THE DSM-5 (the diagnostic Bible published by the American Psychiatric Association) divides bipolar disorder into two types, defined by degrees of mania.
Historically, despite the name, "manic-depression" did not require manic episodes. Then along came the DSM-III of 1980, the first "modern" DSM, which inexplicably and arbitrarily set full-blown mania as its threshold for "bipolar disorder." The DSM-IV of 1994 loosened up somewhat by dividing bipolar into two, "bipolar I" with its hyper-restrictive mania requirement, and "bipolar II" with a rather less severe "hypomania" threshold.
There is a very compelling case for returning to the old "manic-depression" with far less stringent criteria for various types of "up." But for right now, let's focus on bipolar I and mania.
Bipolar I is characterized by at least one full-blown manic episode (which includes symptoms such as grandiosity and risky behavior) lasting at least one week, or shorter if hospitalization is required. The symptoms are severe enough to disrupt the patient's ability to work and socialize, and may require hospitalization to prevent harm to oneself or others. The patient may lose touch with reality to the point of being psychotic.
The other option for bipolar I is at least one "mixed" episode on the part of the patient. One is literally "up" and "down" at the same time.
The DSM-IV defines mania as a "distinct period of abnormally and persistently elevated, expansive, or irritable mood." The DSM-5 would add to this, "abnormally and persistently increased activity or energy." The DSM also notes that the disturbance needs to be severe enough to interfere with work or social activities or relationships, or require hospitalization.
In other words, in mania, we are out of control, we lack judgment. We find ourselves captive to our runaway thoughts and feelings. We find ourselves doing things we would never otherwise contemplate doing in a million years.
Even if we are not a danger to others (and we often are), we are a clear and present danger to ourselves. We are not simply feeling a bit too good for our own good. We are feeling way too good (and in many cases way too bad) for our own good. In a sense, we have gone from dancing on tables to splashing naked in public fountains, from merely drawing attention to ourselves to having the neighbors consider calling 911.
While in mania, everything in our lives is at risk - our jobs, our friendships, our loving relationships, our finances, our reputations, our credit, our personal freedom, our physical safety.
In my book, Living Well with Depression and Bipolar Disorder, I serve up this personal account provided by Billy O:
It seemed so logical at the time. I went to Mexico to convince the local government that I could help them set up a community for recovering alcoholics. I was going to solve their social problems single-handedly. I recall driving to the auxiliary border crossing in southeast San Diego. It was closed due to the late hour. There was no one in sight and nothing but a metal bracket sticking out of the road to prevent passage.
Well that wasn't going to stop me. I had urgent business to attend to. I hit the thing at full speed and it gave under the force of impact. It bent forward to an angle and converted itself from a barricade to a ramp. I must have sailed twenty feet through the air before bashing back down onto the road. I continued into Mexico completely unimpeded feeling pretty proud of myself.
The DSM Mania Symptom List
The DSM mandates at least three of seven possible symptoms, each lasting at least a week (or four days if the mood is irritable) including (slightly edited):
Please note that none of these symptoms are exclusive to mania. Decreased need for sleep, for instance, may be part of a sleep disorder or depression. With the others, we could be talking about ADD, psychosis, anxiety, OCD, narcissism, or (again) depression. (As an added complication, the exact same symptoms feature in hypomania.) What we are looking for is the symptoms clustering together in a way that points to mania (or hypomania). The entire DSM is based on this principle, and one can easily see the logic in this. For instance:
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People who articulate visionary ideas are often mistaken for grandiose, but even monumental grandiosity hardly constitutes proof of mania, much less narcissism or any other mental illness. Yet, people judge all the time. Likewise, an individual who talks fast and loud may simply be excited or anxious or from the Northeast. But signs of grandiosity plus talking fast may actually be an indication that something serious is going on. But what? We need one more symptom:
"Decreased need for sleep."
Whoa! This is where the logic of DSM symptom check-list falls apart. Someone who articulates big ideas and talks fast who happens to stay up late may in fact turn out to be the originator of the next Facebook.
Our Runaway Brain
What we are really looking for is evidence of a runaway brain - beyond reason, lacking insight, untethered to reality. At least give the DSM credit for its explicit emphasis on the "severity" of the episode. Here,grandiosity and pressured speech take on an entirely different context. Instead of the founder of the next Facebook pitching a brilliant idea, we find ourselves suffering through the incoherent ravings of someone whose life is about to become a train wreck. Here is how I would describe it:
Behavior - Subject may display high energy, little need for sleep, pressured speech, a sense of impatience, an inability to control impulses, lack of judgment, and a need to satisfy cravings and indulge in projects or engage in risky behavior.
Behavior must be out of control to the point that subject can no longer responsibly manage his or her affairs or reasonably interact with others.
Plus, we can add:
Thinking - Subject may experience racing thoughts, expansive thoughts, or disturbed thoughts. On one hand, subject may become easily distracted, on the other may be focused to the point of tuning out one's surroundings or neglecting one's responsibilities.
On one hand, subject may experience a state of hyper-awareness; on the other may experience difficulties in basic cognitive tasks.
Thinking must be out of control to the point where subject has a grossly distorted perception of him or herself and his or her surroundings, and is no longer capable of making realistic or responsible decisions.
If you are reading this it is almost certain you are not experiencing mania. You may be experiencing hypomania, instead, a less severe form of mania which is the topic of our next article. Your wheels may be spinning entirely too fast, but for right now the train is still on the tracks, the engineer is still at the controls.
