Where Does Hypomania End and Mania Begin?

As part of my overhaul to 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

The Hypomania Dilemma

I love reading Willa Goodfellow's blog, Prozac Monologues. Willa (pictured here) is smart, insightful, and like all good writers she poses questions rather than serving up easy answers. Case in point:

Willa's wife Helen was invited to a function at the home of Sally Mason, president of the University of Iowa. Willa got to tag along. As she explains it:

Helen likes to show me off, because I am good at parties, can talk with anybody, good social skills. And I am cute.

So far, so good.

Anticipating wine at the function, she decided to skip her afternoon Valium. Besides, she wanted to be mentally sharp. Later into the function, the host engaged Helen and Willa in a conversation. They were standing in front of a bookcase populated with books by Iowa Writers Workshop authors. The workshop is the pride and joy of the university.

In Willa's words, "That is when the evil twin appeared." Pointing to a Pulitzer book, "Gilead" by Marilynne Robinson, the evil twin let loose: "Boring. Boring, boring, boring."

Gracious host that she was, Dr Mason acknowledged it was a difficult book to read. Willa says she could have redeemed herself by offering that it was difficult for her, as well. After all, the book was about depressed small town Iowa clergy, and - guess what? - Willa had been one herself. All manner of fascinating conversation could have flowed.

But, no. Willa pointed to another book. As she reports: "This time I said, 'I hate this book ...'" Dr Mason moved on to other guests.

Willa observes that her psychiatrist would have a ready solution to her unwanted hypomania, namely to go on the meds she had been refusing. But there is a catch, as Willa relates:

Those meds would give me a flat affect, facial tics and forty pounds. Helen would have no reason to let me out of the house at all. I would no longer even be cute.

Willa cites a 2003 study by Pope and Scott that pointed to a clear discordance between psychiatrists and patients. The psychiatrists in the study thought that bipolars went off their meds because we "miss our highs." The patients who quit cited other reasons. In 2006, I heard Dr Scott talk about her study at the International Society of Bipolar Disorder conference in Edinburgh. When I included it as a PowerPoint slide in a grand rounds I gave two years later to clinicians at a hospital in Princeton, NJ I was greeted with stony cold frozen Kelvin grade silence.

It didn't help when the next thing out of my mouth was: "Get over it. When your patients complain to you about feeling like fat stupid zombie eunuchs on the meds you prescribe - and on the meds you overprescribe - they are not doing this to ruin your day."

In an ideal world, we could all be our smart, funny, insightful, and engaging selves without having to worry about causing a social embarrassment. Operating with a clear head is our most valuable asset, but there are risks, illness or no illness. I could opt for faux pas-free life, but at what cost? An existence devoid of laughter?

Psychiatrists tell us we need to stay on our meds, and for many of us that is very good advice. But that is the easy answer. Willa poses questions ...

Craig Venter: Hypomanic

Following is an extract from a lengthy review I first published in my Newsletter in late 2004, and on mcmanweb in 2005 ...

"Up until 2003, only God could claim to have created life. The Almighty must now share that honor with a hypomanic American."

That provocative statement comes from the book, "The Hypomanic Edge: The Link Between (a Little) Craziness and (a Lot of) Success in America" by John Gartner PhD.

Dr Gartner is an associate professor of psychiatry at Johns Hopkins. The book invites an obvious comparison to one published in 2004 by his university colleague Kay Jamison PhD, "Exuberance: The Passion for Life". But that book downplayed the bipolar connection, much to the disappointment of many admirers of her previous "Touched with Fire."

Not so with Dr Gartner’s work, which contends that America would not be what it is today without the hypomanic drive of the people who settled, founded, and shaped a nation in their image. Exhibit A is God’s partner in creating life, Craig Venter.

Readers may recall a June 2000 White House ceremony in which President Clinton announced a "tie" between two competing groups to sequence the human genome: the official government effort, the Human Genome Project (HGP) headed up by Francis Collins and a breakaway private venture bankrolled by a new company, Celera, run by maverick geneticist Craig Venter.

In fact, the tie was a political sham engineered by the White House with the collusion of both parties. Celera had actually run rings around the opposition, smoked them, waxed them, wiped the floor with their face. It wasn’t even close. Not only had Celera crossed the finish line well ahead of the HGP, it delivered a more complete genetic blueprint. To add insult to injury, the only way the HGP could even stay in the race was by scrapping its own plodding methods and game plan for Celera’s.

