Bipolar disorder (previously known as manic depression) is a psychiatric diagnostic category describing a class of mood disorders in which the person experiences clinical depression and/or mania, hypomania, and/or mixed states. Persons suffering from the disorder are considered to be disabled.

Cases of bipolar disorder are generally divided into two diagnostic categories, Bipolar I and Bipolar II. Left untreated, bipolar disorder can be a severely disabling condition, with a risk of death through suicide.

The difference between bipolar disorder and unipolar disorder (also called major depression) is that bipolar disorder involves both elevated and depressive mood states. The duration and intensity of mood states varies widely among people with the illness. Fluctuating from one mood state to the next is called "cycling". Mood swings can cause impairment or improved functioning depending on their severity. There can be changes in one's energy level, sleep pattern, activity level, social rhythms and cognitive functioning. During these times, some people may have difficulty functioning.

Domains of the bipolar spectrum
Bipolar disorder is, almost without exception, a life-long condition that must be carefully managed throughout the individual's lifetime. Because there are many manifestations of the illness, it is increasingly being called bipolar spectrum disorder. The spectrum concept refers to subtypes of bipolar disorder that are sub-syndromal (below the symptom threshold) and typically misdiagnosed as depression. Nassir Ghaemi, M.D., has also contributed to the development of a bipolar spectrum questionnaire. The full bipolar spectrum includes all states or phases of the bipolar disorders.

Bipolar depression
The vast majority of people diagnosed with, or who may be diagnosed with, bipolar disorder suffer from clinical depression. In fact, there is at least a 3 to 1 ratio of time spent depressed versus time spent among euthymic (normal mood), hypomanic and manic states during the course of the bipolar I subtype of the illness. People with the bipolar II subtype remain depressed for substantially longer (37 times longer) according to the study findings discussed in the epidemiology section below.

According to the Mayo Clinic, in the depressive phase, signs and symptoms include: persistent feelings of sadness, anxiety, guilt or hopelessness, disturbances in sleep and appetite, fatigue and loss of interest in daily activities, problems concentrating, irritability, chronic pain without a known cause, recurring thoughts of suicide.[3]

A 2003 study by Robert Hirschfeld, M.D., of the University of Texas, Galveston found bipolar patients fared worse in their depressions than unipolar patients. (See Bipolar Depression.) In terms of disability, lost years of productivity, and potential for suicide, bipolar depression, which is different (in terms of treatment), from unipolar depression, is now recognized as the most insidious aspect of the illness.

Severe depression may be accompanied by symptoms of psychosis. These symptoms include hallucinations (hearing, seeing, or otherwise sensing the presence of stimuli that are not there) and delusions (false personal beliefs that are not subject to reason or contradictory evidence and are not explained by a person's cultural concepts). They may also suffer from paranoid thoughts of being persecuted or monitored by some powerful entity such as the government or a hostile force. Intense and unusual religious beliefs may also be present, such as patients' strong insistence that they have a God-given role to play in the world, a great and historic mission to accomplish, or even that they possess supernatural powers. Delusions in a depression may be far more distressing, sometimes taking the form of intense guilt for supposed wrongs that the patient believes he or she has inflicted on others.

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Mania
Main article: Mania
Researchers at Duke University have refined Kraepelin’s four classes of mania to include hypomania (featuring mainly euphoria), severe mania (including euphoria, grandiosity, high levels of sexual drive, irritability, volatility, psychosis, paranoia, and hostility and aggression), extreme mania (most of the displeasures, hardly any of the pleasures) also known as dysphoric mania, and two forms of mixed mania (where depressive and manic symptoms collide).[1]

The Mayo Clinic and others list as additional possible symptoms of mania: elation, extreme optimism, rapid unstoppable flow of speech, racing thoughts/flights of ideas, agitation, poor judgment, recklessness or taking chances not normally taken, inordinate capacity for activity, difficulty sleeping or lesser need for sleep, tendency to be easily distracted (may constantly shift from one theme or endeavor to another), inability to concentrate, exuberant and flamboyant or colorful dress, authoritative manner, and tendency to believe they are in their best mental state.[4]

Manic patients may be inexhaustibly, excessively, and impulsively involved in various activities without recognizing the inherent social dangers.

Symptoms of psychosis include hallucinations (hearing, seeing, or otherwise sensing the presence of stimuli that are not there) and delusions (false personal beliefs that are not subject to reason or contradictory evidence and are not explained by a person's cultural concepts). Feelings of paranoia, during which the patient believes he or she is being persecuted or monitored by the government or a hostile force. Intense and unusual religious beliefs may also be present, such as a patient's strong insistence that they have a God-given role to play in the world, a great and historic mission to accomplish, or even that they possess supernatural powers. Delusions may or may not be mood congruent.

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Mania and over-the-counter drugs
Phenylpropanolamine or (PPA) is a sympathomimetic drug similar in structure to amphetamine which is present in over 130 medications, primarily decongestants, cough/cold remedies, and anorectic agents.

A report on phenylpropanolamine from the Dept. of Psychiatry, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Pharmacopsychiatry 1988 stated:

We have reviewed 37 cases (published in North America and Europe since 1960) that received diagnoses of acute mania, paranoid schizophrenia, and organic psychosis and that were attributed to PPA product ingestion. Of the 27 North American case reports, more reactions followed the ingestion of combination products than preparations containing PPA alone; more occurred after ingestion of over-the-counter products than those obtained by prescription or on-the-street; and more of the cases followed ingestion of recommended doses than overdoses.
Some reference books have noted that some people developed mental illness symptoms after flu like symptoms, the probability or link to the over-the-counter medications they were taking for their symptoms was sometimes overlooked.

Failure to recognize PPA as an etiological agent in the onset of symptoms usually led to a diagnosis of schizophrenia or mania, lengthy hospitalization, and treatment with substantial doses of neuroleptics or lithium.
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Hypomania
Main article: Hypomania
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.

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Mixed state
Main article: Mixed state (psychiatry)
In the context of bipolar disorder, a mixed state is a condition during which symptoms of mania (or hypomania) and clinical depression occur simultaneously (for example, agitation, anxiety, fatigue, guilt, impulsiveness, insomnia, disturbances appetite, irritability, morbid and/or suicidal ideation, panic, paranoia, psychosis, pressured speech, indecisiveness and rage). [5]

In at least 1/3 of persons with bipolar disorders, the entire attack--or a succession of attacks--occurs as a mixed episode.

Mixed states can be the most dangerous period of mood disorders, during which panic attacks, substance abuse, and suicide attempts increase greatly.

A dysphoric mania consists of a manic episode with depressive symptoms. Increased energy and some form of anger, from irritability to full blown rage, are the most common symptoms. Symptoms may also include auditory hallucinations, confusion, insomnia, persecutory delusions, racing thoughts, restlessness, and suicidal ideation.

Alcohol, drugs of abuse, and antidepressant drugs may trigger or aggravate dysphoric mania in susceptible individuals.

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Cycling
Rapid cycling, defined as having four or more episodes per year, is found in a significant fraction of patients with bipolar disorder.

Ultradian cycling, in which mood cycling can also occur daily or even hourly, is less common. (Although the concept of ultradian cycling has been accepted by many psychiatrists, whether it represents true cycling is far from established.)[6]

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Cognition
Numerous studies show that bipolar disorder affects a patient's ability to think and perform mental tasks, even in states of remission.[2] Deborah Yurgelun-Todd of McLean Hospital in Belmont, Massachusetts has argued these deficits should be included as a core feature of bipolar disorder.

By the same token, research by Kay Redfield Jamison of Johns Hopkins University and others has attributed high rates of creativity and productivity to certain individuals with bipolar disorder. (See Brain Damage.)

There may be no conflict here: Cognitive dysfunction does not necessarily bar creativity.

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Suicide risk
People with bipolar disorder are about three times[citation needed] as likely to commit suicide as those suffering from major depression (12% to 30%).[citation needed] Although many people with bipolar disorder who attempt suicide never actually complete it, the annual average suicide rate in men and women with diagnosed bipolar disorder (0.4%) is 10 to more than 20 times that in the general population [7][8]

Individuals with bipolar disorder tend to become suicidal, especially during mixed states such as dysphoric hypomania and agitated depression. Suicidal symptoms include:

Talking about feeling suicidal or wanting to die
Feeling hopeless, that nothing will ever change or get better
Feeling helpless, that nothing makes a difference
Feeling like a burden to family and friends
Putting affairs in order (for example, organizing finances (paying debts) or giving away possessions to prepare for one's death)
Putting oneself in harm's way, or in situations where there is a danger of being killed
Abusing alcohol or drugs
A patient with these symptoms (or anyone related to said patient) could do the following:

Call the patient's doctor, emergency room, or the emergency telephone number right away to get immediate help
Make sure the suicidal person (be it self or somebody else) is not left alone
Make sure access to large amounts of medication, weapons, or other items that could be used, is prevented
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Diagnosis
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Diagnostic criteria
Main article: Current diagnostic criteria for bipolar disorder
Flux is the fundamental nature of bipolar disorder. Both within and between individuals with the illness, energy, mood, thought, sleep, and activity are among the continually changing biological markers of the disorder. The diagnostic subtypes of bipolar disorder are thus static descriptions--snapshots, perhaps--of an illness in change. Individuals may stay in one subtype, or change into another, over the course of their illness. The DSM V, to be published in 2011, will likely include further subtyping (Akiskal and Ghaemi, 2006).

