Bipolar II

Bipolar II Disorder is most often mistaken for postpartum depression, but it is very different. According to Woman's Moods, it is characterized by feeling full of energy and requiring little sleep (Hypomanic Phase) immediately after delivery. This is followed by severe depression two weeks later. Anti-depressants are usually ineffective, and may even worsen the condition. (Sichel, Deborah, MD; Watson Driscoll, Jeanne, MS, RN, CS; 2000, p. 219)

Diagnostic Criteria for Bipolar II Disorder

1. Presence (or history) of one or more Major Depressive Episodes.
2. Presence (or history) of at least one Hypomanic Episode.
3. There has never been a Manic Episode or a Mixed Episode.
4. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
5. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criteria For Mood Episodes

Major Depressive Episode

1. Five (or more) of the following symptoms have been present during the same 2-week period 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.

   Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

   1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) 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 made by others)
   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 gains.
   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, or a suicide attempt or a specific plan for committing suicide
2. The symptoms do not meet criteria for a Mixed Episode
3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
5. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Hypomanic Episode

1. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.
2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
   1. inflated self-esteem or grandiosity
   2. decreased need for sleep (e.g., feels rested 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)
   6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
   7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
3. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
4. The disturbance in mood and the change in functioning are observable by others.
5. 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.
6. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

   Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder.

Manic Episode

1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
   1. inflated self-esteem or grandiosity
   2. decreased need for sleep (e.g., feels rested 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)
   6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
   7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
3. The symptoms do not meet criteria for a Mixed Episode
4. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
5. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Mixed Episode

1. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.
2. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
3. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

References

• Sichel, Deborah, MD; Watson Driscoll, Jeanne, MS, RN, CS. Women's Moods: What Every Woman Must Know About Hormones, the Brain, and Emotional Health. 2000, Harper Colins Publishers Inc., New York, NY.
• DSM IV

Postpartum Psychosis

On June 20, 2001, Andrea Yates drowned her five children, Noah (7), John (5), Paul (3), Luke (2) and Mary (6 months) in the family bathtub. Andrea thought she was possessed by Satan. Convinced she was a bad mother, she thought she was causing her children to sin. She believed they were still young enough that, if they died, God would “take them up.” If they lived, she thought, they would continue to sin and therefore be eternally damned. So that fateful morning, she methodically held each of her children under water until they died. She later told the police she wanted to be executed so that Satan would be destroyed, because he possessed her.

Andrea, a born-again Christian, former high school valedictorian and registered nurse, was diagnosed with Major Depression with Psychotic features after the birth of her son Luke in 1999. She attempted suicide twice and refused to take her antipsychotic medication. She was hospitalized after each suicide attempt, but sent home each time to take care of five children, two of which she home-schooled, and three were still in diapers. Two days before killing her children, her doctor took her off of the antipsychotic medication and told her to buy herself a dress and “think positive thoughts.” (Ramsland, 2003)

Unfortunately, Andrea is not alone. Evonne Rodriguez, in 1997, believed that her four week old daughter was possessed by demons. She tried to pull them out and ended up killing the child.

In December, 2001, Marilyn Lemak, a former surgical nurse, smothered her three young children and unsuccessfully tried to overdose with sleeping pills. She thought that they would all meet together in Heaven. (Fernandez, 2002)

Teacher of the Year, Marilyn Moffitt suffocated her five week old daughter and herself on July 26, 2004. (Capeloto, 2004)

In fact, 180 children are killed by their mothers every year. (Ramsland, 2003)

Postpartum Psychosis (PPP) is one of the most misunderstood and under-diagnosed conditions plaguing new mothers. One in five hundred births result in PPP, but the women seldom even realize they are ill. (Ramsland, 2003) In a study published in a 1993 issue of Postgraduate Medicine, thirty to fifty percent of women with PPP attempt suicide, with five percent actually succeeding. Up to four percent are at risk for harming their babies. (Knopps)

According to Healthwise, symptoms include:

• Depersonalization: feeling removed from your baby other people, and your surroundings
  
• Disturbed sleep
  
• Extremely confused and disorganized thinking, increasing your risk of harming yourself, your baby or another person
  
• Drastically changing moods and bizarre behavior
  
• Extreme agitation or restlessness
  
• Hallucinations or visions, often involving sight, smell or touch
  
• Delusional thinking that is not based in reality

If you are experiencing these symptoms, or feel like you may hurt your baby, yourself or someone else, call 911 or go to the hospital immediately. Most women do get well if the condition is recognized and treated properly.

Treatment for PPP consists of immediate hospitalization, the use of antipsychotic drugs and psychotherapy with a therapist familiar with postpartum disorders. Mood stabilizers and antidepressants may be used if needed. (Bennett, S.S. et. al. 2003)

References

• Ramsland, Katherine. Andrea Yates: Ill or Evil. http://www.crimelibrary.com/notorious_murderers/women/andrea_yates/index.html, 2003.
• Fernandez, Elizabeth. An Unfathomable Crime: Parents Who Slay Their Kids. San Francisco Chronicle, February 23, 2002.
• Capeloto, Alexa. Two Deaths May Hold Lesson for New Moms. Detroit Free Press, August, 26, 2004.
• Knopps, G. G. Postpartum mood disorders: a startling contrast to the joy of birth. Postgraduate Medicine, (93): 103-116, 1993.
• Postpartum Depression Checklist. Boise, ID, Healthwise, Inc., 2005.
• Bennett, S.S., Indman, P.: Beyond the Blues: A Guide to Understanding and Treating Prenatal and Postpartum Depression. San Hose, CA, Moodswing Press, 2003.