Hypomania
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This article is an expansion of a section entitled Hypomania from within the main article: Bipolar disorder
Hypomania is a state involving a combination of: elevated mood, irritability, racing thoughts, people-seeking, hypersexuality, grandiose thinking, religiosity, and pressured speech. Bipolar II Disorder is characterized by states of hypomania and depression. Hypomania is a less severe form of mania without progression to psychosis. Many of the symptoms of mania are present, but to a lesser degree than in overt mania. People with hypomania are generally perceived as being energetic, euphoric, overflowing with new ideas, and sometimes highly confident and charismatic, and unlike full-blown mania, they are sufficiently capable of coherent thought and action to participate in everyday life.

Although the DSM-IV-TR classifies hypomania as a mood episode, it is only considered part of bipolar disorder in the context of cycles into depression or more severe mania. A small percentage of the population may experience hypomania without ever having experienced depression or mania. Although some of these people may require treatment or therapy, according to DSM criteria they do not have bipolar disorder.

John D. Gartner's The Hypomanic Edge (Simon and Schuster) "draws a line between hypomania - recognized by such markers as inflated self-esteem, a decreased need for sleep, and episodes of risky behavior - and its far more dangerous cousin, mania." He then goes on to illustrate his thesis that there may be an "up" side to the less dangerous hypomania. His thesis includes a strong link between "(a little) Craziness and (a Lot of) Success." Gartner contends that many famous people including Christopher Columbus, Alexander Hamilton, Andrew Carnegie, Louis B Mayer, and Craig Venter (who mapped the human genome) owed their ideas and drive (and eccentricities) to their hypomanic temperaments (it is called the hyperthymic temperament in clinical research). It is questionable whether hypomania occurs without being part of a cycle of mania or depression. Patients rarely, if ever, seek out a psychiatrist complaining of hypomania. The creativity and risky behavior associated with hypomania (and bipolar disorder in general) may suggest why it has survived evolutionary pressures.

Although hypomania sounds in many ways like a desirable condition, it can have significant downsides. Many of the negative symptoms of mania can be present; the primary differentiating factor is the absence of psychosis. Many hypomanic patients have symptoms of disrupted sleep patterns, irritability, racing thoughts, obsessional traits, and poor judgment. Hypomania, like mania, can be associated with recklessness, excessive spending, risky hypersexual activity, general lack of judgment and out-of-character behaviour that the patient may later regret and may cause significant social, interpersonal, career and financial problems.

Hypomania can also signal the beginning of a more severe manic episode, and in people who know that they suffer from bipolar disorder, can be viewed as a warning sign that a manic episode is on the way, allowing them to seek medical treatment while they are still sufficiently self-aware before full-blown mania occurs.



Deceptive Hypomania: Energies Bop, Inhibitions Drop, Ideas Pop


by John McManamy
Thursday, February 23rd, 2006
No one wants to be depressed. Everyone, on the other hand, wants to be hypomanic. Think of hypomania as “mania lite,” for the time being, an elevated mood state that is better than any recreational drug high. Energies bop, inhibitions drop, ideas pop. This is the kind of personality makeover we all pray will happen to us – salesperson of the month productivity combined with life-of-party sociability.

So “right” does hypomania feel to most of us that we are inclined to mistake this state of well-being for our normal selves, Life is a cabaret. Who wants the party to stop? Not surprisingly, psychiatrists never encounter individuals walking into their office for the first time complaining of hypomania.

Psychiatrists and therapists inevitably wag their finger at the mention of hypomania. They’ve seen the consequences in far too many of their patients and clients. Sure, mild hypomania may make us the envy of the human race, but ratchet up the mood a degree or two and we start doing stupid things, make stupid decisions. This may range from spending way too much money to sleeping around to dancing on tables.

Now trouble is brewing. Overly hypomanic individuals are well on the way to destroying their finances, their relationships, their careers, and more, with no insight into the risks they are exposing themselves to. The cabaret is out of control. Life is a parody rather than a party. Events and conversations become out of sync and decidedly unpleasant. No one understands. Everyone is stupid. It’s all their fault. Anger erupts. Voices are raised …

The roller coaster ride is about to begin in earnest. For some, the crash into depression may happen. For others, the terror of full-blown mania is about to take hold.

