Archive for the ‘mania and hypomania’ Category

This article (abstract) compares “Mixed Depression” (major depression + some manic/hypomanic symptoms) with “Dysphoric/Mixed Hypomania” (major depression + full hypomania; as close as you can get to a DSM-defined mixed state (full mania + full depression) and still be bipolar-II. They looked at a lot of bpII outpatients who presented for depression treatment, and also asked a separate bunch of bpII people who weren’t having symptoms at the time to remember what hypomania was like. (Weird study design, but there’s probably a reason for it – maybe just that most people don’t come in complaining of regular hypomania.)

Seventeen percent of people had full-blown hypomania along with their depression, and 66% had mixed depression – that’s a *lot* of mixed states in people who are coming in for depression, not for mixed states.

More specifics at the link. I’m at martial arts camp all this week, and am going to try very hard to keep up with regular content, but may have to just dump some links back in there. After this week, I have no school or work for two weeks, and there will be extra-spiffy stuff then.

People with bipolar disorder often have symptoms of hypo/mania and depression at the same time, and everything I’ve heard or experienced suggests that this is much, much worse than depression alone. (The first time I had plain vanilla depression instead of anxious misery, I thought I was just fine because I was so relaxed after six years of unrelenting anxiety – it was entirely unlike what I thought of as “depression”. I just couldn’t manage any stress, started crying all the time, and couldn’t function very well.)

Under the current DSM, in order to be diagnosed with a mixed state, you have to meet ALL the criteria for BOTH a depressive episode and a manic episode (not hypomanic, but actually manic) almost every day for at least a week.

In practice, though, things that don’t meet that definition – like depressive symptoms occurring with hypomania – still occur plenty often. For example, in a study published in 2005 that assessed mixed and euphoric hypomanias (i.e., mixed and regular) in 908 patients over 7 years found that mixed hypomania was more common than euphoric hypomania (and especially in women) (Suppes et al., 2005, cited in Goodwin & Jamison, 2007). You can get mixed symptoms at different levels of severity, for example “only” with hypomanic and dysthymic symptoms (I really recommend this link for anyone with a mood disorder who is stressed out and miserable all the time – when I first read that page I realized that maybe all those things I thought were components of my personality were actually related to mental illness. More on this when I do a post on personality and identity later.)

The notion here is that mania and depression are not polar opposites, but separate systems. This is where the idea of mixed states as mania + depression comes from.

But, more complicatedly, bipolar disorder may involve several separate systems each of which can be overactive or underactive, and which can cycle independently. Those mood, activity, and thought. So you can have euphoric or depressed mood; be over- or underactive; and have too rapid thought or too little thought. Dr. Jim Phelps of has a quick presentation of the ideas, complete with graphs and he cites the original which I have not yet gotten ahold of (MacKinnon and Pies, 2006).

So, according to this model, you can have different kinds of mixed states. Goodwin and Jamison go into more depth on each and I’m cribbing from that here, and adding some subjective descriptions (beware: anecdotes follow and may not be accurate).

Situation 1: depressed mood, manic activity, and manic thought. You’re miserable, can’t stop moving, your thoughts are racing and your concentration sucks.

Situation 2: you’re just as depressed (mood) and just as physically agitated (activity), but you can’t think. You’re going going going but you’re miserable and your brain just won’t kick in.

Situation 3: your physical energy bottoms out and your mental energy is going and going. You’re still depressed, and have no energy, but your thoughts are going like crazy. You’re miserable and you just sit there while your thoughts churn and you can’t stop them.

I don’t have intuitive descriptions for the euphoric mood ones (off meds my own mood stays almost exclusively in the depressed-dysthymic range), but I hope someone will share some.

Situation 4: your mood is euphoric, you’re overactive, but you can’t think.

Situation 5, a “manic stupor”, you’re still euphoric, but you can’t move or think – except occasionally when you (meaning, some but not all patients) suddenly get loud or violent.

Situation 6: “inhibited mania”, in which you’re euphoric, you still can’t move unless you suddenly get loud or violent (again meaning some, not all, patients) and you can’t stop thinking.

