What is Cyclothymia?

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Person with masks

Bipolar.
Photo courtesy of Pixabay.com

Cyclothymia, Bipolar, and Substance Abuse.

Cyclothymia is generally seen as a milder, subclinical form of Bipolar disorder. If it is the milder form we would expect to see a lot more Cyclothymia than Bipolar disorder. We don’t. So why and what is Cyclothymia?

A person with Cyclothymia is considered to be “temperamental, moody, unpredictable inconsistent and unreliable” (DSM-4-TR.) Cyclothymia seems to also be related to or overlaps Borderline personality disorder. Genetic risk factors, as well as environment and learning, may all play a role in creating Cyclothymia.

Cyclothymia, per the DSM, is a disorder characterized by chronic mood swings that do not meet the criteria for Bipolar disorder. Most mental illnesses require that the person, in order to get the disorder must experience a specific number of symptoms from a list of symptoms.

To be Bipolar I disorder you must have had a manic episode. For Bipolar Two, there must be a hypomanic (near manic) episode. That means that the person in addition to having an episode of elevated mood for at least 4 days must also have 4 of 7 listed symptoms. What if they only have three symptoms or if they have five “almost” symptoms. The way we count symptoms and who does the counting makes a lot of difference.

Cyclothymia waves the 4 day rule but requires that the mood swings go on over at least two years. (We make that one year in children.)  So for over two years the person needs to keep having episodes of depression and episodes of almost hypomania but never reaching the full criteria for depressive or hypomanic episodes.

My experience says that no diagnosis, no treatment, unless you have the money to pay and the motivation to push, like having an overly moody child. So rather than wait the whole year for a child or two years for an adult before treatment is begun, people with these almost hypomanic therefore almost Bipolar diagnoses end up with the label Bipolar NOS or Mood Disorder NOS.

The statistics seem to bear that out. Estimates of the prevalence of Cyclothymia run from 4 to 6 people per 10,000. Bipolar One and Two are in the range of 50 to 150 people per 10,000. Meaning that Cyclothymia despite being thought of as mild Bipolar is much rarer. Mostly Cyclothymia gets diagnosed in people who have suffered for a long time – the full two years before something happened that sent them to treatment.

The criteria say someone with Cyclothymia should be experiencing “almost” depression, mania, or hypomania most of the time over those two years. Those episodes should all be just short of the Bipolar or Major Depressive disorder diagnosis but should cause a lot of distress. There also cannot ever be two months when you don’t have mood swings or we don’t think you meet criteria for Cyclothymia.

To be Cyclothymia you should never have had any psychosis, which includes both hallucinations and severe delusional symptoms. And these symptoms can’t be the result of a medical condition.

Medications and Drugs can cause this.

It is not just street drugs but medications, prescribed and over the counter medications, that can cause Hypomania. Failure to sleep has been reported to cause hypomania and some overlooked products can cause the lack of sleep that induces mania.

Stimulants can interfere with sleep and that includes most of the medications for ADHD. But there is a bigger worry in children.

I feel certain I have seen sleep disruptions, and resulting mood disturbances in kids who take in excessive caffeine. Energy drinks are a problem in teens but the little ones, the preschoolers and the early grade student are also at risk.

Most sodas contain not just obesity causing sugar but massive amounts (relative to body weight) of caffeine. That huge amount of caffeine per pound of body weight causes sleep disruption and sleep disturbances which may be causing mood swings and even inducing Bipolar disorder.

The DSM-5 will tighten up the exclusion for any Drug or medication induced hypomania.

Environmental and learned factors

Some of these symptoms, the swings between depression and hypomania look a lot like what we see in children from abusive, neglectful or deprived backgrounds. Adult children of Alcoholics report that one time they would do something and be praised or rewarded for a behavior, the next time they might get hit.

Inconsistent environment would encourage you to be depressed and anxious at times and when it was safe to possible go overboard at seeking pleasure. So being sort of hypomanic could be adaptive in a dysfunctional environment.

Cognitive Behavioral therapy has been reported as effective in treating people diagnosed with Cyclothymia. This suggests to me that some of these symptoms are learned and that there are core beliefs or schemas supporting this fluctuating mood way-of-being.

There are a host of other factors that influence the expression of Cyclothymia. Sleep changes can trigger changes in mood but so can changes in eating. Social support systems and the level of stress all contribute to mood swings.

Studies of Cyclothymia have the same defects as studies of other mood and anxiety disorders. People who act out and get arrested don’t get included in studies. Neither do people with drug or alcohol problems or those who are suicidal. Psychosis and delusions also get you kicked out of research. So those most likely to really be impaired by Cyclothymia are most likely to be excluded.

Information on Bipolar, Hyperthymia, Cyclothymia, Depression and other Mood disorders is scattered through this blog and I will continue to add to those posts. Check the categories list to the right. To make Bipolar Family posts easier to find there soon will be a separate post devoted to links on this blogs and others places on the subjects of mood disorders.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

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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 my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

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Bipolar, Mania, Cyclothymic and Hyperthymic Posts

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Person with masks

Bipolar.
Photo courtesy of Pixabay.com

Bipolar, Mania, Cyclothymic and Hyperthymic Posts.

Here is the most recent updated list of posts and links on Bipolar Disorders and related conditions.

1. What is Mania?

2. Do medications or drugs cause mania or Bipolar disorder?

 3. What is Mania or a Manic Episode?

4. You Know You’re Manic When

5. Lady Diana, Bipolar, and Borderline Personality Disorder

6. Is everyone Bipolar?

7. Does an adjustment disorder produce depression & mania?

8. Tests for mental illness

9. Hyperthymia, Hyperthymic Personality Disorder and  Bipolar Disorder

10. Bipolar Disorder, Alcoholism, and Addiction 

11. Scared or Excited?

12. More depression these days?

13. Bipolar or Major Depression?

14. Bipolar – misdiagnosed or missing diagnosis?

15. Am I Bipolar?

16. Bipolar doesn’t mean moody

17. What is Cyclothymia?

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

Mania in children?

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Person with masks

Bipolar.
Photo courtesy of Pixabay.com

Do children really have mania?

Parents bring children into the emergency rooms and the psychiatric facilities because their child “flips out” and begins damaging property. Say the child begins breaking out all the windows in a row of buildings. They are angry and out of control. Efforts to get them to stop are unsuccessful and they may continue even when threatened with violence. Is this an early sign that the child has Bipolar disorder?

Diagnosing Bipolar Disorder in children is highly controversial. To make that diagnosis we need to know if children really have episodes of mania or hypomania. No mania and there should be no Bipolar Diagnosis. Anger and mania are related; they may overlap but are they part of the same thing? The researchers in this area are clearly not in agreement. I will save my opinion for the end.

Children have temper outbursts. If we reduce the level of symptoms needed to include those outbursts as a mental illness all children would get the label and the diagnoses would become meaningless.

To be considered Mania it should last 7 days, for Hypomania an episode needs to last for at least four days. This rules out all those brief temper outbursts from consideration.  It also excludes those times when any and all of us might have a time period of excitement when we sleep less or are excited to pursue a new activity, like a new love interest.

Recently there has been an increase in the use of the Bipolar NOS diagnoses in children because this allows for some judgment calls as to the length of episode needed to make the diagnosis. One study (Stringaris et al. 2010) looked at children who had been diagnosed with Bipolar and concluded there was no evidence of mania in children under the age of thirteen, meaning no child that young should be getting the diagnosis of Bipolar. Other researchers disagree.

Stringaris did find that of those children who had brief episodes, too brief to meet criteria for a hypomanic episode, fully 25% did go on to develop all the symptoms needed to diagnose Bipolar Disorder within two years. His conclusion is that we should wait until the teen years and the full criterion is met before diagnosing Bipolar Disorder.

This is a problem for me. Why would we begin treating a child if they do not have an illness? No diagnosis no treatment. So to get the family the help they need, we need the diagnosis. If not Bipolar Disorder then what would we call this child’s problem? Also, the study tells us that 25% of these brief episodes will develop symptoms in 2 years. What about 10 years or 20?  I have not yet found research that answers those questions.

Early onset researchers come up with a different answer. Telling us that – Mania, Bipolar one, mostly starts in the adolescent period (McNamara, 2010.) This study goes on to cite 6 factors that may constitute risk factors for the early development of Bipolar Disorder.

One significant risk factor is a history of being the victim of abuse and neglect. We know that early childhood experiences can induce changes in the wiring of the brain. So can later life traumas. Psycho-social stressors are also listed as risk factors. These are also risk factors for personality disorders and other mental illnesses.

This tells us that experience and learning can be risk factors for developing Bipolar Disorder.

A family history of Bipolar is also a risk factor. Not just family members living in the home, but first-degree family members who have any mood disorder, whether in the home or not, appear to increase the risk of developing Bipolar.

That says that heredity is a risk factor for Bipolar Disorder.

A history of substance abuse, prescribed antidepressants and stimulants and dietary deficiencies all have been implicated as having a connection to Bipolar disorder.

See: Do medications and drugs cause Mania or Bipolar Disorder and other Co-occurring blog posts

Lastly, McNamara sums up the argument for diagnosing Bipolar Disorder in children by saying that most people who go on to get the diagnosis had “prodromal” or early symptoms 10 full years before they were diagnosed.

We know from other mental health research that the sooner an illness is recognized and treated the better the chance of a full recovery.

My opinion

Children who have a brief – one day temper or behavioral outburst are unlikely to be having Bipolar disorder. This is anger or bad behavior and you should try treating them for anger and behavior first. But the pattern needs monitoring.

There are dangers from over treating psychiatric illnesses in children and there are dangers of under-treating. Pick a provider you trust and listen to their advice and judgment. I especially recommend a consultation with a child psychiatrist whenever possible.

Don’t adopt a wait and attitude, even if you decide to skip the medication for now, if your child has these kinds of symptoms get the child counseling or therapy.

Care to share or comment?

Has your child had outbursts that looked like mania or hypomania and have you considered the possibility they may have Bipolar disorder?

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

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Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

Types of Mania and Dual Mania

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Person with masks

Bipolar.
Photo courtesy of Pixabay.com

How many types of mania are there?

Just what mental health symptoms are illnesses and how many mental illnesses are there? Counting Manias is especially difficult.

We think we know mania when we see it, but it is such a diverse group of symptoms that it has become established as “manic episodes” that are building blocks of diagnosis, rather than separate diagnoses. It functions primarily to separate Bipolar Disorder, formerly called manic-depressive disorder from the other depressive conditions.

Mania has been described as the most heterogeneous mental health symptom there is, raising the question “When we say mania are we all talking about the same thing?” Are there types of mania that have different causes and indicate varying diseases?

Currently, there are over 400 recognized disorders or conditions that might be the focus of treatment in the DSM-4. As you may have seen from previous posts many of these disorders have lots of subtypes that look differently in practice and may require different treatments.

Mania and Bipolar disorders are especially difficult because of their wide diversity of symptoms. For more on the DSM-4 and some to be DSM-5 descriptions see: What is mania? And What is hypomania?

Encarta Dictionary definitions of mania include:
1. An excessive and intense interest or enthusiasm for something and 2. A psychiatric disorder characterized by excessive physical activity, rapidly changing ideas and impulsive behavior. The two uses of the word mania don’t have a lot in common.

Kraepelin, whose work has formed much of the foundation for modern efforts to divide up and diagnose illnesses, reported there were 6 types of mania. His distinctions seem to have been blended together into the one thing we now call Mania. But are all manias really the same?

Research has been less than helpful here as most researchers exclude a lot of people from their studies. If you exclude enough people, for enough reasons, the group left may look all alike. That does not mean the resulting study tells us anything about the various problems people with mania are undergoing.

One study (Haro et al., 2006) tells us that they found three very different forms of mania. The most common form of mania they called “typical mania” and this group contained 60% of the people in the study. But the other 40% had symptoms that were so different that the authors separated them into two additional subtypes of mania.

Psychotic mania is not like “Typical mania.”

Psychotic symptoms sometimes end up in making mania for a bipolar diagnosis but psychotic episodes can occur in other illnesses such as schizophrenia. It is common for families to have members who have been diagnosed with bipolar disorders and others who were diagnosed with schizophrenia. Psychotic mania looks a lot like psychosis and bipolar at the same time, but then we have another illness schizoaffective disorder to use for that also. This leaves the diagnosis of psychotic Bipolar in doubt. I have seen doctors record a diagnosis of schizophrenia – bipolar type.

Dual Mania is similar to other dual diagnoses

Dual Mania was described by Haro et al. as significantly different from other types of mania. Dual-diagnosis mania has been poorly recognized simply because most people who abuse substances are routinely excluded from research studies. Haro et al. report that this systematic exclusion of people with multiple problems leaves a huge gap in our understanding of mania and therefore Bipolar Disorder.

Dual Diagnosis client with mania spent significantly more days in the psychiatric hospital and had more suicide attempts. This is consistent with other studies that have shown people with Bipolar Two are at the highest risk for a suicide attempt and that people who abuse substances have higher risks also. Unfortunately acutely suicidal clients are also routinely excluded from studies of mania and Bipolar Disorders despite there being overrepresented in substance abuse treatment and acute psychiatric facilities.

Other characteristics of clients with “dual mania” included being male and younger than others with a manic episode. Dual mania resulted in higher disability levels. Dual mania was also more likely to cause job and relational problems.

Of those clients in the Haro et al study, 25% had a history of alcohol abuse. Of those with dual mania, 40% had a history of marijuana use or abuse. So that means many dual mania clients had abused both.

In substance abuse treatment the pattern of alcohol and marijuana use coupled with job, relational and legal problems is so common as to be almost universal. Among those in treatment for methamphetamine abuse, manic and hypomanic symptoms are commonly reported even when the client is not using drugs. Episodes of manic or hypomanic symptoms are also commonly reported as triggers for substance abuse relapse.

Of those with long-term mania and multiple hospitalizations the “aggressive type, ” all had histories of substance abuse (Soto, 2003.) This study did not specifically include a substance abuse type of mania but noted that among those with long-term mania and a history of substance abuse those who had not used in the last 30 days were no different than those who had used or drank. The suggestion to me is that there is something different about those who experience mania and abuse substances. Mania predisposes people to abuse substances and both conditions need to be treated.

My conclusion

The continued exclusion of substance abusers and those who are suicidal results in research data that excludes those at highest risk and those who most use mental health services.

Comments on Mania, Bipolar co-occurring disorder, and recovery and most anything mental health related are always welcomed.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

How is Hypomania different from Mania or a Manic Episode?

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Person with masks

Bipolar.
Photo courtesy of Pixabay.com

Hypomanic Episodes.

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.

The result?

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.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

Do medications or drugs cause mania or Bipolar disorder?

By David Joel Miller MS, Licensed Therapist & Licensed Counselor.

Drugs.

Drugs.
Photo courtesy of Pixabay.

A connection between taking medication, abusing drugs and Bipolar Mania?

The question of connections between “drugs” and various mental illnesses is a huge concern.  We have known for a long time that there is a connection between some chemicals and Mania. The connection to Bipolar Disorders, formerly called Manic Depressive Disorder, is more problematic.

People seem to think that because a medication is prescribed by a doctor or can be purchased over the counter, it is safe. The huge increase in abuse of prescription medication has made us question that. Now there is evidence that not just street drugs but prescription medications may be setting off episodes of mania.

We all pretty much intuitively know what depression looks like. But Bipolar Disorder that is something else. The official definition of Bipolar disorder requires a lot more than just moodiness.

To get the diagnosis of bipolar you need to have had an episode of mania or hypomania. But the DSM excludes from diagnoses symptoms caused by drugs of abuse. For Bipolar Disorder this includes Bipolar symptoms that were caused by prescribed medications.