And there is the psychiatrist or therapist, with knowing looks, saying, “I told you so.”

But how much does psychiatry truly know about hypomania? The answer is surprisingly – and inexcusably – precious little. The pioneering clinician Emil Kraepelin indentified hypomania in his classic 1920 opus, but until last year no book appeared with the term in the title.

Studies on hypomania are virtually nonexistent, absolutely ZERO clinical trials have been done on treating patients with hypomania, treatment guidelines are entirely silent on this critical phase of the illness, and the DSM provides precious little guidance.

One result is some overly-cautious psychiatrists who err on the side of overmedicating us. Patients then complain to their clinically deaf psychiatrists about feeling like zombies and having to put up with other burdensome side effects. Frustrated, these patients may quit on their meds, with predictable results.

And there’s the psychiatrist, knowing wagging his finger, blaming the poor patient.

In the next several blogs, we will discuss how some experts are challenging commonly-held assumptions, and what they are recommending to patients. Yes, hypomania poses a real danger, but for some of us it may be close to our true baseline, part of our true temperament. Are the people who treat you aware of this? Are they doing anything about it?

Hypomania Part II: What It Means for Depression Treatment


by John McManamy
Monday, February 27th, 2006
Conventional wisdom states that hypomania (see my Feb 23 blog) is a psychopathology that needs to be avoided at all costs. Surprisingly, a literal reading of the DSM does not give that impression.

You could have knocked me over with a feather when, a few years back, I carefully read what the DSM had to say about hypomania. There was the usual laundry list of symptoms, but nowhere was it expressly stated that hypomania ALONE automatically justified admission to the bipolar club. Instead, says the DSM, hypomania needs to be tag-teamed with depression to qualify for the diagnosis of bipolar II. (For bipolar I, mania alone will do.)

This means if your psychiatrist first sees you when you feel like Shizuka Arakawa after winning a gold medal in figure skating then he or she needs to probe for a history of depression. The catch is no one books emergency visits to psychiatrists when they are feeling on top of the world.

Typically, patients seek help when they are depressed. But it is impossibly difficult for individuals who feel depressed to accurately recall those times in their lives when they felt normal or better than normal. Not surprisingly, according to a 1994 DBSA survey and corroborated in subsequent studies, it takes a bipolar patient about 10 years from the time he or she first seeks help to the time his or her psychiatrist (typically the third or fourth one) arrives at a correct diagnosis.

Just to make matters slightly more confusing: There is a very strange DSM diagnosis called bipolar NOS (not otherwise specified) that does give psychiatrists discretionary leeway, but you only have to imagine NOS being applied to criminal law (murder NOS) or quantum physics (itty-bitty small particles NOS) to see the absurdity of this classification.
So hypomania gives us a valuable insight into treating depression. But what about the hypomania, itself. Does hypomania truly justify treatment? And if so, how should it be treated? You would be amazed at what even the experts don’t know.

Hypomania Part III: Can Too Much Hypomania Be Bad For You?


by John McManamy
Monday, March 6th, 2006
In a provocative and important book published last year, “The Hypomanic Edge: The Link Between (A Little) Craziness and (A Lot) of Success in America,” John Gartner, Ph.D. of Johns Hopkins contends that in many individuals hypomania needs to be regarded more as a positive personality temperament than a pathology.

These are America’s success stories, your visionaries and go-getters who are “up” practically all the time without being too far up and who are down only when temporarily sidelined due to their own excesses.

What initially hooked me on the book was that I used to be a financial journalist, and that Dr. Gartner was writing about the very people I used to interview. In a pilot study he conducted, Dr. Gartner surveyed 10 Internet CEOs, and asked them to rate on a scale of one to five how certain personality traits (such as “feels brilliant, special, chosen, perhaps even destined to change the world”) applied to them. “Many,” he reported, “gave ratings that were right off the chart … One subject repeatedly begged me to let me give him a seven.”

