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Mania and Hypomania

A colleague of mine once told me about a manic inpatient he had treated for many years at an Ivy League–affiliated psychiatric teaching hospital. The patient’s father was the CEO of a Fortune 500 company. Each time he visited his son on the unit, he would behave in a dramatically hypomanic fashion. For example, he would make numerous business phone calls around the world on the patients’ pay phone, while frantically yelling “Back off!” at patients or staff who tried to interrupt him. Clearly, Dad was not normal, but he had made his hypomania work for him. He was a very rich man.

This family’s story illustrates the concrete relationship between mania and hypomania. Manics and hypomanics are often blood relatives. Both conditions run together in families at much higher rates than we would predict by chance.6 We know that their genes overlap, though we don’t know how.

This family’s story also illustrates the most radical difference
between mania and hypomania. Mania is a severe illness. The son was disabled—a long-term inpatient at a psychiatric hospital. Manic episodes almost always end in hospitalization. People who are highly energized, and also in most cases psychotic, do bizarre things that are dangerous, frightening, and disruptive. They urgently require external control for everyone’s safety, especially their own. Most people who have experienced a manic episode remember it as a nightmare.

By contrast, hypomania is not, in and of itself, an illness. It is a temperament characterized by an elevated mood state that feels “highly intoxicating, powerful, productive and desirable” to the hypomanic, according to Frederick K. Goodwin and Kay Red-
field Jamison, authors of the definitive nine-hundred-page Manic-Depressive Illness.7 Most hypomanics describe it as their happiest and healthiest state; they feel creative, energetic, and alive. A hypomanic only has a bipolar disorder if hypomania alternates, at some point in life, with major depression. This pattern, first identified only in 1976, is called bipolar disorder type II to distinguish it from bipolar disorder type I, the classic manic-depressive illness, which has been well known since the time of the ancient Greeks. If a hypomanic seeks outpatient treatment it is usually for depression, and he will define recovery as a return to his old energetic self. Not all hypomanics cycle down into depression. What goes up can stay up. Thus, we cannot conclude that someone has a psychiatric disorder just because he may be hypomanic. The most we can say is that hypomanics are at much greater risk for depression than the average population. The things most likely to make them depressed are failure, loss, or anything that prevents them from continuing at their preferred breakneck pace.
Given how radically different mania and hypomania are, it is perhaps surprising that the diagnostic criteria for these two conditions are identical according to the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (usually referred to simply as DSM-IV):

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week.
B. And at least three of the following:

  1. Inflated self-esteem or grandiosity
  2. Decreased need for sleep (e.g., feels rested after only three 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 school, or sexually) or psychomotor agitation
  7. 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)




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