Whee. Anyway, I like this research (and these classification schemes) because it accounts for a broader range of symptoms than manic/depressed. I really hope it’s going to leak into the hypersimplified and inaccurate common stereotype where bipolar disorder = unhappy vs. real real happy.

I was in the second of two all-day meetings today. The first I got through by being actively interested plus taking adderall, but by today I was so tired of paying attention that the adderall wasn’t much help. (It doesn’t fix not wanting to pay attention, luckily; the first add medication I tried caused me to pay attention to everything anybody said no matter what even if I really wanted to think about something else.) So tonight is Random Facts From Goodwin & Jamison (2007) Night, instead of semi-coherent post on something substantive night.

  • People first developing bipolar disorder are, on average, 22.2 years old. In 1990 that figure was six years higher for studies with similar inclusion/exclusion criteria. Why? They mention a couple hypotheses: more people are being diagnosed bipolar instead of schizophrenic (and psychotic features appear to show up earlier), and antidepressants and stimulants are kicking off episodes earlier than they would naturally have occurred.
  • A few entries from a long list of conditions and drugs reported to precipitate manic episodes: influenza, Syndenham’s chorea (movement disorder caused by infection), bromide (a sedative used in the late 19th and early 20th centuries), and Q fever.
  • Apparently lithium during pregnancy isn’t anywhere near as likely to lead to a heart defect as we used to believe. (But you still shouldn’t breastfeed on it.)

Some terminology used for states in bipolar disorder:

mania: euphoria and/or irritability. People who don’t know much about it sometimes think it’s the same thing as being extra-super-happy, and would like to have it.

hypomania: somewhat less euphoria and/or irritability. People who don’t know much about it usually don’t know that it’s mania to a lesser degree, and therefore not as destructive, but if they did, they’d probably pick hypomania out as the fun mood state to be in, and pay more for this than mania. (I’d sure pay a lot personally to trade out what I actually get for these happy, productive hypomanias.)

mixed state: a lot of people know something more about bipolar disorder aren’t familiar with this term. It involves having symptoms of mania and depression at the same time. Anybody who paid for this would want a refund.

dysphoric mania: Not a DSM term, and as far as I can tell, accounted for by the fact that even euphoric mania can suck, and the fact that mania with depression mixed in gets termed a mixed state. Maybe someone will rescue it but I think this might be a red-headed stepchild.

depression: real depression (as opposed to fake-ass glamorous depression) is probably not worth much to anyone who isn’t in a mixed state.

First, mania and hypomania
I’m going to leave out all the objectively bad things for you that can happen during hypomania/mania – damaging relationships, losing jobs, spending yourself into debt, etc. – and instead concentrate on the subjective-type-stuff that happens during mania (data from table in Goodwin and Jamison):

percentage and symptom

76% flight of ideas / racing thoughts

75% Distractibility / poor concentration

29% confusion

54% delusions
29% persecutory/paranoid delusions

Hallucinations: 18% auditory, 12% visual, 15% olfactory

19% thought disorder

By definition you can’t get delusions or hallucinations in hypomania (if you do, it’s considered mania instead), but you can certainly get racing thoughts and crappy concentration (I don’t know how common confusion is, but I’ve seen the first two mentioned a lot).

I have no doubt that some people with bipolar disorder get the euphoric kind of mania without the subjectively unpleasant stuff, and that some get the euphoric kind of hypomania that is also useful and productive and doesn’t even screw up their life and people write books on it about how hypomania is great and how to prolong and maintain it.

But man, let’s have a little recognition of those of us who can barely read through a paragraph or write an email while we’re so pointlessly overenergized, and who can’t sleep or calm down or do anything because we can’t slow down or stop our speeding thoughts, etc. All bipolar disorder sucks ass, but things suck especial ass when there’s a perception that there’s a good side for you that helps make up for the bad side, when it’s mostly just different kinds and degrees of painful.

And that’s mania and hypomania, the more positive side of bipolar disorder. Later I’ll write about mixed states, which were what I actually wanted to write about, since there is some damn nifty research and theory on them. And since they are also under-recognized, particularly popularly.