Treating Elevated Mood— Principles and the Challenges

Treating Elevated Mood— Principles and the Challenges

The first several chapters of this text describe the evolution in understanding hypomania and elevated mood starting from a purely phenomenologic perspective and moving to a more biologic and genetic perspective. As the understanding of causality and the underlying biologic parameters that lead to hypomania become elucidated, more precise treatments will emerge. Meanwhile, we must continue to treat hypomanic individuals with the information we have. This chapter, as well as those that follow, is devoted to elements of treatment that we can utilize now. We will focus first on management principles of mildly elevated mood and activity, before discussing treatment of more severe conditions. In addition to identifying the elements of treatment
that facilitate improvement, we will also look at potential therapeutic pitfalls and how to avoid or remedy them.

What is normal?

Many factors play into the assessment of what, on the surface, appears to be a simple question, “What is normal?” The clinician’s response to this query is essential in devising a treatment strategy that has been mutually agreed upon for elevated mood. Many clinicians are afraid of a potential “wildfire” of mania and may become overly concerned about even minimal elevations of mood or energized behavior. If the clinician assumes a suppressive monolithic approach toward this condition, the patient will rebel, become noncompliant, or drop out of treatment altogether. Therefore, the more appropriate question is not “What is normal?” but “What is normal for this patient?” In many cases, reestablishing a previous, but not necessarily optimal, level of functioning will be adequate treatment that is agreeable to the patient. On occasion, there may be the patient who wants to remain hypomanic, however, the clinician is aware that such a mood state is inappropriate, dysfunctional, or likely to result in increased mood swings. In these cases, the therapist must educate the patient about the dangers of flagrant hypomania. In circumstances where a reasonable treatment plan cannot be reached between the therapist and the patient, the therapist will need to withdraw from treatment. Further exploration of the topic, patients wanting to remain hypomanic, is presented later in the chapter.

Stability is in the eye of the beholder

Even with considerable mood instability, a patient may not necessarily see this as a problem. Stability is in the eye of the beholder. Some patients are remarkably willing to accept an unstable mood if the alternative is seen as becoming “flat” or “boring.” They may view stabilizing treatment as modifying essential elements of their individuality or personality, which they do not wish to relinquish. Many patients with elevated mood tolerate mood instability if their functional deficits and/or depressive episodes are infrequent or mild. In such cases, the patient may be unlikely to seek treatment unless symptoms markedly impair functioning. Other patients decide “This is the way I am,” tolerate the cycling, and reject psychotherapeutic or medication interventions. This may be in spite of clinical recommendations, family, or workplace pressure.

The pain of dealing with hypomania/depression cycling prompts the patient to seek and maintain treatment. If patients feel minimal or no psychic pain/discomfort, or have no family, financial, or work consequences to their cycling disorder, they are less likely to see a need for treatment. Medical analogies to the situation include the treatment of blood pressure or arteriosclerotic cardiovascular disease. An asymptomatic hypertensive patient may be erratic
or resistant to treatment, whereas a patient experiencing a transient ischemic attack (TIA) from elevated blood pressure is likely frightened and therefore more amenable to treatment. Likewise, when patient’s poor diet and exercise habits result in weight and cholesterol abnormalities, changes may be made only when an episode of angina occurs. And so, hypomanic patients become more amenable to treatment when the pain or consequences of impulsive elevated mood or depression interfere significantly in their lives.

“Just a little off the top”

This instruction, often given to a barber, also provides us with a way of thinking about hypomania treatment. Even as patients with significant symptomatology wish to minimize their cycles of hypomania, they do not wish to lose the positive attributes that are inherent in hyperthymic temperament and/or mild hypomania. Few of these patients desire or require a “buzz cut.” Just “a little off, here and there” is the desired approach. In the collaborative patientcentered approach discussed in this text, moderation and modulation of the most severe and frequent symptoms of elevated mood is an appropriate goal of treatment and may be the only one acceptable to the patient. Totally eliminating elevated mood, although sometimes possible, is seldom desirable or acceptable to the patient.

When is treatment needed?

As with any mental health condition, even when hypomania is diagnosed, it may or may not require treatment. This section describes collaboration with patients in deciding whether treatment is necessary and appropriate.

