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Your Good Health: The signs of bipolar I versus bipolar II disorder

Bipolar disorder is not uncommon, but is frequently missed as a diagnosis and occasionally diagnosed incorrectly in people who have a different condition.
Dr. Keith Roach

Dear Dr. Roach: My husband’s brother and paternal uncle were both diagnosed with bipolar disorder. His uncle struggled miserably for decades before his death; his brother has been in and out of institutions and outpatient programs for years.

Because of the pain this has caused our family, my husband and I have both tried to learn as much about bipolar disorder as possible. One thing I’ve read repeatedly is that a person is born with bipolar tendencies, and that it can be treated but never cured.

All of this reading, as well as our family’s experience, makes me terrified that my husband will also someday become bipolar, and I watch maybe too closely for signs. So, when he goes from being super chatty with strangers at the store, singing and dancing in the aisles, to telling me a few days later that he doesn’t feel like talking and is going to eat dinner behind a closed door, I can’t help but worry.

However, I don’t see a way to bring this subject up with him, especially without more “extreme” behavior having occurred.

Are there absolute alarm-bell signs that warrant a frank conversation?


Bipolar disorder is not uncommon, but is frequently missed as a diagnosis and occasionally diagnosed incorrectly in people who have a different condition.

The necessary symptom to diagnose bipolar I disorder is mania. Mania, by definition, is an abnormally and persistently elevated, expansive or irritable mood, along with increased energy or goal-directed activity. The symptoms that go along with this include inflated self-esteem, decreased need for sleep, being more talkative than usual, racing thoughts, distractibility and excessive involvement in activities that can lead to painful consequences (overspending, sexual indiscretions, etc.).

That last symptom is certainly an absolute alarm-bell sign. Most of us have had some of those symptoms, but it’s the abnormal and persistent nature of them that alerts a clinician (or family member) to the possibility of bipolar disorder.

Bipolar II disorder is similar, but it is less intense and of less duration. In bipolar I, symptoms need to last at least a week, while four days are necessary with bipolar II. Although nearly everyone with bipolar I disorder suffers from an episode of depression (separate from an episode of mania), an episode of major depression is required to make the diagnosis of bipolar II. Finally, people who have at least four episodes of mood changes in a year are referred to as “rapid cyclers.”

Bipolar disease of any kind does run in families to some extent. A person who has a first-degree relative (sibling, parent or child) with bipolar, like your husband does, is estimated to have a 5% to 10% lifetime risk of being diagnosed with bipolar disorder.

I understand why you are concerned, but I don’t have enough information to tell you whether your husband has this diagnosis. Many people have ups and downs without meeting the criteria for diagnosis. There are screening tools available, but nothing replaces the ability of an experienced clinician to make the diagnosis after a careful evaluation.

In this case, a psychiatrist is the best consultant. I know there remains a stigma in seeing a psychiatrist, but it would not be a bad idea for your husband to find a clinician he is comfortable with who can get to know him, help decide whether the diagnosis is likely and be there in case of an “alarm-bell” symptom.

Finally, I caution against the use of recreational drugs, including alcohol and cannabis, which can both confuse the diagnosis and trigger the condition. It’s important for all of us to get regular sleep, but particularly so for a person at risk of bipolar illness.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected]