“… In the early stages, I feel good about the world and everybody in it … I like it. All of a sudden I have the confidence that I could do what I set out to do. I take on more projects, largely because I’m not worried about running out of energy. I’m not grandiose, but I feel vigorous and active; accelerated, willing to take more risk. This feeling can last for days, sometimes weeks and it’s wonderful. There’s no other way of describing it.” “… It’s a very infectious kind of thing. We all have an appreciation for someone who’s positive and upbeat. Others respond to the energy. People … seem happy around me. It is very easy to make friends. There’s also the personal sense…of an enhanced ability to act and reason.” (1)
“When you’re high, it’s tremendous. The ideas and feelings are fast and frequent like shooting stars … But, somewhere this changes. The fast ideas are far too fast and there are far too many … Overwhelming confusion replaces clarity. Everything previously moving with the grain is now against—you are irritable, angry, frightened and uncontrollable …” (2)
Mania, derived from the Greek word for madness, has been described from antiquity. “Hypo” mania, again from Greek, is hierarchically below or beneath mania, and fills the gap between the full syndrome of mania and the more normal states of joy and elation. The formal term hypomania was first introduced by Mendel in 1891 (3).
The early history of elevated mood
The history of hypomania is long and intermingled with the concepts of mania, cyclothymia, bipolar disorder, and elevated mood in general. Elevated mood as a mental condition was identified as early as the 5th century BC by Hippocrates, who speculated on the biologic origin of mental disorders and felt that mania was attributed to an increase in yellow bile. Aristotle later speculated that the heart, rather than the brain, was the impaired organ responsible for elevated mood. In the 2nd century AD, Areteaus of Cappadocia was one of the first to suggest that elevated mood was an end-stage process of melancholia and described cyclothymia as a form of mental disease alternating between periods of depression and mania.
Nineteenth century scholars, including Falret and Baillarger, independently suggested that mania and depression were different expressions of the same disease occurring in a biphasic illness, dubbed folie circulaire or circular insanity. Hypomania was described as “that form of mania that typically shows itself only in the mild stages, abortively so to speak” (3). In the same century, Kahlbaum described cyclothymia as episodes of both depression and elevated mood that did not end in dementia. Emil Kraeplin, in his 1921 seminal work on what we now call bipolar disorder, described hypomania as one manifestation of the illness distinct from acute mania, delusional mania, and depressive or anxious mania.
More modern definitions of mania and hypomania derive from the studies of Clayton, Pitts, and Winokur whose published criteria were eventually incorporated into the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) (4). These were further refined by Dunner et al. in 1970 into bipolar type I and bipolar type II disorders. The latter term described individuals with severe depression and milder manic symptoms, who did not appear to suffer from the disruption of the full mania of bipolar type I disorder. From this work, bipolar type II disorder became an official part of DSM-IV as well as the 10th revision of the International Classification of Diseases (ICD-10). It replaces “atypical bipolar disorder” to describe conditions characterized by depression and hypomania. The bipolar type II category was based in part on family pedigrees and follow-up studies suggesting a distinct subgrouping of persons with milder elevated mood. This group was also characterized by increased rates of suicide and suicide attempts, as well as a high risk of bipolar disorder in their relatives (5,6). Of particular note to this text and current diagnostic criteria is the proposal of Dunner et al. that a period of 3 or more days of hypomania is necessary for bipolar type II disorder to be diagnosed. ICD-10 later included a 4-day or longer period of hypomania as the minimal duration of hypomanic symptoms necessary for the diagnosis. As we shall see, these time frames have recently been challenged by several authors, carrying potentially significant ramifications.
TABLE 1.1 DSM-IV criteria for a hypomanic episode
A. A distinct period of persistently elevated, expansive, or irritable mood, lasting through at least 4 days, that is clearly different from the usual nondepressed mood
B. During the period of mood disturbance, three or more of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. Increase in goal-directed activity (either socially, at work, or at school) or psychomotor agitation
7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic
D. The disturbance in mood and change in functioning are observable by others
E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization and there are no psychotic features
F. The symptoms are not due to the direct physiologic effect of a substance or a general medical condition
According to the DSM-IV criteria (see Table 1.1) hypomania is characterized by less intense, manic-like symptoms including elevated, expansive, or irritable mood during which time the person experiences inflated self-esteem or grandiosity. There is a decreased need for sleep, pressure to talk, flight of ideas, or racing thoughts. These symptoms are increasingly distractible and result in an increase in psychomotor activity and/or agitation.
Hypomania is symptomatically and categorically distinguished (at least in theory) from full mania that has the criteria shown in Table 1.2.