Bipolar disorder is more prevalent in the US than in Europe, says Dr. Gartner, and his theory to explain this is that it took driven individuals who were crazy enough to risk their lives to leave their familiar surroundings at home for an uncertain future on a strange shore. Their genes live on in today’s generation of bright sparks, entrepreneurs and political and religious zealots.

In this context, genetic transmission refers to temperament as well as a biological predisposition to mental illness. In Darwinian terms, the risk of full-blown mania and depression justified the positive benefit in passing on high-performance DNA to the next generation.

Dr. Gartner illustrates his thesis by examining the lives of a number of figures who explored, settled, founded and otherwise defined America. Queen Isabella’s advisers, for example, thought Columbus was mad for more reasons than simply wanting to sail west to reach the East (such as wanting to use the profits from his venture to fund a new Crusade). The Puritans were religious fanatics, but they were also entrepreneurs whose “risk capital” amounted to their very lives.

Then there was Alexander Hamilton, who led a foolhardy charge at Yorktown, saved a fledgling nation from bankruptcy, set the scene for US capitalism and foolishly stopped Aaron Burr’s bullet. Yes, too much hypomania can be bad for you.

There was no keeping Andrew Carnegie down. A dirt-poor immigrant with big ambitions, young Carnegie came to the attention of his superiors by showing initiative and breaking the rules. He broke yet more rules by getting into steel in the middle of an economic depression. The rest is history.

Movie mogul Louis B. Mayer played golf five balls at a time, while geneticist Craig Ventner mapped the human genome years ahead of schedule, only to get fired from the company he founded. Hypomanic individuals can be a wacky and wild lot.

As Dr. Gartner’s book makes clear, even successful individuals with hypomanic temperaments can engage in self-destructive behavior. Treatment may be justified, but intervention shouldn’t be equated with medicating the personality out of individuals. This is what so many of our population are fearful of.
But lest we confuse hypomania with an exuberant joy ride, first we need to look at its dark side.

Hypomania Part IV: It Can Make Us Want to Crawl Out of Our Own Skin


by John McManamy
Friday, March 10th, 2006
Hypomania is not all fun and games.

While working on technical update to the DSM, Trisha Suppes MD, PhD of the University of Texas Medical Center in Dallas carefully read its criteria for hypomania, and had an epiphany. “I said, wait,” she told a UCLA grand rounds lecture in April 2003, “where are all those patients of mine who are hypomanic and say they don’t feel good?”

These are your typical road rage cases. Why was there no mention of that in hypomania? Dr Suppes wondered. A subsequent literature search yielded virtually no data.

The DSM defines hypomania as “a distinct period of persistently elevated, expansive, or irritable mood.” Note that overlooked word, irritable. We’re not talking about letting the good times roll. In an irritable state, depression symptoms typically intrude into hypomania, what is called a “mixed” state. Unaccountably, although the DSM acknowledges mixed states in full blown mania, it is silent on the phenomenon in hypomania.

Many of us wind up spending a good deal of our lives feeling miserable in hypomania, and in a study published in the October 2005 Archives of General Psychiatry, Dr. Suppes provided proof. Drawing from patients in seven clinics associated with the Stanley Foundation Bipolar Treatment Network, Dr. Suppes found that the majority of hypomanic patients “met criteria for mixed hypomania,” that is at least mild hypomania combined with at least mild depression.

Meanwhile, in a study published in Bipolar Disorders the same month, Hagop Akiskal, MD of the University of California, San Diego and Franco Benazzi, MD of the Hecker Outpatient Center (Ravenna) found individuals with “dysphoric hypomania” experienced more agitated depressions by a wide margin than “pure” bipolar II patients.

I see these individuals in my support group all the time, and I am often one of them. We tend not to feel comfortable in our own minds and own bodies, as if we need to crawl out of our skin. It’s as if our brains had a minor power surge and power outage at the same time. Predictably, we are not prime candidates for Miss Congeniality. This is where you want to throw Richard Simmons off the Carnival Cruise ship. Okay, many normal people feel that way, too, but in this state of mind you want to do it in waters frequented by sharks who are slow picky eaters.

The authors of both studies observe that because clinicians are under the misconception that hypomania is supposed to be euphoric, misdiagnosis is common. People who should be diagnosed as bipolar II instead are classified as having unipolar depression or some kind of personality disorder, then are put on the wrong treatments. (To learn more about treatments for depression, read our treatment guide.)

