A NUMBER of years ago, I took a careful read of hypomania in the DSM and had one of those knock-me-over-with-a-feather moments. Hypomania was listed as an episode rather than an illness, and not only that, "the episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization …"
Sure, the DSM refers to the type of behavior that could cause you to lose your job, your family, and your assets in a heartbeat, but apparently none of that qualifies as a "marked impairment."
If you took the DSM at face value, you would think that hypomania was little more than the good cholesterol of mood. For bipolar I, mania is clearly the bad cholesterol. Hypomania is even not a requirement for bipolar I and barely rates a mention. In bipolar II, the bad cholesterol is depression. If you’re lucky, you get to have hypomania.
The DSM does reserve the "Not Otherwise Specified (NOS)" category for apparently unipolar hypomanics and other diagnostic oddballs, but the understanding is that this designation is only applied on Feb 29.
So are psychiatrists simply not treating hypomania? Hardly. Are they treating hypomania exactly as they would be treating mania? That’s worth exploring.
The pioneering diagnostician Emil Kraepelin identified hypomania in his classic 1921 work, but few have written about it since. A Jan 10, 2011 PubMed search revealed only 1059 entries for hypomania, up from the 659 from five and a half years before, but obviously well short of the 31,870 hits for mania and 251,868 for depression. As of June 30, 2016, we are up to 1,520. A seminal 1976 article by Goodwin, Gershon, and Dunner proposed a new bipolar II diagnosis that would incorporate hypomania, but it took until 1994 for the DSM to get with the program.
In recent years, Akiskal, Hirschfeld, Angst, Cassano, and others have more closely examined the phenomenon of hypomania, as well as the populations in which they occur. Their findings suggest that instead of just two percent bipolars in the general population evenly divided among Is and IIs, we may have as many as six percent, nearly all of them bipolar IIs or people with depression who have some hypomanic features.
Said John Gartner PhD, an associate professor of clinical psychiatry at Johns Hopkins and author of "The Hypomanic Edge: The Link Between a Little Craziness and a Lot of Success in America," in a 2005 interview with this writer, "the most common form of this disorder is being treated as if it were a rare weird variation."
In his book Dr Gartner views hypomania as a genetically transmitted temperament whose adaptive advantages far outweighs the disadvantages. Thanks to the people brave enough (and crazy enough) to leave their settled existences to strike out for an uncertain life on a strange shore, argues Dr Gartner, America has been blessed with a generous supply of wild wacky creative geniuses and go-getters, plus an abundance of those egging them on. This is often a source of dismay to the Europeans, who are alarmed by our excesses, even as they embrace the many positive aspects of our culture.
One of Dr Gartner’s case studies is the brilliant Founding Father Alexander Hamilton, who had a spot reserved on Mt Rushmore until he stupidly offered up his body for target practice. Which raises some interesting questions. Suppose lithium and other meds had been available to Hamilton. Would the treatment have dulled his brain to the point where he would have opted to become a Founding Bystander rather than a Founding Father? Or would he have prudently skipped his appointment with Aaron Burr and gone on to become America’s greatest President?
The $64,000 question for psychiatrists: If Alexander Hamilton were your patient, how would you treat him? Is this the same standard you apply to your other patients?
Certainly, many of us feel hypomania is our true identity, not just a mood aberration to be medicated out of existence. "That’s very important," Dr Gartner told me. "When you think about it, how many people have died just to preserve their sense of identity? Think of all the Jews who died because they wouldn't renounce their religion. All they had to say was, yes I’m a Christian. It’s hard for people who are not hypomanic to appreciate how integral this is to someone’s identity and how important it is to preserve that."
This led to the crux of our interview: "First of all, most psychiatrists don’t know when their patients are hypomanic because they haven’t been trained to look for it. Also, no one ever came to their offices saying, I’ve got hypomania, please cure me. When they do become aware that the patient has hypomanic symptoms, then I think their tendency is to over-react, react as if it is the same as mania, which it is not in terms of the risk and the danger."
Some people can obviously benefit from meds, but Dr Gartner makes it clear we are talking of the equivalent to microsurgery involving careful microadjustments "to take the edge off of the edge."
"I liken it to the pitcher in Bull Durham," he related, "the guy who has the 100 mile per hour fastball but keeps beaning the mascot. He needs a little bit more control. He’s got speed. You wouldn’t want to give him so much medicine that he threw a fifty mile per hour fastball. We want to slow it down just enough so that he can deliver the ball where it’s supposed to be."
Think of Hamilton, brilliant as ever, lightening up a tad on Aaron Burr.
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This may involve clinicians rethinking their concept of therapeutic doses. Current dosing levels are based on trials involving bipolar I patients in the acute (initial) stage of mania. Even lithium, the most studied mood stabilizer, has not been tested for hypomania. Clinical treatment guidelines are silent on the topic. In this so-called era of evidence-based medicine, we simply have no evidence.
It Gets Complicated
Willa's wife Helen was invited to a function at the home of Sally Mason, president of the University of Iowa. Willa got to tag along. As she explains it:
Helen likes to show me off, because I am good at parties, can talk with anybody, good social skills. And I am cute.
So far, so good.
Anticipating wine at the function, she decided to skip her afternoon Valium. Besides, she wanted to be mentally sharp. Later into the function, the host engaged Helen and Willa in a conversation. They were standing in front of a bookcase populated with books by Iowa Writers Workshop authors. The workshop is the pride and joy of the university.