Do prescribed medications cause Mania or Hypomania? They sure do.

The creation of Manic symptoms by the taking of medications is so common that some researchers have proposed a separate “type” of Bipolar Disorder, Bipolar III, for those times when taking a medication causes manic symptoms (Akiskal 1999, 2003, Williams 2006.)

Here is the Bipolar medication dilemma.

Most people who get diagnosed with Bipolar Disorder have had one or more episodes of depression first. Then they have an episode of mania or hypomania and the diagnosis gets changed. Taking antidepressants is well known to result in propelling some people into a manic episode. This happens to about 10% of all people prescribed some antidepressants. Also if someone has EVER had an episode of mania or hypomania that risk of sudden switching increases to 20% (Breggin 2010.)

That drug or medication-induced mania is specifically excluded from the diagnosis under the DSM-4.

In practice, it has come to be common that a person who has a sudden extreme reaction to an antidepressant is a likely candidate for a Bipolar Diagnosis despite the DSM-4 exclusion.

If it was only antidepressants that created mania things would be simple. Lots of other drugs and medications can result in manic or near manic episodes.

There is a huge difference between someone being “maniacy” when under the influence or while withdrawing and those people who take a medication one time and are propelled into recurring bouts of mania or hypomania.

We see manic-like symptoms in people who use and abuse stimulants. Even excess of caffeine can create those sort of symptoms. But medications that we do not think of as stimulants can cause manic and hypomanic episodes.

Antibiotics have been shown to induce manic episodes. So have anti-anxiety meds and some over the counter medications. Other medications like steroids, both prescribed and abused have been suspected of creating this effect also. That connection remains uncertain.

So the question becomes, “Do prescribe medications create a manic episode?” It looks like the answer to that is yes, sometimes they do. Does that mean this is just an allergic reaction or side effect of that medication? This is iffier as some people have that response and others don’t.

Is it possible that people who have an undiagnosed Bipolar Disorder are likely to be propelled into a manic or hypomanic episode when they are exposed to a medication to which they are sensitive?  I am inclined to think so.

We also see a huge overlap between substance abuse disorders, especially alcohol abuse, and Bipolar Disorders. Does alcohol abuse cause a Bipolar condition? Are people with undiagnosed Bipolar Disorder more likely to abuse alcohol?

Does this medication-induced mania matter? Williams says it does and reports that the rate of suicide attempts by people who switch to mania as a result of taking an antidepressant is even higher than for those with Bipolar II.

But there is more

People with anxiety are sometimes treated with an antidepressant. They also can experience an episode of mania or hypomania.

All this points out to me that with all we know about Bipolar Disorder there is still a lot more we don’t know and a lot more research is needed in this area.

It also suggests that there may be multiple types of Bipolar or even several different disorders currently being lumped together under one name.

For more on Bipolar disorders see:

Hyperthymia and Bipolar Disorder

Do drugs cause mental illness?

Bipolar – Misdiagnosed or missing diagnosis?

Bipolar or Major Depression?

Bipolar doesn’t mean moody    

Or the category list to the right.

Anyone have the experience of taking or doing something and then having an episode of Mania which resulted in the diagnosis of Bipolar Disorder that you would care to share?

Staying connected with David Joel Miller

Three David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

SasquatchWandering through a hole in time, they encounter Sasquatch. Can they survive? The guests had come to Meditation Mountain to find themselves. Trapped in the Menhirs during a sudden desert storm, two guests move through a porthole in time and encounter long extinct monsters. They want to get back to their own time, but the Sasquatch intends to kill them.

For these and my upcoming books; please visit my Author Page – David Joel Miller

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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 my Facebook author’s page, davidjoelmillerwriter. If you are in the Fresno California area, information about my private practice is at counselorfresno.com. Do drugs cause mania?

What is Mania or a Manic Episode?

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Person with masks

Bipolar.
Photo courtesy of Pixabay.com

Manic Episodes.

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.

The result

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.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.