Patients with relatively mild symptomatology of elevated mood may never present for treatment. Those with hyperthymic temperament may function adequately, or even at a superior level without any psychiatric intervention. As has been discussed in Chapter 4, by far the most common problem that brings a person with hypomania to mental health practitioners is the presence of depression. In these cases, hypomania is diagnosed using the principles described in Chapters 3 and 4 to elucidate a history of hypomania in the patient presenting with depression. At times, hypomanic or hyperthymic individuals present in the mental health setting not because of depression but because one or more symptoms of elevated mood have become bothersome, intense, exaggerated, or intrusive in the patient’s life. Such symptoms can include excessive irritability, agitation, or a sleep disorder resistant to typical treatment modalities. Other patients request treatment for conditions that are ancillary to hypomania itself such as alcohol, or drug abuse, or marital dysfunction. In most cases, however, hypomanic individuals tend not to seek treatment solely for hypomania unless their hypomania is spiraling up toward mania, contains significant elements of anxiety or panic, or when they have previously experienced a hypomanic prelude to mania. This latter group has
often had a hospitalization or outpatient treatment with medication to bring down the symptoms of mania but may have residual symptoms of a mild, moderate, or severe nature that require follow-up treatment.

Treatment by functional severity

Arriving at a diagnosis of elevated mood may not be sufficient enough to undertake treatment. Although the therapist may feel that treatment is appropriate, the patient must see the benefits of treatment. In general, rather than commenting about one symptom, the therapist’s approach should focus on a more general assessment of the patient’s life and how this hypomanic and/or depressive mood pattern fits in. It is within this broader picture that the current presenting symptoms are viewed. Two separate but equally useful techniques to accomplish this can be summarized in the phrase “use both a telescope and a microscope.”

First use a “telescope” to look at the whole of the patient’s life to determine if treatment is necessary at all. How does this episode fit in the overall functionality of the patient’s life? Is this a distinct aberration? How often have such aberrations occurred? What is the level of severity of this particular episode? Who else is affected by the patient’s behavior other than the patient himself? What risks may be taken by not treating the identified episode? As was discussed in Chapter 3, the use of lifetime charting can be a useful tool to visually and graphically view the patient’s functionality over time. It is only in the context of unpredictability, irregularity, and periods of functional disability that some patients can see the impact of their condition on the overall fabric of their lives.

The converse is also a useful technique. Here, the therapist attempts to use a “microscope” to tease apart the various phenomenologic and symptom elements of the patient’s condition. The practitioner identifies those elements of the patient’s life that work well and those that are functionally problematic and need attention. Examine separately symptoms such as irritability, sleep pattern and fatigue, work productivity, marital and family relationships, income production, and the presence or absence of depression. This way, the patient and the practitioner attempt to recognize strengths and useful behaviors, as well as potentially problematic symptoms and behaviors. A patient is much more likely to participate in treatment for specific problem areas when the entirety of their mood and behavior is not challenged. Once individual strengths and weaknesses are assessed, a “bottom line analysis” can be made, from which a treatment plan can be forged.

Presenting the diagnosis

After completing diagnostic questions using the techniques previously outlined, the manner in which the diagnosis and prognosis are presented to the patient is crucial to patient acceptance. Receiving any psychiatric diagnosis
may be “bad news” for some patients and the therapist will need to carefully determine the best way to proceed with each individual.

For example, it is not always necessary to use a formal psychiatric diagnosis when first presenting an assessment. If the therapist feels that this patient would be distinctly upset about receiving a diagnosis of hypomania or bipolar disorder, it may be preferable to present the assessment in a less formal way. Although it may be necessary to make a formal diagnosis for insurance or paperwork purposes, the therapist’s conclusions can be stated in a less alarming way with phrases such as

  • “mood swings,”

  • “a problem with irritability,”

  • “being unable to slow down,”

  • “being in overdrive,” or

  • “cycling.”

It may be much easier for a patient to accept a specific symptom assessment rather than deal with being labeled as “bipolar” or “hypomanic.” The evaluator simply discusses those symptoms that are most problematic and identifies treatment options. At a later date, the concept of bipolarity or hypomania may be made clearer, once the patient has stabilized and the therapeutic alliance is firmly set. In some cases, the “official” diagnosis is never used except for insurance purposes and discussed only if patients ask. This request for a diagnosis usually signifies that the patient is now ready to hear the answer.