Craig Venter was a wild man from day one. As a kid, he liked to race his bike on the local airport runway as planes took off. In the Army, he frequently got on the wrong side of his superiors. On acceptance to a university faculty position, he wasted no time turning colleagues into enemies, then evinced surprise when they refused to grant him tenure. He arrived at the NIH and caught the attention of his hero, James Watson, but became disillusioned when the great man tactlessly treated him as a mere technician and publicly humiliated him in a Senate hearing.

Venter acknowledged to Dr Gartner that he probably has "a very mild case of manic depression." When the author described bipolar II to him, he replied, "That characterizes some pretty big stretches of my life."

Driven into the private sector, Venter in 1995 revolutionized microbiology by successfully mapping the H flu genome using a novel "shotgun" method. At the time, the HGP was in full swing. Three years later, with the support of Celera, Venter made the surprise announcement that he would map the human genome four years ahead of the HGP’s target date at one tenth the cost. As Dr Gartner describes it: "What psychiatrists call ‘impulsivity,’ entrepreneurs call ‘seizing the moment.’"

Venter added that Collins’ team should just quit now and stick to mapping the mouse.

A few days later he turned up uninvited at a HGP meeting and taunted the participants. One scientist wanted to slug him and another strangle him. But the affront energized the opposition and instilled in them a newfound sense of urgency. Meanwhile, Venter mobilized his troops with the charismatic élan of a battlefield commander. A colleague compared his efforts to high dives into empty pools, timed so that the water would be there by the time he hit bottom.

In the end, Venter nailed all his landings, a full five years ahead of HGP’s original schedule. Under the terms of the White House agreement, neither party was supposed to attack the other’s work, but embittered HGP scientists simply couldn’t help themselves. Even Mother Teresa would hate the guy.

Venter proved equally successful in alienating his financial backers. In 2002, Celera fired him and he went into a depression, only to bounce back as head of the privately-funded "Genesis Project," which effectively created life by building a virus from scratch. A team at the State University of New York at Stony Book had accomplished a similar feat shortly before, but their effort had taken three years compared to Venter’s 14 days.

Now science was truly playing God, for better or for worse, with the potential to transform the world or destroy it. It’s the kind of challenge that hypomanics live for.

See the full review on mcmanweb

Columbus, religious dissidents, Alexander Hamilton, Andrew Carnegie, the Hollywood moguls ...

Rerun: Treating Marilyn

My most recent blog piece touched on a section of a grand rounds I delivered on meds compliance two years ago at a psychiatric facility in Princeton. That section, "The Problem Clinician," received a decidedly frosty reception from my audience of clinicians. This section, from "The Problem Patient," went over a lot better.

This piece first appeared on my blog in Feb, 2009.

The following is based on the first part of a talk I gave to clinicians on meds compliance as part of a grand rounds at a psychiatric facility in Princeton:

'Marilyn walks into your office," I began. "She reveals her moods have been all over the place. Everything points to bipolar. Okay. How do you treat her?"

Believe it or not, no one raised their hands. I was the one who had to suggest that a mood stabilizer might be a good idea, then I had to make sure we had a consensus. Then I went to the catch, namely how does the most important person in the equation - the patient - feel? After all, even the best med in the world is useless if patients won't take it.

Maybe we need to ask Marilyn a few more questions, I suggested. Consider:

Marilyn is literally larger than life. Over the top is her baseline. It's a legitimate part of her personality. How long do you think she is going to stay on her mood stabilizer if she thinks her personality is getting medicated out of her?

Hypomania is the first thing to come to mind when thinking of Marilyn, but the operative word from the DSM regarding this type of behavior is "uncharacteristic."

"For someone else to act like Marilyn," I said, "that may be hypomanic. For Marilyn to act like Marilyn - that's normal."

In support, I cited Ronald Fieve MD of Columbia University, who coined the term, "the hypomanic advantage."

"Keep in mind," I said, "a lot of us view the world through the eyes of artists and poets and visionaries and mystics. Not to mention through the eyes of highly successful professionals and entrepreneurs. We don't want to be like you."

How can I describe the look of surprise from my audience? Like I had let rip a roof-rattler and they were too polite to laugh - I think that best sums it up. I should have thrown away my prepared talk at that stage. Seriously, I should have said. We don't want to be like you. Why should that surprise you?