There are currently 4 types of bipolar illness. The DSM-IV-TR details 4 categories of bipolar disorder, Bipolar I, Bipolar II, Cyclothymia, and Bipolar Disorder NOS (Not Otherwise Specified).

According to the DSM-IV-TR, a diagnosis of Bipolar I disorder requires one or more manic or mixed episodes. A depressive episode is not required for a diagnosis of BP I disorder, although the overwhelming majority of people with BP I suffer from them as well.

Bipolar II, the more common but by no means less severe type of the disorder, is characterized by some episodes of hypomania and disabling, severe depression; crippling depression with episodes of hypomania. A diagnosis of bipolar II disorder requires at least one hypomanic episode. This is used mainly to differentiate it from unipolar depression. Although a patient may be depressed, it is very important to find out from the patient or patient's family or friends if hypomania has ever been present, using careful questioning. This, again, avoids the antidepressant problem. Recent screening tools such as the Hypomanic Check List Questionnaire (HCL-32) have been developed to assist the sometimes difficult detection of Bipolar II disorders.

A diagnosis of Cyclothymic Disorder requires the presence of numerous hypomanic episodes, intermingled with depressive episodes that do not meet full criteria for major depressive episodes. The main idea here is that there is a low-grade cycling of mood which appears to the observer as a personality trait, but interferes with functioning.

If an individual clearly seems to be suffering from some type of bipolar disorder but does not meet the criteria for one of the subtypes above, he or she receives a diagnosis of Bipolar Disorder NOS (Not Otherwise Specified).

The criteria for "major depression" may apply to unipolar or bipolar depression.

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Misdiagnosis
There are many problems with symptom accuracy, relevance, and reliability in making a diagnosis of bipolar disorder in the DSM-IV-TR. These problems all too often lead to misdiagnosis.

In fact, University of California at San Diego's Hagop Akiskal M.D. believes that the way the bipolar disorders in the DSM are conceptualized and presented routinely lead many primary care doctors and mental health professionals to misdiagnose bipolar patients with unipolar depression, when a careful history from patient, family, and/or friends would yield the correct diagnosis.

If misdiagnosed with depression, patients are usually prescribed antidepressants, and the person with bipolar depression can become agitated, angry, hostile, suicidal, and even homicidal (these are all symptoms of hypomania, mania, and mixed states).

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Treatment lag
The behavioral manifestations of bipolar disorder are often not recognized by mental health professionals, so people may suffer unnecessarily for many years (over 10 years, according to research conducted by bipolar disorders expert Nassir Ghaemi M.D.) before receiving proper treatment.

That treatment lag is apparently not decreasing, even though there is now increased public awareness of the illness in popular magazines and health websites. Recent TV specials, for example MTV's "True Life: I'm Bipolar", talk shows, and public radio shows have focused on mental illnesses thereby further raising public awareness.

Despite this increased focus, individuals are still commonly misdiagnosed. (See the 2005 American Journal of Managed Care.)

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Children
Bipolar disorder is a frequent co-morbid condition among children who have experienced early chronic maltreatment, such as physical and sexual abuse or neglect, and who have Reactive attachment disorder.

There is a strong genetic component to this disorder, and parents who severely maltreat their children are themselves likely to suffer from significant mental health issues, such as Bipolar disorder.

About 50% of children who have Reactive attachment disorder also have Bipolar I disorder. [3]. Children with Bipolar disorder often do not meet the strict DSM-IV definition, because in pediatric cases the cycling can occur very quickly (see section above on rapid cycling). [4].

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Treatment
Main article: Treatment of bipolar disorder
Currently, bipolar disorder has not been cured, though many psychiatrists and psychologists believe that it can be managed.

The emphasis of treatment is on effective management of the long-term course of the illness, which can involve treatment of emergent symptoms. Treatment methods include pharmacological and psychological techniques.

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Prognosis and the goals of long-term treatment
A good prognosis results from good treatment which, in turn, results from an accurate diagnosis. Because bipolar disorder continues to have a high rate of both underdiagnosis and misdiagnosis, it is often difficult for individuals with the illness to receive timely and competent treatment.

Bipolar disorder is a severely disabling medical condition. In fact, it is the 6th cause of disability in the world, according to the World Health Organization. However, with appropriate treatment, many individuals with bipolar disorder can live full and satisfying lives. Persons with bipolar disorder are likely to have periods of normal or near normal functioning between episodes.

The prognosis for bipolar disorder is, in general, better than that for schizophrenia. However, many atypical antipsychotics, which were originally developed to treat schizophrenia, have also been shown to be effective in bipolar mania.