For other patients, breaking the “bad news” is actually “good news,” in the sense that the patient may now have an explanation for behaviors that previously they attributed to personal weakness, a seemingly senseless series of adverse consequences, or “bad luck.” With this group, receiving a diagnosis is a great relief and will provide considerable understanding and clarity. As noted in Chapter 6 on the nonmedication treatments of elevated mood, making a diagnosis followed by a “re-view” of the patient’s life in the context of the diagnosis may provide significant illumination. The understanding of previously mysterious elements of the fabric of a person’s life can provide significant benefit even before any other treatment is undertaken. Broad generalizations such as “you have unstable mood that we need to stabilize,” “You are too high and we need to help you come down” are likely to be rejected out of hand by the patient.

The patient must see the advantage of treatment

The therapeutic alliance with the hypomanic patient can be fragile, particularly at the beginning of treatment. With elevated mood, the therapist must go to significant lengths to outline the nature and course of treatment and the expected benefits. Be prepared to answer questions about how treatment might negatively affect the patient, how medications might have side effects, or
how creativity, energy, and productivity may be impacted. Clear transparency as to the potential advantages and disadvantages of treatment is critical. Forthrightness will cement the relationship for those patients who are willing to undertake treatment. Forging a therapeutic alliance and a contract to work may not be accomplished in the initial session. For some patients, particularly those with significant anxiety about treatment, developing and agreeing on a treatment contract may take several sessions.

In some situations, the sum total of an initial agreement may consist of a plan to conduct a more extended evaluation. If symptom intensity is mild and the risk of dangerous behavior is low, it is helpful and appropriate for the therapist to take a “wait-and-see” approach while monitoring symptoms and behaviors. Some patients may take weeks or months to agree to fully participate in therapy. Initially, a patient may be only willing to fill out mood and behavior charts, or have their spouse come in for further input about their condition. Some therapists, especially inexperienced ones, might feel that they will “lose” the patient if they do not solidify a therapeutic agreement at the first or second session. Although this is possible, particularly with some grandiose hypomanic patients, there is simply no viable alternative. A larger percentage of hypomanic patients will be engaged in therapy if the slower, more patient approach is taken.

For example, when patients present at the insistence of another person (e.g., a spouse, a parent, an adult child, or a supervisor), they are often wary, angry, and less amenable to problem recognition. These individuals will often label the problem as originating and residing in the person who insisted on the evaluation and be unable to see any deficits within themselves. In such situations phrases such as “Let’s put ourselves in his/her shoes and see what they see,” can be a useful way to gain perspective. It is also useful to ask the patient “Do you respect him/her?” (the person who insisted on an evaluation)Would there be any reason for this person to exaggerate or insist on an evaluation other than for your own good?

Despite a clinician’s therapeutic technique, a certain number of individuals with elevated mood may be simply unwilling to enter a treatment contract. Even when identifying potential risks, we cannot, as practitioners, always protect individuals from themselves. Some patients need to “hit bottom” before they are more willing to accept their diagnosis, engage in therapy, or take medication. An approach by the therapist such as, “I think you would benefit by being in treatment, but if you need time to think about this, I remain open to seeing you at some point in the future,” may sometimes be all that is possible during an initial evaluation.

Principles of clinical treatment

Basic supportive or psychodynamically oriented technique often falls short with the hypomanic patient. Likewise, typical psychoanalytic therapy using primarily free association and intermittent interpretation is also not likely to
be the best method in treating hypomania. Although listening is important, hypomanic patients require an active therapist who is willing to intervene with limit setting, psychoeducation, and suggestions for behavioral change. As with any patient, the therapist must listen carefully and attentively but intervene with limits if necessary. Additionally, the therapist may need to interrupt the patient in order to make appropriate verbal or behavioral interventions.

Broad-brush maxims or assessments rarely work. To tell patients that they are “high,” “too speeded up,” or hypomanic” may well produce an angry and resistant patient. It is far more therapeutic to precisely identify target symptoms necessitating treatment or intervention.

The hypomanic patient is often skeptical that there is need for therapy at all and may be openly doubtful of any therapeutic process. Grandiose, hypomanic patients often feel superior in their self-knowledge and feel free to say so! Interpretations or advice are, in their view, unneeded and unwanted. Hypomanic individuals may directly challenge the therapist’s knowledge and/or expertise. The clinician should ignore or minimize any such challenges unless they directly threaten continuation of the evaluation or therapy. Participating in a challenge of egos with a hypomanic patient is not only unproductive, but may also result in creating emotional distance between therapist and patient. Although patients indeed know their own story best, they may be unwilling or unable to see any problems resulting from their moods or behaviors. If the patient berates or minimizes the treater’s ability, this can serve as an opportunity to not only gain more information but also to defuse and calm an upset patient. One possible approach is “You are right. You do know yourself better than I do. Can you help me get to know you better?