For an individual in mania, his or her best hope lies in being rescued by a change in the cycle. If he or she is "lucky," there will be a crash into depression. Luckier still is a slow glide to a soft landing. Hopefully, when you come to your senses, you still have a job to go back to. I didn't. At least I didn't wind up in the criminal justice system.
One of the biggest myths in all of bipolar is that mania is a super-happy state, and in a "euphoric" mania this is certainly the case. These are your "pure" and "classic" manias, with no complications. I would describe it this way:
Euphoric mania - Subject may experience uncharacteristic feelings of extreme joy, superhuman positive abilities, and a sense of connectedness with the world, him or herself, and those around him or her. Subject may project a magnanimous "larger than life" presence.
But manias have a way of turning sour. All too often, depressive symptoms intrude - what the experts refer to as "mixed states," of cycles in collision - turning life into an energized hell. Thus:
Dysphoric Mania - Subject may experience uncharacteristic feelings of extreme irritability, superhuman positive and negative abilities, and a sense of disconnectedness with the world, him or herself, and those around him or her. Subject may project a hostile menacing presence.
The pioneering diagnostician Emil Kraepelin observed various manic states ranging from high euphoria to high dysphoria with shadings in between. This also included delusional mania, with high levels of psychosis, paranoia, and aggression (see Psychosis in Mania).
Researchers at Duke University refined Kraepelin's breakdown into five categories, and noted that more than half the 327 bipolar inpatients they observed in a study fell into the three categories that could broadly described as dysphoric.
The Duke team noted that the current DSM criteria for mixed states (full depression concurrent with full mania) is far too restrictive and excludes a good many dysphoric patients. The next DSM would partly address this, but you can hardly afford to wait till 2013 for psychiatry to get it right.
The DSM-5 (due out in 2013) would include three depressive symproms in mania, but this focus on symptom-counting overlooks the real issue. What we are really looking for is evidence of anything that may turn a euphoric state into a dysphoric one. As I report in a blog on HealthCentral's BipolarConnect:
It may take just one depressive symptom for that to happen. Or it may involve a bit of anxiety. Or the simple fact may be that our manias have turned on us with no input from depression of anxiety at all.
That simple thought never seems to have entered psychiatry's collective mind. Yes, we all love it when our brains are operating on rocket fuel - who wouldn't? - but now everything inside and outside of us is going way too fast for our own comfort. It's as if we've suddenly discovered the accelerator super-glued to the floor with the brake cable cut.
How how do we feel in this state of terror? Certainly not euphoric. Seriously, any time I hear our doctors say that we don't take our meds because we're addicted to our highs, well don't get me started.
At the 2003 Fifth International Conference on Bipolar Disorder, Gary Sachs MD of Harvard and principal investigator of the NIMH-funded STEP-BD reported that of the first 500 patients in the study, about 50 percent had a co-occurring (comorbid) anxiety disorder.
Dr Sachs suggested that in light of these numbers, comorbid may be a misnomer, that anxiety could actually be a manifestation of bipolar. About 60 percent of bipolar patients with a current anxiety disorder had attempted suicide as opposed to 30 percent with no anxiety. Among those with PTSD, more than 70 percent had attempted suicide.
Your best way of controlling mania is anticipating it, and acting promptly when you pick up subtle early warning signs, such as increased energy. My articles in the Recovery section go into considerable detail with various mindfulness, cognitive, stress-management, and lifestyle practices. For the time being, it pays to know that even though manias may be embedded into one's cycling, they don't generally appear out of nowhere. In all likelihood, these episodes follow from stressful events, anxiety, lack of sleep, personal difficulties, long-distance travel, and changes in living situations.
Basically, anything that goes wrong (or even right) in your life has the potential to "trigger" an episode. Smart patients are acutely aware of this. Your best prevention against mania, then, is a mindful and disciplined life. A smart meds strategy goes with the territory (see the articles in the Treatment section), but I would emphasize that over the long term, meds need to be regarded as a complement to your recovery strategies, not the other way around.
If you are faced with a friend or a loved one or a colleague or stranger who appears to be behaving in a manic manner, it is essential to keep in mind that reasoning with this individual is virtually impossible and is very likely to be counter-productive. Confronting this individual, even in a non-threatening way, is certain to be seen as a provocation and draw a hostile reaction.
Your best bet is to very calmly meet the individual on his or her level of reality, however absurd it may seem to you. "I'm listening," and "I see your point" are two very good things to say, which may have a calming effect. (I go into this in more detail in Validating Family Pain). But also acknowledge your best option may be leaving the scene or calling for help.
Despite all the attention focused on mania, the condition is a fairly rare occurrence. Individuals with bipolar I spend three times longer depressed rather than manic. For those with bipolar II, mania is a no-show (though there is hypomania to contend with). We also have a considerable population of so-called "unipolars" who could be considered bipolar were the hypomania diagnostic thresholds lowered just a tad.
Thus, out of a wider bipolar population, at best probably only one in four have ever experienced mania, probably far fewer. Nevertheless, the other three-quarters are at risk. As I am wont to point out, only half-jokingly: Unipolar is bipolar II waiting to happen. Bipolar II is bipolar I waiting to happen. And with all seriousness I add - the indiscriminate way doctors prescribe antidepressants means anyone can find themselves in a manic episode overnight.
One mania in a lifetime is one mania too many. By the same token, opting to spend the rest of your life as an over-medicated zombie only makes sense to your doctor. It's your life. Be smart, be careful.
Next article: Bipolar II and Hypomania
Previous article: Bipolar Disorder - Really a Cycling Illness
See also: Treating Mania