Bipolar II and Hypomania
Hypomania is one of the most common conditions in all mental illness. Now if we only knew something about it.
Bipolar disorder symptoms. Depression is far and away the most dominant state of bipolar II, but hypomania is what alerts us to the fact that we are dealing with something more than just depression. In a seminal 1976 journal article, Dunner, Goodwin, and Gershon observed that patients with recurrent depression interspersed with hypomania appeared to have a different course to their illness than those with unipolar depression or those with a history of mania.
One way of interpreting this is we need to figure out precisely how high is "up" in order to get a read on how we treat "down." Once we have crossed the diagnostic divide from unipolar to bipolar, the old assumptions go out the window.
My New Book! Coming Soon!
In my book, "Living Well with Depression and Bipolar Disorder," Cindy relates:
Thursday night I was so angry it was difficult to keep from throwing and breaking everything within reach. Friday I was elated, giddy, fun to be around. Saturday seemed fine, happy but calm. Sunday morning I woke up and started cleaning the apartment...I moved furniture, on hands and knees I scrubbed every bit of carpet and floor, I vacuumed, I mopped, I took the vacuum and cleaned out all the vents and heaters, I reorganized my closets ...
Emil Kraepelin identified hypomania as far back as 1921, but it took the DSM till 1994 to finally recognize bipolar II and hypomania. The DSM-IV lists the exact same symptoms for hypomania as for mania (such as grandiosity and racing thoughts), but with a four-day minimum rather than seven. Moreover, "the episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization.
In other words, there is nothing about hypomania in and of itself that justifies medical or therapeutic intervention. True, the individual may not be his or her "normal" self (which the DSM makes clear), but who wants to be normal when you can be hypomanic? In many cases, this is the kind of personality makeover we all pray will happen to us - salesperson of the month productivity combined with life-of-party sociability, with a bit of God and three of your favorite humans thrown in.
So "right," in fact, does hypomania feel to most of us that we are inclined to mistake this state of well-being for our normal selves. Life is a cabaret. Who wants the party to stop? Needless to say, psychiatrists never encounter individuals walking into their office for the first time complaining of hypomania.
But - alas! - the sun rises, the sun sets. The wind blows to the south and turns to the north ...
Sure, hypomania may temporarily make us the envy of the human race, but ratchet up the mood a degree or two and life becomes a parody rather than a party. Events and conversations progressively swirl out of sync to the point where we find ourselves in our own slow-loading video, powerless to align two distinctly separate universes, our personal one with the stupid one everyone else has inexplicably opted for. Idiots! Doesn't anyone understand?
Things only fall apart from there.
If only we could cycle between hypomania and normal. Well, actually a fair number of people do. These people seem always up, never down. They may come across as a little bit crazy, but a little bit is good. Again, who wants to be normal? Normal sucks. Contrary to what psychiatry may tell us, not everything this side of normal is bad. Some fortunate souls are born blessedly dysnormal, and we know who they are. We attend their movies, vote them into high office, wear their labels, and buy stock in their companies.
As for the rest of us - our personal wheels of fortune are numbered a bit differently. There we are, time to make that next spin, knowing full well where we are likely to land next. For those of us with bipolar I, hypomania may be the opening act to mania. Maybe we can escape it, but by the time we are aware of the danger it is almost always too late. We have already been lured into the trap.
Or maybe depression is our next stop (for bipolar I and bipolar II, alike). There we are, like Wile E Coyote, both feet over the edge of the cliff, with only gaseous molecules and trace particles between our soles and the canyon floor a thousand feet below. We look down. We have just enough time to experience a sinking feeling in our gut before gravity becomes fully operational.
Hypomania - It's All About Context
Again, we are looking for evidence of "up" to give us an indication of how to treat "down." Depressed patients hardly feel the need to report their dancing-on-tables moments to their doctors, nor are their doctors inclined to press for them. The issue is complicated by the fact that depression robs us of our ability to recall feeling good, anyway. A further complication is that we tend to mistake our peak moments for normal.
The consequences of a clinician missing our ups can be catastrophic. Misdiagnosis with major depressive disorder is the rule rather than the exception, where we are subjected to antidepressants which tend to make us worse rather than better (see the articles in the Treatment section). In the context of bipolar II, it's the depressions that need to be treated, or rather the cycle that drives these depressions.
Depressions in bipolar II are severe, with the evidence pointing to greater levels of debilitation than both unipolar depression (if such a thing is possible) and bipolar I depressions. By contrast, the (hypo)manias in bipolar II are not severe, and may well be enjoyable, or at least tolerable. These manias are called hypomania for a reason, to distinguish them from the life-wrecking manias found in bipolar I.
While hypomanias definitely require a clinician's attention, there is a good chance they may not require his or her intervention. Way too often, clinicians fail to appreciate this vital fact of life. They think hypomania needs to be treated and over-treated - as if it were a 911 manic attack - which has the paradoxical effect of worsening the numero uno problem, those debilitating depressions.
It's All About Context - Again
At all times, our moods need to be contrasted with our personality, and nowhere is this more in evidence than with hypomania. Are we hypomanic, for instance, or merely exuberant? Are we hypomanic or merely experiencing a normal reaction to good news? The experts distinguish between hypomanic and "hyperthymic." Hypomanic is the "state," part of our illness. Hyperthymic is the trait, embedded into our personality. A variation is "cyclothymic," where personality fluctuates from melancholic to exuberance.
