mcmanweb, I've scrapped most of my old articles on the diagnostic aspects of bipolar and replaced them with new pieces. The following is extracted from a much longer piece on hypomania. Enjoy ...
The DSM mandates that if psychosis is present, then it has to be mania, not hypomania. Otherwise the only separator is severity, and here the DSM is highly confusing and contradictory. On one hand the DSM reassures us:
The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization ...
On the other, symptom number seven (a direct copy and paste from the mania symptom list) tells us:
Excessive involvement in pleasurable activities that have a high potential for painful consequences ...
So - wait! First, we're being informed that there is nothing to worry about. Next, we're being told to go to DEFCON One. Which one is it?
There are no easy answers, but one possible solution is to eliminate symptom seven in hypomania and make it mandatory (rather than merely optional) for mania. In other words, if the individual is entering the danger zone - putting his or her livelihood, relationships, and safety at risk - then it is mania, not hypomania.
Another piece of the puzzle is control. In my article on mania, I suggest my own diagnostic guide:
Behavior must be out of control to the point that subject can no longer responsibly manage his or her affairs or reasonably interact with others. ... Thinking must be out of control to the point where subject has a grossly distorted perception of him or herself and his or her surroundings, and is no longer capable of making realistic or responsible decisions.
Whereas with hypomania, it's more like this:
Subject may exhibit unusual or unexpected behavior, but is still capable of responsibly managing his or her affairs and interacting with others. ... Subject may have a mildly distorted perception of him or herself and his or her surroundings, but is still capable of making realistic and responsible decisions.
Finally, there is the matter of presentation. In euphoric states, I would contrast a "magnanimous larger than life presence" (mania) with a rather more diminutive "sociable charismatic presence" (hypomania). In dysphoric states, I would contrast a "hostile menacing presence" with an "unpleasant mildly threatening presence."
But nothing is ever that simple. In bipolar, our brains are always in perpetual motion, so even in a seemingly benign hypomania there is always room for worry.
New mcmanweb bipolar articles:
Bipolar Disorder - Really a Cycling Illness
Bipolar I and Mania
Bipolar II and Hypomania