Many textbooks have been written on mood disorders or elevated mood. Most of these focus on the most severe form of elevated mood—mania—and touch on hypomania as an afterthought. Theoretically, hypomania is often viewed as a milder form of mania or, in some cases, a benign precursor. Michael Stone’s chapter in the American Psychiatric Association Publishing Textbook of Mood Disorders (3) lists 89 references to depression and melancholy, 60 references to mania and manic behavior, but only 8 references to hypomania, 2 to hyperthymic temperament, and 2 to bipolar spectrum disorder. As will be seen, hypomania is crucial to, and connected with the latter two concepts. Research literature is likewise centered on evaluating and studying acute mania, but underrepresented with research and articles about hypomania, although recent studies suggest that hypomania may be five to ten times as common as acute mania (7,8,9,10,11,12).
TABLE 1.2 Diagnostic criteria for a manic episodea
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
a. Inflated self-esteem or grandiosity
b. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
c. More talkative than usual or pressure to keep talking
d. Flight of ideas or subjective experience that thoughts are racing
e. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
f. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
g. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The symptoms do not meet criteria for a mixed episode
D. The mood disturbance is as follows:
a. Sufficiently severe to cause marked impairment in occupational functions, usual social activities, or relationships with others
b. Necessitates hospitalization to prevent harm to self or others, or
c. Has psychotic feature
E. The symptoms are not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism)
a Adapted from DSM-IV TR; manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy (ECT), light therapy) should not count toward a diagnosis of bipolar I disorder.
Until recently, hypomania has been seen as a minor condition, and potentially less worthy of study, and has been relegated to a less visible position in the hierarchy of psychiatric diagnoses. This text will take a new perspective and focus on elevated mood from the point of view of milder mood states, particularly hypomania. This information will serve as a bridge between the more severe states of manic mood and “normal” mood states. It is suggested that hypomania is, in fact, a significant and crucial diagnosis both for practical and theoretical reasons. Hypomania and subsyndromal elevated mood states will be seen as important elements in accurate diagnosis and quality mental health treatment. They will also be seen as holding a central position in a continuum of elevated mood. In order to advance these theses, we need to first understand why hypomania has been underappreciated and also the definitions of those conditions that border on hypomania in the spectrum of elevated mood.
Why hypomania has been underappreciated
There are a variety of reasons for this diagnosis being underappreciated or overlooked, as listed in Table 1.3.
The underappreciation of hypomania begins with its overlapping similarities with normal traits that are valued and appreciated in the human personality and society. High energy, work productivity, social jocularity, friendliness, and talkativeness are all traits which are often admired. As these are also traits associated with mild to moderate hypomania, it is no wonder that, for many individuals and their families, periods of hypomania are often not seen as an illness. Conversely, these periods are viewed as a strength and evidence of good mental health. Even when symptoms are exaggerated, elevated mood can be viewed as an expected result of circumstances (a promotion, receiving praise, completing a life goal, etc.). At other times, the patient is simply seen to be “feeling good” or “having a great day.” When, on the other hand, the symptoms of hypomania are not euphoric and grandiose but angry and irritable, the patient may be seen as “grouchy,” “moody” or the symptoms are viewed as a part of a patient’s “touchy,” “volatile” personality. Significant numbers of individuals with hypomania, therefore, never present to medical professionals for evaluation or treatment, and are seldom seen by mental health practitioners.
TABLE 1.3 The underappreciation of hypomania
Hypomania has been viewed or assessed as follows:
• A normal part of personality and not an illness
• A condition containing elements that are socially valued and encouraged
• A lesser form of mania, which is the condition of real importance
• Simply a “way station” to or from mania
• A welcome relief as a patient recovers from depression
• A condition categorized by overly rigid diagnostic criteria as noted in DSM-IV TR
When hypomanic patients do present to mental health offices, there may also be a lack of spontaneous reporting of hypomania to clinicians because patients are embarrassed and reluctant to report elevated mood behaviors which may be viewed as indiscretions. Even when directly questioned, some patients will deny impulsive, reckless, or contradictory behaviors for fear of admonishment or disdain on the part of the clinician. On occasion, patient may even repress the memory of these behaviors unless confronted with irrefutable evidence.
Beyond embarrassment, some patients may fail to spontaneously report mild to moderate hypomanic behaviors/feelings because they do not see them as “symptoms” at all. Even detailed questioning by astute clinicians may fail to elicit hypomanic symptoms unless family members, employers, or others who know the patient can give a full picture of the patient’s behavior.
Hypomania may also be seen by clinicians as simply a lesser form of mania, a transient phase on the “way up” to or on the “way down” from mania. When elevated mood and hypomania exist in the context of depressive bouts (which, as we shall see, are very common) hypomanic symptoms may be missed by the clinician and the patient, as they are seen as a welcome sign that depression is lifting. Many patients who have been treated for depression cease treatment shortly after they start feeling better and the hypomanic elements of their outcome are lost to evaluation and further treatment. Whether the depressed patient has reached a normothymic mood and subsequently experiences hypomania, or proceeds directly into hypomania, this hypomanic mood state is often not observed by the clinician. Even if patients present for subsequent episodes of depression, they may not report the presence of the intervening hypomanic symptoms unless specifically asked by the clinician.