Ultimately one's prognosis depends on many factors, which are, in fact, under the individual's control: the right medicines; the right dose of each; a very informed patient; a good working relationship with a competent medical doctor; a competent, supportive, and warm therapist; a supportive family or significant other; and a balanced lifestyle that includes exercise. One of the most important lifestyle changes is regular sleep and wake times; this cannot be stressed enough.

There are obviously other factors that lead to a good prognosis, as well, such as being very aware of small changes in one's energy, mood, sleep and eating behaviors, as well as having a plan in conjunction with one's doctor for how to manage subtle changes that might indicate the beginning of a mood swing. Some people find that keeping a log of their moods can assist them in predicting changes.

The goals of long-term treatment should be to help the individual achieve the highest level of functioning, and to avoid relapse.

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Relapse
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Even when on medication, some people may still experience weaker episodes, or have a complete manic or depressive episode.

The following behaviors can lead to depressive or manic relapse:

Discontinuing or lowering one's dose of medication, without consulting one's physician.
Being under- or over-medicated. Generally, taking a lower dosage of a mood stabilizer can lead to relapse into mania. Taking a lower dosage of an antidepressant, may cause the patient to relapse into depression, while higher doses can cause destabilization into mixed-states or mania.
Taking hard drugs – recreationally or not – such as cocaine, alcohol, amphetamines, or opiates. These can cause the condition to worsen.
An inconsistent sleep schedule can destabilize the illness. Too much sleep (possibly caused by medication) can lead to depression, while too little sleep can lead to mixed states or mania.
Caffeine can cause destabilization of mood toward irritability, dysphoria, and mania. Anecdotal evidence seems to suggest that lower dosages of caffeine can have effects ranging from anti-depressant to mania-inducing.
Inadequate stress management and poor lifestyle choices. If unmedicated, excessive stress can cause the individual to relapse. Medication raises the stress threshold somewhat, but too much stress still causes relapse.
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Research findings
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Heritability or inheritance
Bipolar disorder runs in families.[9] More than 2/3 of people with bipolar disorder have at least one close relative with the disorder or with unipolar major depression, indicating that the disease has a genetic component.

Studies seeking to identify the genetic basis of bipolar disorder indicate that susceptibility stems from multiple genes. Scientists are continuing their search for these genes, using advanced genetic analytic methods and large samples of families affected by the illness. The researchers are hopeful that identification of susceptibility genes for bipolar disorder, and the brain proteins they code for, will make it possible to develop better treatments and preventive interventions targeted at the underlying illness process.

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Genetic research
Bipolar disorder is considered to be a result of complex interactions between genes and environment.

The monozygotic concordance rate for the disorder is 70%. This means that if a person has the disorder, an identical twin has a 70% likelihood of having the disorder as well. Dizygotic twins have a 23% concordance rate. These concordance rates are not universally replicated in the literature; recent studies have shown rates of around 40% for monozygotic and <10% for dizygotic twins (see Kieseppa, 2004 [5] and Cardno, 1999 [6]).

In 2003, a group of American and Canadian researchers published a paper that used gene linkage techniques to identify a mutation in the GRK3 gene as a possible cause of up to 10% of cases of bipolar disorder. This gene is associated with a kinase enzyme called G protein receptor kinase 3, which appears to be involved in dopamine metabolism, and may provide a possible target for new drugs for bipolar disorder.[7]

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Ongoing research
The following studies are ongoing, and are recruiting volunteers:

The Maudsley Bipolar Twin Study, based at the Institute of Psychiatry in London is conducting research about the genetic basis of bipolar disorder using twin methdology. Currently recruiting volunteers: identical and non-identical twins pairs, where either one or both twins has a diagnosis of bipolar I or II.

The MRC eMonitoring Project, another research study based at the Institute of Psychiatry and Newcastle Universities, is conducting novel research on electronic monitoring methodologies (electronic mood diaries and actigraphy) for tracking bipolar symptom fluctuations in Bipolar individuals who are interested in self-managing their condition.

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Medical imaging
Researchers are using advanced brain imaging techniques to examine brain function and structure in people with bipolar disorder, particularly using the functional MRI and positron emission tomography. An important area of neuroimaging research focuses on identifying and characterizing networks of interconnected nerve cells in the brain, interactions among which form the basis for normal and abnormal behaviors. Researchers hypothesize that abnormalities in the structure and/or function of certain brain circuits could underlie bipolar and other mood disorders, and studies have found anatomical differences in areas such as the prefrontal cortex[8] and hippocampus.

Better understanding of the neural circuits involved in regulating mood states, and genetic factors such as the cadherin gene FAT linked to bipolar disorder,[9] may influence the development of new and better treatments, and may ultimately aid in early diagnosis and even a cure.