Not that we know the right treatments. There are no major studies involving treating patients with mixed hypomania, much less any mention in any of the treatment guidelines.

For this, the dark side of hypomania, we are truly in the dark ages.

Hypomania Part V: How Little We Really Know


by John McManamy
Thursday, March 16th, 2006
The conventional view is that hypomania is part of an illness rather than our true personality, and so requires medical intervention.

But hold on, you’re Alexander Hamilton and you’ve just come up with a brilliant plan that will guarantee a new nation’s solvency for generations to come. But there’s also this insufferable prat named Aaron Burr who is bugging the hell out of you.

Now imagine you’re Hamilton’s psychiatrist. Do you reach for the Zyprexa?

Not so fast, says John Gartner, PhD, author of The Hypomanic Edge: The Link Between (a Little) Craziness) and (a Lot of) Success in America. Rather than part of an illness, Dr Gartner contends that in many individuals hypomania may be a true part of a person’s temperament – the good, the bad, and the ugly. Yes, it may be okay to reach for the prescription pad to tone down Hamilton just a tad – just enough to keep his hot head from getting hotter – but not enough to medicate the brilliance out of him.

That was the gist of an interview I had last year with Dr. Gartner. His remarks came to me as such a breath of fresh air that I could only think, “Man, the psychiatric establishment is going to hate this guy.”

I did my own research and what I found – or rather didn’t find – truly dismayed me: A PubMed search from May last year revealed only 652 article entries for hypomania vs 19,537 for mania and 176,667 for depression. There were no published clinical trials for treating patients with hypomania, and no information in any of the treatment guidelines on what to do for patients in this state of mind.

In short, psychiatry has no authority – zero, zip, nada – for treating patients with hypomania, an extremely frightening thought considering how common this phase of the illness is. Standard practice, instead, involves extrapolating from studies and clinical experience involving patients having manic episodes. These tend to be your 911 cases who generally require meds overkill to bring them out of danger.

But Alexander Hamilton was not a 911 case, though we know he was a slowly ticking time bomb. What do we do? Dr. Gartner likens the situation to the pitcher in Bull Durham with the 100 MPH fast-ball who keeps beaning the mascot. We want to slow him down a little bit so he has control, but not so he throws at 50 MPH. Dr. Gartner refers to this as “taking the edge off of the edge.”

This may involve careful micro-adjustments with small doses until you and your psychiatrist find the sweet spot. The sweet spot for you may be mildly hypomanic, with room to cycle down as well as shift sideways into occasional grumpy periods – in short, you. It feels right and you feel reasonably safe.

It’s a different story if you don’t feel reasonably safe. Many people only know hypomania as the prelude to something dreadful about to happen, either as the beginning of an ascent into mania or the start of a long drop into depression. If you’re one of these individuals, you already know that immediate and unequivocal meds intervention is a must.

Psychiatrists have good reason to be fearful of hypomania. But we often tend to fear most the things we know least. Oh, how little we know.

Hypomania Part VI: Coping


by John McManamy
Friday, March 31st, 2006
In previous blogs, I pointed out how frighteningly little the psychiatric profession knows about hypomania and its treatment. The best information we have, believe it or not, comes from our fellow patients.

In an eye-opening article in the March 2005 Australian and New Zealand Journal of Psychiatry, Sarah Russell PhD of the Melbourne-based Research Matters reported on her survey of 100 bipolar patients who were doing well and what they did to stay well. So novel was the idea of a researcher actually seeking advice from patients that I awarded Dr Russell with “Study of the Year” honors in a newsletter I publish.

Dr Russell’s findings were recently expanded into a small but highly informative book, A Lifelong Journey: Staying Well with Manic Depression/Bipolar Disorder. The book deals with how patients successfully manage all phases of their illness, but what they have to say about controlling their swings into hypomania is particularly insightful:

Jodie, who has been free of serious episodes for three years, has learned to take her pills without resentment, has limited her social activities and involvement in various projects, and has established a regular sleep schedule and other routines. Especially important, Jodie has developed “the capacity and insight to see episodes coming on.” For example, when she finds herself talking very quickly and craving excitement, she implements her “action plan.”