More recently, another reason for underdiagnosis of hypomania has been pointed out by Akiskal, Angst, et al. (8,9,10,11,12). Although discussed in more detail later, suffice it to say that proposals from a growing group of international researchers suggest that the DSM-IV TR (text revision) criteria for hypomania are too rigid and overly narrow, resulting in lesser forms of hypomania and subsyndromal elements of elevated mood being clinically overlooked. Currently, in order to satisfy the DSM-IV criteria for hypomania, a person must have had 4 or more days of symptoms and three to four specific behaviors. With less rigid criteria, many patients with elevated mood may be seen to experience hypomanic intervals for shorter periods of time or of lesser severity, but are hypomanic nonetheless.
The many definitions of hypomania
One would think that with the criteria outlined previously in DSM-IV, most clinicians would have a standard conceptual and symptomatic understanding of hypomania. Unfortunately, this is not the case. Some professionals view hypomania only as a temporary state on the “way up” to or “way down” from mania whereas others see hypomania as a “final destination,” that is, a state which can persist for lengthy periods of time. Even if the time course and symptoms of hypomania are agreed upon (which they are not), there are other factors that may complicate the diagnosis. The borderline dividing highly energetic (hyperthymic) personality traits and hypomania is not clearly defined. Purely symptomatic assessment does not reliably identify a distinct borderline between severe hypomania and true mania. Because hypomania can exist and persist with virtually no elements of depression (although this is relatively uncommon), hypomania presenting with episodes of depression (bipolar type II) may be different than pure hypomania without such depressive elements.
The approach taken by DSM-IV TR and previous editions of the DSM has at times been labeled as a Chinese menu approach, where the clinician selects one item from column A and several from column B in order to make the diagnosis. Staying with this analogy, such an approach would result in very different meals if, for example, a person selected a meal of three fish dishes, as compared to a meal with one pork dish and two with beef, or three vegetarian choices. Likewise, hypomania may appear quite different depending on the symptoms identified in any given individual. A pressured, driven, and irritable hypomanic will look and act differently than a person who presents with rapid speech, distractibility, and grandiose ideas. They may, in fact, not even have the same form of the illness. Chapter 2 will suggest that the term hypomania describes a heterogeneous group of symptoms and does not reflect a truly uniform population of patients.
Why is hypomania important?
If, as stated in the preceding text, the patient, the family, researchers, and some practitioners seem not to recognize or seemingly care about hypomania, why should the reader? It is perhaps one of the most important questions that makes this text necessary. In order to answer this question appropriately, one needs to look at the consequences of not recognizing hypomania. Beyond the possible philosophic and theoretic consequences of a wrong diagnosis, there are practical concerns that have direct and serious ramifications for the patient and for the practitioner. These elements are listed in Table 1.4.
Consequences of misdiagnosis
Bipolar disorder has long been linked to impaired quality of life and functional status. When compared with unipolar depression, bipolar disorder has also been associated with impaired occupational functioning, greater health care utilization, and increased medical costs. Two surveys of the members of the National Depressive and Manic Depressive Associations (DMDA), conducted 8 years apart, reveal that bipolar disorder misdiagnosis is a widespread problem. In 1992, when the first survey was conducted, 73% of the 500 bipolar disorder patients surveyed reported receiving alternative explanations of their symptoms before being correctly diagnosed with bipolar disorder. Almost half the number of these patients had consulted at least three professionals before receiving the appropriate diagnosis. More than a third of patients had 10 years elapse between their first professional contact and being correctly diagnosed with bipolar disorder (13). The second survey in the year 2000 showed that 69% of the 600 patients surveyed said they had initially been misdiagnosed (14). Several other studies by Ghaemi et al. (15,16) and Dilsaver (17) further support evidence of frequent misdiagnosis in clinical patient populations.
TABLE 1.4 Risks of hypomania misdiagnosis
•
The presence of hypomania is a strong signal that an illness is moving toward the bipolar end of the spectrum of mood disorders and away from a unipolar disorder
•
When compared with unipolar disorder, mood disorders with bipolar characteristics require different treatments and carry different risks
•
Standard treatments for unipolar depression (e.g., traditional antidepressants) may worsen hypomanic and bipolar symptoms
•
Misdiagnosis and inappropriate treatment of hypomania can lead to increased incidence of suicide
There are practical consequences to missing the presence of hypomania or bipolar disorder. When bipolar disorder is misdiagnosed during an initial mental health evaluation prompted by depressive rather than manic symptoms, antidepressants are often used as monotherapy without a mood stabilizer, thereby delaying the most effective treatment for bipolar disorder (18). Treatment with antidepressants can worsen the prognosis for the patient by potentially inducing hypomania, mania, or increasing cycle frequency (15,19,20,21,22). Misdiagnosis results in increased direct and indirect health care costs and higher rates of psychiatric hospitalization (23,24). Of particular note is the increased suicidal ideation and attempts in these misdiagnosed patients (24). Suicidality has been noted to be particularly high in bipolar II disorder and hypomania, when compared with lower rates in bipolar I disorder patients with pure manic episodes (25).
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