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Personality types or traits
An evolving literature exists concerning the nature of personality and temperament in bipolar disorder patients, compared to major depressive disorder (unipolar) patients and non-sufferers. Such differences may be diagnostically relevant. Using MBTI continuum scores, bipolar patients were significantly more extroverted, intuitive, and perceiving, and less introverted, sensing, and judging than were unipolar patients[citation needed]. This suggests that there might be a correlation between the Jungian extraverted intuiting process and bipolar disorder.

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New treatments
In late 2003, researchers at McLean Hospital found tentative evidence of improvements in mood during echo-planar magnetic resonance spectroscopic imaging (EP-MRSI), and attempts are being made to develop this into a form which can be evaluated as a possible treatment.[10],[11]

NIMH has initiated a large-scale study at 20 sites across the U.S. to determine the most effective treatment strategies for people with bipolar disorder. This study, the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), will follow patients and document their treatment outcome for 5-8 years. For more information, visit the Clinical Trials page of the NIMH Web site[10].

Transcranial magnetic stimulation is another fairly new technique being studied.

Pharmaceutical research is extensive and ongoing, as seen at clinicaltrials.gov.

Gene therapy and nanotechnology are two more areas of future development.

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Causes (Etiology)
According to the US government's National Institute of Mental Health (NIMH), "There is no single cause for bipolar disorder—rather, many factors act together to produce the illness." "Because bipolar disorder tends to run in families, researchers have been searching for specific genes—the microscopic "building blocks" of DNA inside all cells that influence how the body and mind work and grow—passed down through generations that may increase a person's chance of developing the illness." "In addition, findings from gene research suggest that bipolar disorder, like other mental illnesses, does not occur because of a single gene." [11].

It is well established that bipolar disorder is a genetically influenced condition which can respond very well to medication (Johnson & Leahy, 2004; Miklowitz & Goldstein, 1997; Frank, 2005). (See treatment of bipolar disorder for a more detailed discussion of treatment.)

Psychological factors also play a strong role in both the psychopathology of the disorder and the psychotherapeutic factors aimed at alleviating core symptoms, recognizing episode triggers, reducing negative expressed emotion in relationships, recognizing prodromal symptoms before full-blown recurrence, and, practicing the factors that lead to maintenance of remission (Lam et al, 1999; Johnson & Leahy, 2004; Basco & Rush, 2005; Miklowitz & Goldstein, 1997; Frank, 2005). Modern evidence based psychotherapies designed specifically for bipolar disorder when used in combination with standard medication treatment increase the time the individual stays well significantly longer than medications alone (Frank, 2005). These psychotherapies are Interpersonal and Social Rhythm Therapy for Bipolar Disorder, Family Focused Therapy for Bipolar Disorder, Psychoeducation, Cognitive Therapy for Bipolar Disorder, and Prodrome Detection. All except psychoeducation and prodrome detection are available as books.

Brain scientist Husseini K. Manji M.D. of the NIMH states that at their most basic level, the bipolar disorders involve problems in brain structure and function. He stated that these structural changes respond very well to treatment with lithium and valproate in a University of California, Los Angeles Neuropsychiatric Institute (NPI) Grand Rounds Talkgiven in 2003 (requires Real Player and a high-speed internet connection).

Early in the course of the illness brain structural abnormalities may lead to feelings of anxiety and lower stress resilience. When faced with a very stressful, negative major life event, such as a failure in an important area, an individual may have his first major depression. Conversely, when an individual accomplishes a major achievement he may experience his first hypomanic or manic episode. Individuals with bipolar disorder tend to experience episode triggers involving either interpersonal or achievement-related life events. An example of interpersonal-life events include falling in love or, conversely, the death of a close friend. Achievement-related life events include acceptance into an elite graduate school or by contrast, being fired from work (Miklowitz & Goldstein, 1997).

Veteran brain researcher Robert Post M.D. of the U.S. NIMH proposed the "kindling" theory [12] which asserts that people who are genetically predisposed toward bipolar disorder experience a series of stressful events, each of which lowers the threshold at which mood changes occur. Eventually, the mood episode starts (and becomes recurrent) by itself. Not all individuals experience subsequent mood episodes in the absence of positive or negative life events, however.

Individuals with late-adolescent/early adult onset of the disorder will very likely have experienced childhood anxiety and depression. Childhood onset bipolar disorder should be treated early because according to Joseph Calabrese of Case Western Reserve University, childhood forms of the illness may be easier to treat than adult forms of the illness. (See his University of California, Los Angeles NPI Grand Rounds Talk on rapid-cycling in October 2003.)

It is becoming increasingly clear that bipolar and unipolar mood disorders have a genetic component. For example, a family history of bipolar spectrum disorders can impart a genetic predisposition towards developing a bipolar spectrum disorder[13]. Since bipolar disorders are polygenic (involving many genes), there are apt to be many unipolar and bipolar disordered individuals in the same family pedigree. This is very often the case (Barondes, 1998). Anxiety disorders, clinical depression, eating disorders, premenstrual dysphoric disorder, postpartum depression, postpartum psychosis and/or schizophrenia may be part of the patient's family history and reflects a term called "genetic loading".

