By David Joel Miller
In a post on Manic Episodes we talked about how episodes, according to the DSM are not diagnoses, they are “building blocks” out of which diagnosis are created. Someone could have either a manic episode or a hypomanic episode. The primary significance is the decision on labeling the condition as Bipolar one or Bipolar two. No Manic or Hypomanic Episode and you will not get the Bipolar label.
The Bipolar Disorder spectrum currently is very confused and confusing. It includes Bipolar I, Bipolar II, proposals for Bipolar III, IV and so on, as well as hypomania, mania, Cyclothymic Disorder, Hyperthymia, Hyperthymic personality disorder and so on. This spectrum is a very divergent group. Disorders involving an elevated mood may be the most Heterogeneous group there is (Van O’s et al. 2007.)
Lumping all these variety’s together may be overlooking the possibility that there are “Types of Bipolar Disorders.”
Hypomania requires a specific time period in which someone has had the symptoms of “elevated, expansive or irritable mood.” The difference is that for full mania the period needs to last for a full week, hypomania need only last for four days.
This creates some problems. What if you have manic-like symptoms for only three days? Do you get left out of the Bipolar spectrum? If someone has serious mania but it only lasts 6 days do they get Bipolar II not Bipolar I?
The effort to separate out conditions by the length of symptom duration may help psychiatrists decide what medication to prescribe but it does not make much difference to the client who has short but intense episodes of manic-like symptoms.
Since some of the changes in Hypomania may be subtle we take the word of others who know you or live with you to make this decision.
Most of the symptoms used to define hypomania are the same as those used to define a manic episode. The primary difference is the duration, four days to six is hypomania and a week or more is mania.
The exception here is that since hypomania is supposed to be a milder or different from mania.
If you have ever had hallucinations or delusions (not caused by drugs) then we skip the hypomania label and go directly to mania.
Here are the hypomania symptoms, then the exclusions. This narrative parallels the DSM but is my less technical, more colorful explanation.
The symptoms list is a lot like the list for Mania. I have italicized some of the differences.
A. For at least 4 days 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 this episode is really bad we may waive the 4-day rule.
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 even from time to time for the same person and the same clinician.
Here are the 7 symptoms needed to make a manic episode.
1. Grandiosity and excessive self-esteem. They can make no mistakes and can’t understand why people question them.
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 three or four hours a night. And in the morning they are not tired.
This reduced need for sleep may be a little less than in mania but the result is the same. People who are going manic or hypomanic get accused of drug use but if tested they have no drugs in the system or at least no drugs that explain the excess energy.
This is a troubling part of the diagnosis. Research studies (Carver & Johnson 2008) say that a lack of sleep can “induce” mania. So the 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. If the hallucinations or delusions are noticeable to others we call it mania, not hypomania.
3. They talk a lot.
In hypomania, you may be able to interrupt them but not for long. They have a lot to say. Sometimes they talk too loudly and too emphatically. This is not the same as the way we old people talk when wound up, but that might give you a picture.
4. They feel their thoughts are “racing.”
Too many things to think about. In kids, this looks a lot like ADHD.
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.
6. Increased goal-directed activity.
In mania it is excessive, in hypomania, those around them notice an increase but can’t explain why.
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.
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 hypomanic 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 with hypomania, the symptoms can be milder, more of a judgment call and can be briefer in time duration.
If you or someone you know has symptoms of hypomania 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.
BIG QUESTION: What about people who have these symptoms for less than four days? Or those that move in and out of Hypomania very quickly? Are we missing some other type of Bipolar Disorder? Or is that moodiness something else?
Stay tuned for more on Mania, Hypomania, Cyclothymia and Bipolar Disorder and Types of Bipolar Disorder and the things we know and don’t know about all these topics.
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For more about David Joel Miller and my work in the areas of mental health, substance abuse and Co-occurring disorders see the about the author page. For information about my other writing work beyond this blog check out my Google+ page or the Facebook author’s page, up under David Joel Miller. Posts to the “books, trainings and classes” category will tell you about those activities. If you are in the Fresno California area, information about my private practice is at counselorfresno.com. A list of books I have read and can recommend is over at Recommended Books