Thus, it's not the dancing on tables that is a sign that something may be wrong - it's WHO is dancing on tables. If it's Marilyn Monroe in "Some Like it Hot," there may be nothing to worry about. If it's Colin Firth in "The King's Speech," we may need to summon someone other than a speech therapist.
Your doctor is not in a position to figure this out for you. You have to do this yourself, ideally with the help of trusted friends. The articles in the Behavior section go into this in considerable detail.
Hypomania - Gift or Curse?
For some of us, hypomania may be entirely too frightening to deal with. We are out of our element, we are terrified over what may happen next, we want no part of it. A good many of us, though, find it feels right. If it's not an actual part of our personality, it is certainly in alignment with it. From an evolutionary standpoint, the selective advantage in transmitting these genes from generation to generation is self-evident, notwithstanding the obvious drawbacks.
If ever there were a gift of fire, this is it.
Euphoric Hypomania and Dysphoric Hypomania
Obviously, if these distinctions exist in mania, they are going to exist in hypomania, but the DSM is not with the program - yet.
Euphoric hypomania is what we all wish we could put into a bottle and sell. Dysphoric hypomania, by contrast, is psychiatry's dirty dark secret. These are your mixed states, your road rage states, where symptoms of depression collide with symptoms of hypomania. Thus, instead of dancing on tables you may be banging your shoe on one. The DSM-IV confines mixed states to bipolar I, but the DSM-5 (due out in 2013) would recognize mixed states in both unipolar depression and bipolar II.
The symptom-counting exercise the DSM-5 engages in is highly confusing at best and in the final analysis totally irrelevant. For instance, in unipolar depression, the DSM-5 demands a full manic episode on top of full depression, whereas in hypomania and mania the DSM demands only three depressive symptoms inside hypomania and mania.
Basically, we are talking about agitated (or energized) depressions and dysphoric hypomanias, and there is little point in distinguishing the two, much less in counting symptoms. Call it agitated depression, call it dysphoric hypomania, it's the same hell on earth.
Anxiety in Hypomania
The STEP-BD study mentioned in the mania article applies with equal force here. Basically, 50 percent of those with bipolar II have co-occurring anxiety. The first symptom for generalized anxiety disorder - "restlessness or feeling keyed up or on edge" - serves notice that these two conditions essentially share a lot of the same neural circuits.
Where Does Hypomania End and Mania Begin?
The DSM mandates that if psychosis is present, then it has to be mania, not hypomania. Otherwise the only separator is severity, and here the DSM is highly confusing and contradictory. On one hand the DSM reassures us:
The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization ...
On the other, symptom number seven (a direct copy and paste from the mania symptom list) tells us:
Excessive involvement in pleasurable activities that have a high potential for painful consequences ...
So - wait! First, we're being informed that there is nothing to worry about. Next, we're being told to go to DEFCON One. Which one is it?
There are no easy answers, but one possible solution is to eliminate symptom seven in hypomania and make it mandatory (rather than merely optional) for mania. In other words, if the individual is entering the danger zone - putting his or her livelihood, relationships, and safety at risk - then it is mania, not hypomania.
Another piece of the puzzle is control. In my article on mania, I suggest my own diagnostic guide:
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. ... 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.
Whereas with hypomania, it's more like this:
Subject may exhibit unusual or unexpected behavior, but is still capable of responsibly managing his or her affairs and interacting with others. ... Subject may have a mildly distorted perception of him or herself and his or her surroundings, but is still capable of making realistic and responsible decisions.
Finally, there is the matter of presentation. In euphoric states, I would contrast a "magnanimous larger than life presence" (mania) with a rather more diminutive "sociable charismatic presence" (hypomania). In dysphoric states, I would contrast a "hostile menacing presence" with an "unpleasant mildly threatening presence."
But nothing is ever that simple. In bipolar, our brains are always in perpetual motion, so even in a seemingly benign hypomania there is always room for worry.
Where Does Hypomania End and Simply Feeling Good Begin?
The DSM four-day minimum for a hypomania episode is widely regarded as arbitrary. Lowering the criteria to two days would embrace a much larger population. I would argue that "up" merely has to be higher than "down." Again, in this context, it's not about treating up. It's about how to treat down. Evidence of up points to cycling, and by now you see where I'm going with this.
As with mania, the best way of controlling hypomania is to anticipate it, and then act promptly. The articles in the Recovery section offer helpful tips. Full strength meds are probably over-kill, but may be your best option if you feel yourself at risk of cycling into full-blown mania. (See Treating Hypomania.)
It is possible to reason with someone who appears to be in a hypomanic state, but you have your work cut out for you. One miscue is likely to result in a hostile reaction. At all times, maintain a sense of calm. Your mission is to establish a rapport by making the individual feel emotionally safe. Avoid all temptation to smack the other party with a rolled up newspaper. "I'm listening," works much better.
For one of the most common conditions in all mental illness - the hub, in effect, connecting depression, mania, wellness, and personality - one that we are required to pay extremely close attention to, very little research has been devoted to it. A PubMed search inevitably reveals hypomania discussed (usually in passing) in the context of something else. In all my years attending mental health conferences, in fact, I have yet to come across a session on how to recognize and treat hypomania.
Scary, isn't it?
See also: Treating Hypomania
First published April 1, 2011
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