Bipolar disorder is more than just biological and psychological. Since "many factors act together to produce the illness", bipolar disorder is called a multifactorial illness, because many genes and environmental factors conspire to create the disorder (Johnson & Leahy, 2004).

Since bipolar disorder is so heterogeneous, it is likely that people experience different pathways towards the illness (Miklowitz & Goldstein, 1997).

Hi Bizi,

I had read most of this post earlier today and for some reason left. It is a lot to take in my wandering mind. I did get a lot of of it though Thank you. I wonder if bi-polar gets better with age?

befuddled2

I am sorry this is so long perhaps I should edit this?
good for you for trying to get thru some of it.
(((HUGS)))
bizi

Hi bizi,

I think your post is good the way it is. It is comprehensive and what I didn't think related to me I kind of skimmed over or skipped. Someone might take what I left.

befuddled2

Hey- thanks for this! Interesting. Still working through my new diagnosis. ....

That is a great post. Very interesting and very true. As far as how much or how little I really know.

I saw myself there too.

Thanks for sharing.

Hugs, Nikko

the top 10 myths about bipolar disorder

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By John McManamy

Like many mental illnesses, the commentary surrounding bipolar disorder is saturated with myths--it's hard to tell what's true and what's not. Below you'll find the real story, from our expert patient John McManamy.

1. Everyone has their ups and downs, so mine aren’t that serious.

Yes, everyone has good days and bad days, but when these ups and downs seriously interfere with your ability to work, relate to others and function effectively, it is advisable to seek out a psychiatrist.

2. Bipolar disorder is a mood disorder.

Half true. Bipolar disorder certainly affects mood, but it also affects cognition and the ability to perform mental tasks. Some days we can out-think Stephen Hawking. Other days we make Forrest Gump look like an intellectual.

3. Yes, but bipolar disorder is still a mood disorder.

Granted, but for most of us it is also part of a package deal that may include anxiety, substance and alcohol abuse and sleep disorders. Also, researchers are finding smoking guns linking the illness to heart disease, migraines and other physical ailments.

4. Bipolar disorder is characterized by mood swings ranging from severely depressed to wildly manic.

Not necessarily. Most people with bipolar disorder are depressed far more often than they are manic. Often, the manias are so subtle that they are overlooked by both patient and psychiatrist, resulting in misdiagnosis. People with bipolar disorder can also enter long periods of remission.

5. Mania is like being on top of the world—if you could only put it in a bottle and sell it.

You wouldn’t want to with most manias. True, some forms of mild mania are characterized by feelings of elation, but other types have road rage features built in. More severe mania turns up the heat, resulting in different kinds of out-of-control behavior that can ruin your career, relationships and reputation.

6. Bipolar disorder is caused by a chemical imbalance of the brain.

This is the simpler explanation—what you tell your family and friends. What you need to know is our genes, biology and life experience make us extremely sensitive to stress. Various stressors, such as personal relationships and financial worries, have the potential to trigger a mood episode if not effectively nipped in the bud.

7. Medications are all you need to combat bipolar disorder.

False. While medications are the foundation of treatment for bipolar disorder, recovery is problematic without a good lifestyle regimen (diet, exercise and sleep), effective coping skills and a support network. People with bipolar disorder also benefit from various forms of talking therapy and religious/spiritual practice.

8. Medications don’t work for me.

For some people this may be true, but we all need to give our meds a chance. Treatment guidelines anticipate initial failures, and while no two guidelines are in agreement they are all based on the premise that eventually you will find a medication or combination of medications that will help you.

9. Lower quality of life and sluggish cognition are fair trade-offs for reducing mood symptoms.

False, big time. In the initial phase of treatment, meds overkill may be justified to bring your illness under control. But full recovery is based on improving your overall health and ability to function, not just eliminating mood symptoms. Over time, the side effects of medication tend to go away, so patience is advised. You may choose to live with minor side effects such as mild hand tremors. But if major side effects persist, you should work with your psychiatrist in adjusting doses or switching to different meds. The onus is on you to alert your psychiatrist to major side effects and to insist he or she take appropriate action.

10. Once you’ve been diagnosed with bipolar disorder, you can forget about leading a normal life.

False. Living with bipolar disorder is a challenge, and you may have to change your expectations, but you should never give up on living a rewarding and productive life.

newly diagnosed?