By the time the hypomanic good times start to roll, Dr. Russell points out, it’s generally too late for most of us. Instead, the people she talked to were microscopically attuned to far more subtle shifts in their moods and behaviors and energy levels, as well as their environment. Rather than simply taking their meds and forgetting about their illness (an impression created by their doctors), patients would “move swiftly to intercept a mood swing.” Moving swiftly often meant a decent night’s sleep and other strategic stop and smell the roses moments.

Susie, for instance, knows her main triggers are family stress and caffeine. When she finds herself buying more than one lotto ticket, visiting adult bookshops and writing late at night, she goes to battle stations. This includes limiting her coffee, restricting her access to cash, turning off her computer after 6 pm, and not going to night clubs on her own.

The people Dr. Russell talked to were uniformly fanatic about maintaining their sleep. When disruptions to their routines did happen, these individuals did not hesitate to take a sleep medication. Adjusting meds doses was par for the course, but meds changes were seen as minor compared to the life and lifestyle changes Susie and Jodie and the others were willing to make.

Common tools included yoga and other stress-busters, but Dr. Russell was quick to note that some found these practices boring. Basically, we are all unique and need to come up with our means of coping. The people in Dr. Russell’s study were smart enough to do just that.

Hypomania Part VII: We Are Not Helpless Bystanders


by John McManamy
Thursday, April 13th, 2006
Last year I received a request from a publisher to write a blurb for an upcoming book entitled, “The Bipolar Workbook: Tools for Controlling Your Mood Swings.” I’m fairly skeptical of workbooks, but I had heard the author Monica Basco PhD of the University of Texas Southwestern Medical Center at Dallas speak at a conference several years back.

“I do not believe you should be a passive recipient of care,” she told me at that conference. So I gave the publisher the go-ahead to send me a manuscript copy of the book.

“The era of take your meds and shut up is over,” I wrote after reading the manuscript. Naturally, I didn’t expect the publisher to use my remarks, but there I was six months later on the back cover, featured as the top blurb. “Yes, we need our meds,” I went on to say, “but we also require the personal skills to be smart and vigilant about our illness.”

Dr. Basco is a leading proponent of cognitive behavioral therapy. The therapy is used extensively for treating depression, and is starting to come into its own to catch swings into hypomania and mania. The first section of “The Bipolar Workbook” sets the tone: “See It Coming,” says the heading. Emotions such as sadness or euphoria, Dr. Basco says, change the type of things you think about, as well as the quality of your thinking, which affects behavior.

Her book covers all aspects of bipolar disorder, but what she has to say about nipping baby manias in the bud is particularly apropos. For instance, the euphoria of a brewing mania can bring on the perception of a bright idea and the impetus to take on a new enterprise. This may lead one to stay up all night working on the idea, which sets us up for arriving at our day job exhausted and with racing thoughts. The bullet train to our next serious episode is about to leave the station.

“The problem was not the project,” Dr. Basco writes. “The problem was the timing … Emotions can set you up to overreact to internal or external events.”

”Walk away from the situation,” Dr. Basco advises. Take time to evaluate it. Sleep on it, get the advice of your friends. Count to ten.

Self-knowledge is the key. Most of us have learned the hard way. We don’t want to go there again. From our bitter experience we can take stock, spot patterns, recognize triggers. Dr. Basco uses various terms, but what she is driving at is mindfulness, the ability to recognize when the brain is starting to play tricks on us. We may personalize, catastrophize, engage in mind-reading and fortune-telling, think in absolutes, and on and on.

Catch the distortions in thinking as they occur, Dr. Basco advises, Control them by keeping them from influencing your behavior. Correct any errors in your logic.

Cognitive behavioral therapy is manual-based (no idle chit-chat), time limited (10 or 12 sessions max), and focuses on the here and now (you can’t change what happened in your childhood).

Because the therapy delivers results, it gets a strong thumbs-up from those in my support group who have tried it. Your medical plan may pick up the tab, but the short-term aspect of the therapy means you can contain your costs if you’re forced to foot the bill.