Additional challenges to the therapist may present when the patient’s history involves some indiscretions or embarrassing behaviors. In such cases, the patient may attempt to minimize the therapist’s skills as a defense against feeling belittled or humiliated. Here, a helpful technique would be to recognize value in the patient’s positive traits, but to point out that when not controlled, even positive traits may result in negative consequences. One way to help the patient recognize both these positive and negative outcomes could be phrased in this way:

“Your level of energy is of obvious benefit in certain situations such as at work. It allows you to be in the upper echelon of productivity. As long as your drive to produce does not alienate or irritate other coworkers, I suspect that your supervisor values your efforts. This same energy and activity may work against you at home. Your wife has indicated that your wish to be constantly active and always “on the go,” leaves her feeling fatigued and she becomes irritated with you. It may be useful for us to look at how you utilize your energy in family and social situations. As you become better able to recognize when others may not wish to operate at the same speed that you do, you may have increased
control and increased ability to have others respect you rather than be irritated with you.”


“I know that you expect much of yourself and have perfectionistic traits. With your schoolwork, this has been helpful in obtaining good grades. When you feel that you are “tuned in” and that your mind is “really clicking” you have the energy to make your essays and term papers of consistently high quality. Your boyfriend however gets angry when you apply this same level of scrutiny and drive for perfection to his behavior and appearance. Rapid-fire comments about his hair, his dress, or his interactions with others when you are together are driving you apart.”

The soft, slow, and persistent approach

Therapists who treat patients with elevated mood must earn the patient’s respect, not expect it. Such respect is earned through gentle persistence rather than abrupt pronouncements. Often when patients are speeded up, clinicians may themselves feel accelerated. Additionally, there may be a tendency for the therapist to insert too much material into a session. It is generally better to make a single comment or interpretation on which you both can agree. Similarly, the therapist must take a cooperative and gentle approach to interpretations and interventions. When dealing with a patient who may be brusque, accelerated in thought and speech, grandiose, or even openly antagonistic, there is a temptation to respond in kind or to be intense in order to be heard. Without realizing it, therapists may feel they need to “hit patients over the head” in order to get them to “see the problem.” These approaches are not only unhelpful, but also counterproductive. The therapist may also feel that unless significant interventions are made rapidly with a hypomanic patient, the patient might leave therapy before help can be given. Some patients may terminate treatment, but it is very unlikely that strong or rapid-fire interpretations will save a therapy. As with any psychiatric condition, a strong bond between treater and patient is essential for productive treatment. If patients see the therapist as knowledgeable, balanced, and with the patient’s best interests at heart, they are much more likely to be willing to participate in therapy for hypomania.

Although the quality of the relationship between therapist and patient is always important, nowhere is it more important than when treating the patient with elevated mood. Patients with irritable, self-inflated and, at times, frankly grandiose personality elements must have adequate confidence in the therapist to maintain satisfactory compliance. In addition to such elements as professional office milieu, helpful and friendly office staff, an open and direct manner with patients, and an ability to speak in plain language, the therapist needs to take special note of how the patient is responding
to interventions and attempt to provide therapy “with the patient” rather than “to the patient.” When the treatment relationship is strong, the patient is more likely to comply with recommendations and the overall response to treatment is likely to be enhanced. A strong therapeutic relationship also helps overcome “errors” that the therapist will inevitably make. These “errors” can be psychotherapeutic—lack of understanding or lack of recognition of the patient’s feeling of specialness, or with medication, prescriptions that are intolerable because of side effects or lack effectiveness. These mistakes are often overlooked or tolerated in the context of a strong therapeutic alliance.

Life stressors and elevated mood

Although elevated mood and mood disorders have strong biologic underpinnings that usually require biologic treatment, their ultimate course and outcome are substantially affected by life stressors and the patient’s ability to successfully manage those stressors (1,2). Such stressors may include divorce, deaths, job change, and family dysfunction, to name a few.