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The First 48 Hours with Bipolar Disorder

By John McManamy

You never find happy individuals walking into a psychiatrist’s office for the first time. People with bipolar disorder only seek help when their life is going terribly wrong or when their brains have taken them hostage. Your situation is probably looking pretty bleak at the moment, and the last thing you need to be told is you are not normal—whatever normal is. "How can I live with a brain I can’t trust?" you may be wondering. "How can I face my family and friends and colleagues—the ones who are still talking to me, anyway? Will I ever be able to get my old life back, or what’s left of it?"

At the same time, you may be feeling an overwhelming sense of relief. Finally, someone has fingered your invisible nemesis and given it a name. Suddenly your whole life begins to make sense, and it has nothing to do with any moral or character weakness on your part. You’ve smoked the beast out into the open. For the first time in your life, you have a fighting chance.

But let’s not kid ourselves. Bipolar disorder takes no prisoners. You’re going to have to fight this with all you’ve got. Here’s what you need to know now that you’ve been diagnosed.

Your Psychiatrist Is Your Partner, Not Your Boss

Your psychiatrist has probably sent you out of the office with a prescription for one or more psychiatric medications. [Read more about medications and drug information.] If you’re one of the lucky ones, the meds will work like a charm. Most likely, an extended adjustment period lies ahead. For starters, you are biologically unique, and no two cases of bipolar are the same. What works for one person may not work for you. Second, medications for bipolar disorder are by no means perfect. They may only get you half-well for now, and you may have to contend with troublesome side effects.

You have already passed your biggest hurdle: you sought help. Now comes your second-biggest hurdle: forging a working partnership with your psychiatrist. Forget about being a passive patient. Treating bipolar disorder is not the equivalent of taking statins and watching your cholesterol go down—if only life were that simple. All too often, patients quit in frustration when their meds aren’t working right, only to find themselves back in crisis days or weeks or even months later. Often, the problem lies with a psychiatrist who doesn’t listen. More often than not, the patient neglects to speak up.

The onus is on you. Psychiatrists these days have severe constraints on their time. If you don’t badger them, they won’t ask that vital extra question. Remember, psychiatrists are only as good as what you tell them. This is no time to be shy. Here’s a brief list of what I consider to be your rights as a patient:

1. Your psychiatrist has a duty to listen. If you feel this is not happening, find one who does.

2. The American Psychiatric Association, in its 2000 Bipolar Treatment Guidelines, stipulates that the goal of treatment is to achieve remission. The APA goes on to say that this means having virtually no symptoms and functioning fully. Basically, your psychiatrist writing you off is not an option, no matter how bad things may be going for you at the time.

3. You should not have to settle for dulled cognition and a diminished capacity to enjoy life as the price of reduced mood symptoms. Many side effects of major medication tend to go away as your body adjusts to the meds, and you should allow for this. But you should not have to put up with meds that make you feel worse. You can discuss the side effects of bipolar meds on our message boards.

4. You have the right to give your psychiatrist the third degree concerning every medication he or she may prescribe. If you are not satisfied with the answers, you have the right to refuse to take that particular medication or medications.

5. Less may be more. It's overkill is justifiable for a crisis, but is not the right strategy for long-term recovery. There may be valid reasons for remaining on many meds in high doses, but the onus should be on your psychiatrist to provide satisfactory explanations.

6. You’re entitled to timely responses from your psychiatrist. Phone messages should be returned at first opportunity, and your psychiatrist should be available in a crisis.

If you have just been diagnosed, you are probably in a crisis, or are just emerging from one. For the time being, your psychiatrist will be the lead partner. But once you start moving into the recovery phase, you need to show some initiative. Only an equal partnership will get the job done.

Lifestyle Is Just As Important As Meds

You may not want to commit yourself to an improved lifestyle regimen the way you are feeling right now, but your new meds may force you to take immediate action.

Some medications are notorious weight-gainers, and patients are often caught by surprise, with no warning from their psychiatrists. It is not uncommon for patients to put on 20 pounds in a matter of weeks or months and 60 pounds over a year. Sudden weight gain works against the intended result of medications, as the extra pounds contribute to feelings of sluggishness and low self-esteem, which are symptoms of depression. You may have no choice but to take these meds, but you do have the choice to start eating low-fat food. As soon as you’re able, you can work on a more permanent diet and nutrition strategy.

It is wise to cut down on “mood-buster” foods. A 20-oz Coke contains 15 teaspoons of sugar. Sugar has been linked to depression and mood spikes and crashes. Caffeine should be used sparingly and alcohol only with your doctor’s permission. Think before you drink (and eat). Folates, omega-3s, and various vitamins and minerals, on the other hand, have been linked to improved mood and brain function.

Just about everyone with a mood disorder has a sleep problem; they either are unable to fall asleep or sleep too much. A missed night’s sleep can trigger a manic episode. Staying in bed can make depression worse. Sticking to some kind of regular schedule is vital, and establishing sound sleep hygiene is a must. Once sleep is resolved, often with the aid of medications, many mood and cognitive symptoms clear up.