In Willa's words, "That is when the evil twin appeared." Pointing to a Pulitzer book, "Gilead" by Marilynne Robinson, the evil twin let loose: "Boring. Boring, boring, boring."
Gracious host that she was, Dr Mason acknowledged it was a difficult book to read. Willa says she could have redeemed herself by offering that it was difficult for her, as well. After all, the book was about depressed small town Iowa clergy, and - guess what? - Willa had been one herself. All manner of fascinating conversation could have flowed.But, no. Willa pointed to another book. As she reports: "This time I said, 'I hate this book ...'" Dr Mason moved on to other guests.Willa observed that her psychiatrist would have a ready solution to her unwanted hypomania, namely to go on the meds she had been refusing. But there was a catch, as Willa relates: Those meds would give me a flat affect, facial tics and forty pounds. Helen would have no reason to let me out of the house at all. I would no longer even be cute. In an ideal world, we could all be our smart, funny, insightful, and engaging selves without having to worry about causing a social embarrassment. Operating with a clear head is our most valuable asset, but there are risks, illness or no illness. I could opt for faux pas-free life, but at what cost? An existence devoid of laughter? Psychiatrists tell us we need to stay on our meds, and for many of us that is very good advice. But that is the easy answer. Willa poses questions.
While working on the American Psychiatric Association’s 2000 DSM IV-TR (a technical update), Trisha Suppes, now at Stanford University, beat me by seven or eight years in carefully reading its criteria for hypomania. Like me, she had an epiphany. "I said, wait," she told a UCLA grand rounds lecture in April 2003 and webcast the same day, "where are all those patients of mine who are hypomanic and say they don’t feel good?"
Apparently, there is more to hypomania than mere mania lite. Dr Suppes had in mind a different type of patient, say one who experiences road rage and can’t sleep. Why was there no mention of that in hypomania? she wondered. A subsequent literature search yielded virtually no data.
The DSM alludes to mixed states where full-blown mania and major depression collide in a raging sound and fury, but nowhere does it account for more subtle manifestations, often the type of states many bipolar patients may spend a good deal of their lives in. (This will change in the DSM-5, thanks in large part to Dr Suppes.)
The treatment implications can be enormous. Dr Suppes referred to a secondary analysis by Swann of a Bowden study of patients with acute mania on lithium or Depakote which found that even two or three depressed symptoms in mania were a predictor of outcome.
Clinicians commonly refer to these under-the-DSM radar mixed states as dysphoric hypomania or agitated depression, often using the terms interchangeably. Dr Suppes defines the former as "an energized depression," which she and her colleagues made the object of in a prospective study of 919 outpatients from the Stanley Bipolar Treatment Network. Of 17,648 patient visits, 6993 involved depressive symptoms, 1,294 hypomania, and 9,361 were euthymic (symptom-free). Of the hypomania visits, 60 percent (783) met her criteria for dysphoric hypomania. Females accounted for 58.3 percent of those with the condition.
Think of the Bull Durham pitcher in Dr Gartner's analogy. This time we're taking about Tim Robbins deliberately beaning the mascot. For the time being, psychiatry has left him high and dry.
Yet More Complications
A research psychiatrist explained to me that even if we don't view hypomania as a disabling condition that needs treatment, we need to regard the state as a "marker," possibly signaling a crash into depression, possibly signaling a ratcheting up into mania. This returns us to viewing bipolar in its correct context as a cycling illness rather than an episodic illness.
In other words, patients and their doctors need to anticipate the next phase of the cycle. If you have bipolar II, your idea of a wacky and wild night out may be coupon night at the Olive Garden. Maybe you should take full advantage of your temporary leave of absence from depression and indulge yourself in the all-the-pasta-you-can-eat special.
Or, in Willa's case, it was obviously putting her on the fast track to social leper status. For others, it could be the gentle fresh breeze that heralds the raging manic storm. But is meds overkill justified? Or is there a middle way? It is worth quoting this passage from an article in the Recovery section to this site, Staying Well, based on a study conducted by Melbourne researcher Sarah Russell:
Damien is microscopically attuned to early shifts toward depression or mania. Herbal tea, he says, usually "does the trick" for heading off a potential manic attack, but he has Zyprexa handy – as a standby med with the permission of his psychiatrist - just in case. He has used the Zyprexa twice in the past year. He maintains "humdrum" sleep and work schedules and relies on friends for support. He is not afraid to hit the mattress and "batten down the hatches" till a foul mood passes. "I have a fridge magnet," he concludes, "that says ‘Next Mood Swing in Six Minutes.’ Unfortunately, my low moods can last a bit longer than that."
The core to Damien's stay well strategy is mindfulness, of spotting trouble before it happens and then acting fast, before the next phase of the cycle overwhelms him. In this context, the medications are an adjunct to his stay well strategy, not the other way aroud.
This bears special emphasis. Physicians view medications as the foundation of bipolar treatment, and this is certainly true in the early going. But later, the emphasis shifts to the patient managing his or her own illness, which puts the key decision-making in the hands of the patient rather than the clinician.
Wrapping It Up
There are no easy answers, only hard questions. But if you are not asking the questions, you won't come up with any answers. Live well, ask questions ...
Companion article: Treating Mania
Reviewed June 30, 2016
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