Stressful life events can significantly complicate the course of bipolar disorder (3). It has been shown that negative life events are linked with a threefold increase in time to recover from a bipolar episode and also increase rates of relapse into another episode (4). It is critical that psychotherapeutic interventions in modulating, adjusting to, or eliminating sources of stress be employed to lessen the likelihood of a manic or depressive relapse.

In general, for persons with more significant hypomania, the initial focus should be on moderating elevated mood with medication. However, the therapist cannot settle for lowered mood as a sole end point. Following mood stabilization, the therapist can be exceptionally helpful in clarifying complex interpersonal situations, assisting the patient to simplify and “detoxify” their lifestyle, and advising on the management of specific behavioral crises. By working in partnership to identify and solve life stressors, patient and therapist can often ameliorate situations that might otherwise destabilize a balanced state.

When patients want to take on additional tasks, a useful question is “What are you going to eliminate in order to make room for this new activity?” A common patient response is “nothing” as they can “shoehorn” this new activity into an already busy schedule. In such cases, it is useful to make an hourly assessment of the patient’s daily activities over the course of a week, determining how much time is required for current tasks and how much can be allotted to additional activity. Often without realizing it, the patient has minimized the impact of the time necessary for the new activity. Alternatively, the patients may assume they will shorten sleep time to accommodate the new activity. In both the long and short run, such sleep loss is not healthy and should be advised against.

The wish to remain hypomanic

It is sometimes assumed that patients “like to be manic” or cannot give up “being high.” Depressed patients can yearn for a return to a hypomanic state to remedy the pain of depression. When patients are feeling depressed, many miss “that old spark” or wish to return to the “quick pace” that they felt when hypomanic. Managing this wish to return to hypomania is one of the central challenges to the therapist. A treatment approach that advocates that the patient can “never be hypomanic again” or “must remain level” may well alienate the patient. A more helpful technique is to identify with the patient the pros and cons of their hypomanic behavior, particularly in its extremes. By identifying hypomanic symptoms, behaviors, and their consequences, the therapist and patient can arrive at reasonable goals for therapy. For example, using a combination of medication and sleep hygiene to achieve a minimum of 6 hours of sleep per night may be a reasonable compromise for the patient who insists on working a 14-hour day.

Another useful technique is helping the patient understand the trade-offs in allowing full hypomania to recur. The most distressing of these tradeoffs is an almost certain depression that will follow the high. Although being seemingly attractive, hypomanic episodes are often followed by deep depression in an ongoing repeated pattern, the occurrence of depression, with loss of productivity, intense mental pain, and damage to work, social, and family relationships can be a powerful disincentive to the wish for elevated mood. When a cycling pattern is present, it is important for the therapist to underscore the temporal connection between hypomania and depression. Even with great therapeutic encouragement, patients may need to endure several episodes of hypomania/depression before the cycle is identified and accepted. Once understood, patient and therapist can use this cycle to form the basis for a solid and mutually accepted treatment contract.

Down from the high—necessary grieving

Some cycling patients find that when a diagnosis of their symptoms is made, they are relieved that someone (the therapist) can make sense out of the chaos in their lives. For these patients, diagnosis is a great relief. As the patient’s mood and energy level therapeutically decrease to more normal levels, there is an inevitable sense of loss. It is extremely important for the therapist to be aware of this feeling and to help the patient grieve the losses that occur over the ensuing weeks or months. Even if euthymic, the patient may continue to idealize their previous level of hypomanic functioning. The therapist needs to help the patient be realistic in assessing his or her current and past clinical state. Many patients have the perception of great positive benefits and increased levels of functioning when in an elevated state. The chaos created by the hypomania is often diminished or forgotten. The therapist should recognize with the patient any positive value of hypomania that may be missing in the euthymic states.

When true hypomania is present, however, patients usually feel that they functioned much better than they actually did in reality. Levels of productivity or the ease of sociability tend to be exaggerated. Patients may have functioned rapidly and completed more tasks, but not necessarily as effectively as they thought. More work may have been produced, but it may have been less organized than remembered. The patient may have stayed up late at night and arisen early; however, the commotion that it created in the house may have been totally overlooked. By working with the patient on the effects of hypomanic behavior, elements of truly increased productivity and interactivity can be separated from those that just appeared to be improved, or were improved at a price.

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Jul 29, 2016 | Posted by in GENERAL | Comments Off on Treating Elevated Mood— Principles and the Challenges
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