Exercise has been linked to improved mood and brain function, increased energy and higher self-esteem. A regular exercise routine is an essential part of your wellness strategy, though right now you are probably in no shape to make the effort. Resolve to start small, perhaps with a five-minute walk, and add more as you progress through recovery.

Spiritual and religious practice has been linked to improved physical and mental health. This may be because prayer and meditation kick-start a number of beneficial biological processes. Then again, it could be pure God-power. You may feel God has abandoned you right now, but don’t be afraid to rekindle the relationship.

Read more about Therapy and Lifestyle Changes.

Support Is Vital

Whether or not to disclose your illness to family, friends and colleagues is a tough call. Bipolar disorder still carries a heavy stigma that could result in your losing companionship and employment. For good reason, most patients choose to keep their illness a secret from their employers. But your job may be at risk if you don’t clue your employer in on your situation. You may need certain accommodations in order to keep working, such as flexible hours, and you may be surprised at how enlightened some employers can be. If you choose to disclose the information, do it through your organization’s human resources department.

Bipolar disorder is a burden you shouldn’t carry alone. You will almost certainly need to disclose your condition to selected family and friends. Finding a network of people who share your illness is also essential. You are in the right place with this online community. You can find support through our message boards as well as a comprehensive list of other sites that offer support on our support groups page. Face-to-face support is also strongly recommended. The Depression and Bipolar Support Alliance has 1,000 support groups throughout the United States.

Coping Is Your Survival Tool

Over time, you will pick up an invaluable array of coping skills. Learning from fellow patients (such as people you meet in a support group) will help you avoid mistakes others have already made. Successful patients are acutely attuned to the subtleties of their moods and behaviors, and can often nip potential episodes in the bud, before they reach the point of no return. Sometimes it’s as simple as ensuring you get a good night’s sleep or some strategic downtime.

Any practice aimed at reducing stress is worth checking out. This includes meditation, yoga, breathing exercises, relaxation exercises, physical exercise, quality time to yourself, and selectively disengaging from potentially stressful family and work situations.

There are three main types of talking therapy aimed at helping you cope: cognitive therapy, behavioral therapy and interpersonal therapy. These therapies are about the “here and now.” They do not get inside your head. By the end of 12 or so sessions, you will be on your way to turning your “It’s the end of the world” thoughts into “Let’s find a solution.” Read more about therapy here.

Over the long term you may want to seek out talking therapy to help you resolve deep-seated trauma and abuse and other issues, but now is not the time. You are in no shape right now to deal with bad memories and past and present injustices. Work on getting stabilized first. If you are in a toxic working environment or a bad marriage, your meds aren’t going to make your life better. They will help get you back on your feet, but you will find yourself right back in bed or bouncing off walls if you don’t work on correcting the underlying problems.

Isolation Kills

Perhaps worse than the illness is the isolation it brings on. The depressed phase of our disorder turns us into wounded animals seeking the solace of a quiet cave. The manic phase is all about how to lose friends and alienate people. Add to that the stigma and the shame of bipolar disorder, and suddenly Robinson Crusoe looks like a party animal. Once deprived of meaningful human contact, the illness tends to feed on itself, starting a destructive cycle that sends us deeper into depression and robs us of the social skills needed to successfully negotiate stressful situations.

You may be in no mood to talk to others right now, but you can resolve to get out of the house once a day. You may be unable to work, but this should not stop you from performing volunteer work. You may despise egotistical loudmouths, but this should not prevent you from seeking out kindred spirits.

Finally, You Are Not a Helpless Bystander

By now you have learned that meds are just one part of the picture. The bad news is they are unlikely to get the entire job done. The good news is there is a lot you can do to help yourself.

You have just survived a horrific experience and are not yet out of the woods. Please take comfort in the fact that you are much stronger than you think. Living with bipolar disorder will always be a test, but a meaningful and productive life is not out of your reac—however, different it may turn out from your original expectations. Be hopeful. We all hate our illness, but we hardly hate what this illness has made of us. Yes, we would all trade it in in a heartbeat, but we would choose to hold on to the wisdom and insight and deeper sense of humanity and divinity we picked up along the way.

Live smart. Be well.

Hypomania
From Wikipedia, the free encyclopedia

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.

Some basics thing s that you can do starting today:

First, get eight hours of sleep, at night, every night. You have to keep your body rhythyms regular, and here's the place to start. Second, get thirty minutes of exercise every day. If you can get outside in the sun that's the best. Even if you just walk down to the corner and back a few times, it's critical that you do this. Good nutrition is also important...moderation in everything is the key. Are you in therapy? You will double your chances of recovery with both drug therapy and talk therapy. Also, find a support group in your area...go to www.DBSAlliance.org or www.nami.org to find a group in your area.