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Mania and Hypomania
A colleague of mine once told me about a manic inpatient
he had treated for many years at an Ivy League–affiliated
psychiatric teaching hospital. The patient’s father
was the CEO of a Fortune 500 company. Each time he visited
his son on the unit, he would behave in a dramatically hypomanic
fashion. For example, he would make numerous business phone
calls around the world on the patients’ pay phone, while
frantically yelling “Back off!” at patients or
staff who tried to interrupt him. Clearly, Dad was not normal,
but he had made his hypomania work for him. He was a very
rich man.
This family’s story illustrates the concrete relationship
between mania and hypomania. Manics and hypomanics are often
blood relatives. Both conditions run together in families
at much higher rates than we would predict by chance.6 We
know that their genes overlap, though we don’t know
how.
This family’s story also illustrates the most radical
difference
between mania and hypomania. Mania is a severe illness. The
son was disabled—a long-term inpatient at a psychiatric
hospital. Manic episodes almost always end in hospitalization.
People who are highly energized, and also in most cases psychotic,
do bizarre things that are dangerous, frightening, and disruptive.
They urgently require external control for everyone’s
safety, especially their own. Most people who have experienced
a manic episode remember it as a nightmare.
By contrast, hypomania is not, in and of itself, an illness.
It is a temperament characterized by an elevated mood state
that feels “highly intoxicating, powerful, productive
and desirable” to the hypomanic, according to Frederick
K. Goodwin and Kay Red-
field Jamison, authors of the definitive nine-hundred-page
Manic-Depressive Illness.7 Most hypomanics describe it as
their happiest and healthiest state; they feel creative, energetic,
and alive. A hypomanic only has a bipolar disorder if hypomania
alternates, at some point in life, with major depression.
This pattern, first identified only in 1976, is called bipolar
disorder type II to distinguish it from bipolar disorder type
I, the classic manic-depressive illness, which has been well
known since the time of the ancient Greeks. If a hypomanic
seeks outpatient treatment it is usually for depression, and
he will define recovery as a return to his old energetic self.
Not all hypomanics cycle down into depression. What goes up
can stay up. Thus, we cannot conclude that someone has a psychiatric
disorder just because he may be hypomanic. The most we can
say is that hypomanics are at much greater risk for depression
than the average population. The things most likely to make
them depressed are failure, loss, or anything that prevents
them from continuing at their preferred breakneck pace.
Given how radically different mania and hypomania are, it
is perhaps surprising that the diagnostic criteria for these
two conditions are identical according to the Diagnostic and
Statistical Manual of Mental Disorders of the American Psychiatric
Association (usually referred to simply as DSM-IV):
A. A distinct period of abnormally and persistently
elevated, expansive, or irritable mood, lasting at least one
week.
B. And at least three of the following:
- Inflated self-esteem or grandiosity
- Decreased need for sleep (e.g., feels rested after only
three hours of sleep)
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts
are racing
- Distractibility (i.e., attention too easily drawn to unimportant
or irrelevant external stimuli)
- Increase in goal-directed activity (either socially, at
work or school, or sexually) or psychomotor agitation
- Excessive involvement in pleasurable activities that
have a high potential for painful consequences (e.g., engaging
in unrestrained buying sprees, sexual indiscretions, or
foolish business investments)
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