By David Joel Miller
Episodes, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) are not diagnoses, they are “building blocks” out of which diagnosis are created.
Mania and its milder cousin Hypomania are linked, closer than most marriages, to the Bipolar diagnoses. To get the Bipolar tag you must have had either a manic or a hypomanic episode and there is only a hand full of other things that might create a Manic or manic-like episode that is not Bipolar.
Some of these symptoms are a matter of judgment and intensity. There has been lots of research on the area of Mania and Bipolar disorders but the more we learn the more questions we have.
Currently, there are no laboratory tests, not even brain scans that are clearly diagnostic of mania. There are some differences in some tests but nothing that so far is clearly convincing enough to make the diagnosis.
The DSM-4-TR tells us that there may be differences in the functioning of some neurotransmitters. Then it lists five different transmitters that may vary. There are lots of ways any one transmitter may vary and any one person could have variations in from one to five transmitters. That whole approach so far is not very helpful to the clinicians or the people who have mania.
So in practice, we look for a whole list of symptoms, add them up with exclusions, inclusions, and severity, look for other explanations and when all else is ruled out what is left we call a manic episode.
If you have EVER had a Manic Episode for which we cannot find a medical cause you get the diagnosis of Bipolar I. First the symptoms, then the exclusions. This narrative parallels the DSM but is my less technical, more colorful explanation.
A. For over a week the person has an episode of “elevated, expansive or irritable mood.” Elevated does not mean happy. There are lots of descriptions of these elevated moods and they vary from person to person but the key factor is that these episodes are not like other people and that there are times when this person is not like this. If you get yourself locked up, usually this is in a psychiatric hospital; we wave the full week requirement.
B. Pick 3 or four symptoms from a list of seven.
Each of these symptoms can vary in intensity and it is a judgment call. The result is that diagnosis can vary from clinician to clinician and ever from time to time for the same person and the same clinician. For example, studies show that young children in the U.S. get diagnosed with Bipolar a lot. Show the same file to a psychiatrist in the U.K and the child is more likely to get OCD or ADHD (Dubicka et al. 2008.)
Here are the 7 symptoms needed to make a manic episode.
1. Big-shotism, to use a 12 step term. a sudden burst of confidence or thinking you are better, more intelligent or smarter than others. Plans to cure cancer, run for president and write a novel all in the same week. This can be fun for the person with Bipolar until others start disagreeing with you.
2. Sleep changes. You don’t need to sleep. Someone with Bipolar I can stay up for days and is full of energy. They may only sleep two, three or four hours a night. And in the morning they are not tired.
This looks a lot like a Meth user only they don’t need drugs to stay up and they get to sleep just a little each night.
The DSM says this is the big one of all the symptoms. To quote the DSM – “Almost invariably, there is a decreased need for sleep.”
This is a troubling part of the diagnosis. Research studies (Carver & Johnson 2008) say that a lack of sleep can “induce” mania. So a lack of sleep is both a cause and a symptom of Mania? This sleep mania question needs more research. If the definitive study of this connection has been done so far I have not found it.
Not sleeping and not feeling tired does not mean that the person is rested. The longer this below normal sleep episode goes on the more irritable and delusional the person is likely to get. They may even begin to hallucinate. Only they don’t know they are delusional. They are convinced they are right and other people are dumb to not see how smart they are.
3. They talk a lot.
Not used car salesman or late night infomercial type rapid talk. Professionals call this “pressured Speech.” The person has so much going on in their head they can’t talk fast enough to say it all. The can jump from subject to subject, include extra unrelated stuff and just generally talk so only they know what they are talking about. Sometimes even they can’t figure out what they were trying to say.
4. They feel their thoughts are “racing” or they keep jumping subjects like that old-school record with a scratch.
This also gets mentioned by clients diagnosed with anxiety based disorders. Are Bipolar and Anxiety related? We know that depression and anxiety co-occur commonly, why not Bipolar and anxiety?
5. Lack of focus and easily distracted.
They are in such a hurry they move from topic to topic, project to project and can’t figure out what to do next. Lots of things left half-finished and on to the next one.
This sort of lack of focus reminds me of sitting with a channel surfer who keeps changing the T.V. channel in mid-sentence. This is more a matter of being over-interested in too many things than of losing interest in any one thing.
This characteristic looks a lot like a symptom of ADHD and so given the same person and the same symptoms one clinician may see this as Bipolar and another will see ADHD.
6. Excessive goal-directed activity.
This can be trying to do too much at work, socially, sexually or in most any area of life. This over goal-directed activity can lead to excessive physical motion like a person whose engine is always running. This characteristic called “psychomotor agitation” also looks like the “hyperactivity” in ADHD further leading to the question are those two conditions related or do they just get confused?
7. Overdoing pleasurable activities
Hard to believe that someone could have too much fun but what we are looking for here is not that they have a lot of fun but that they continue to do pleasurable things despite negative consequences. This could also be affected by the assessor’s values judgments.
Examples of excesses are overspending, reckless or dangerous activities, “sexual indiscretions” and so forth. This needs to be more than someone who just likes to do something, like collect something. There is an episodic nature to these activities and most everyone will agree that this person has binges of overdoing things despite them getting in trouble.
This characteristic is highly related to the continued use despite negative consequences we see in substance abuse. As a matter of fact, people with a Bipolar diagnosis are much more likely to also have addiction and alcoholism issues than the general population.
To be diagnosed with a manic episode you need to have three of the seven symptoms. We want four if you are just irritable but not expansive or elevated in mood.
But look at how many of these things are judgment calls. Was Steve Jobs grandiose? How about Bill Gates? How much can I work or write before it becomes “excessive goal-directed behavior.” Are all writers Bipolar? (I need to think about that one.) How many books can I buy this week before it becomes excessive involvement with pleasurable activities?
Sorry, this post is running long. My short explanation of manic episodes leaves more questions unanswered than it answered. Like: How could you be manic and not have Bipolar disorder? What is hypomania and how is it related to all this? Are their different types of mania? What is a mixed episode? What things cause mania? How will this all change when we get the DSM-5?
If you or someone you know has symptoms of mania please see a professional. This article is not meant to be enough for you to do “do it yourself diagnosis.” There are many effective treatments for Mania, Bipolar Disorder, and related conditions.
Stay tuned for more on Mania, Hypomania, Cyclothymia and Bipolar Disorder and the things we know and don’t know about all these topics.
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