recommended dose increase schedule. Treatment begins with a relatively low dose of the drug, which is increased very slowly (over a period of weeks) until the recommended maintenance dose is reached. If administration is interrupted for three or more days, the dose must be increased again gradually. Sudden manic episodes are increasingly treated with antipsychotics Classes of antipsychotics Psychosis refers to symptoms such as delusions, hallucinations, disorganized thinking and speech, and bizarre and inappropriate behavior that may indicate a loss of… Learn More second-generation medications are treated because they have a rapid onset of action and are less likely to cause severe side effects than other medications used to treat bipolar disorder. Such medications include aripiprazole, lurasidone, olanzapine, quetiapine, risperidone, ziprasidone, and cariprazine. In bipolar depression certain antipsychotics may be the best choice. Some of these are given together with an antidepressant. Certain antidepressants are occasionally used to treat major depression in individuals with bipolar disorder, but their use is controversial. Therefore, these medications are given only briefly and are usually combined with a mood-stabilizing medication or antipsychotic. Electroconvulsive therapy (ECT – sometimes called “shock therapy”) is sometimes used for treatment-resistant depression and mania. Phototherapy, in which patients look into bright lights that simulate sunlight, may be useful for treating seasonal (with fall-winter depression and spring-summer hypomania) or nonseasonal bipolar I or bipolar II disorder. Ideally, it is used in addition to other treatments. Transcranial magnetic stimulation, in which a device applies a harmless magnetic field to the head and is used to treat severe resistant depression, has also been shown to be useful in treating bipolar depression. Psychotherapy is often recommended for people who are taking mood-stabilizing medications. In most cases, this is done so that they can complete their medication regimen as ordered. A Group therapy often helps sufferers and their partners or loved ones understand bipolar disorder and its effects. An individual psychotherapy can help sufferers better cope with their everyday problems. Information about the effects of the medications administered to treat the disorder can help sufferers take them as directed. Some patients resist taking these medications because they believe it makes them less alert or creative. However, decreased creativity is relatively uncommon, as phase prophylactics usually enable patients to function better at work, in school, as well as in relationships and in artistic endeavors. Sufferers should learn how to recognize symptoms right at the beginning and what can prevent them. For example, avoiding stimulants (such as caffeine and nicotine) and alcohol can help, as can getting enough sleep. Doctors and therapists can talk to patients about the consequences of their actions. For example, if sufferers are prone to sexual excess, they are informed about how their actions may affect their marriage and the health risks their sexual permissiveness poses, especially AIDS. If individuals are financially prone to profligacy, they may be advised to hire a trusted family member to manage their money. It is important for family members to understand what bipolar disorder is all about, to be involved in treatment, and to support the sufferer. Support groups can help by providing a forum for sharing experiences and feelings. The following are some English language resources that may be useful. Please note that the MANUAL is not responsible for the content of these resources.

  • Mental Health America (MHA), Bipolar Disorder: general information about bipolar disorder, including an explanation of diagnoses and other terms related to bipolar disorder.
  • National Institutes of Mental Health (NIMH), Bipolar Disorder: general information about many aspects of bipolar disorder, including treatment and therapies, educational materials, and information about research and clinical trials

Understanding Bipolar 2.

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