Instead I plowed ahead:

"We don't want to fly too close to the sun," I continued. "But don't clip our wings. Obviously Marilyn needs to be reeled in a bit. But how do we proceed? What do we have to go on?"

Believe it or not, there are zero published studies for treating hypomania. Zip, zilch, nada. The only solid evidence base involves the acute phase of full-blown mania, when we're bouncing off walls, 911 cases.

"So," I asked, "are you thinking of giving someone with hypomania an industrial strength dose?"

What else is going on with Marilyn? Personality issues? Quirky behavior? Does the bipolar itself affect her capacity to think rationally?

"You're the rational ones," I said. "We know where you are coming from. But do you know where your patients are coming from?"

I clicked to two slides: Fear/feeling threatened, problems accepting authority, cognitive distortions ...

The list went on and on. "Looking like a lot of your patients?" I asked.

"Here's the point I'm making," I continued. "Not only are you treating the illness. You are treating any behaviors and attitudes that come in the way of treatment. And you're not going to find that out unless you talk to the patient - and listen."

I wasn't through: "Just sending a patient out the door with a prescription - in my opinion - is not treatment."

Back to Marilyn. She's Marilyn. She has enormous gifts and doesn't want her wings clipped. She has various personality issues. And her illness is affecting her judgment.

"We have the advantage of knowing the tragic outcome," I concluded. "Knowing what you know, are you happy just writing her a prescription and sending her out the door?"

Postscript: This first part of my talk - "The Problem Patient" - went fairly well, perhaps because the audience could spin my message in a way that assigned all blame to the patient. There was no way they could do that with the next two sections, "Problem Meds" and "The Problem Clinician," and I got a very different reaction.

More later ...

Treating Marilyn

The following is based on the first part of a talk I gave to clinicians on meds compliance as part of a grand rounds at a psychiatric facility in Princeton:

'Marilyn walks into your office," I began. "She reveals her moods have been all over the place. Everything points to bipolar. Okay. How do you treat her?"

Believe it or not, no one raised their hands. I was the one who had to suggest that a mood stabilizer might be a good idea, then I had to make sure we had a consensus. Then I went to the catch, namely how does the most important person in the equation - the patient - feel? After all, even the best med in the world is useless if patients won't take it.

Maybe we need to ask Marilyn a few more questions, I suggested. Consider:

Marilyn is literally larger than life. Over the top is her baseline. It's a legitimate part of her personality. How long do you think she is going to stay on her mood stabilizer if she thinks her personality is getting medicated out of her?

Hypomania is the first thing to come to mind when thinking of Marilyn, but the operative word from the DSM regarding this type of behavior is "uncharacteristic."

"For someone else to act like Marilyn," I said, "that may be hypomanic. For Marilyn to act like Marilyn - that's normal."

In support, I cited Ronald Fieve MD of Columbia University, who coined the term, "the hypomanic advantage."

"Keep in mind," I said, "a lot of us view the world through the eyes of artists and poets and visionaries and mystics. Not to mention through the eyes of highly successful professionals and entrepreneurs. We don't want to be like you."

How can I describe the look of surprise from my audience? Like I had let rip a roof-rattler and they were too polite to laugh - I think that best sums it up. I should have thrown away my prepared talk at that stage. Seriously, I should have said. We don't want to be like you. Why should that surprise you?

Instead I plowed ahead:

"We don't want to fly too close to the sun," I continued. "But don't clip our wings. Obviously Marilyn needs to be reeled in a bit. But how do we proceed? What do we have to go on?"

Believe it or not, there are zero published studies for treating hypomania. Zip, zilch, nada. The only solid evidence base involves the acute phase of full-blown mania, when we're bouncing off walls, 911 cases.

"So," I asked, "are you thinking of giving someone with hypomania an industrial strength dose?"

What else is going on with Marilyn? Personality issues? Quirky behavior? Does the bipolar itself affect her capacity to think rationally?

"You're the rational ones," I said. "We know where you are coming from. But do you know where your patients are coming from?"

I clicked to two slides: Fear/feeling threatened, problems accepting authority, cognitive distortions ...

The list went on and on. "Looking like a lot of your patients?" I asked.

"Here's the point I'm making," I continued. "Not only are you treating the illness. You are treating any behaviors and attitudes that come in the way of treatment. And you're not going to find that out unless you talk to the patient - and listen."

I wasn't through: "Just sending a patient out the door with a prescription - in my opinion - is not treatment."

Back to Marilyn. She's Marilyn. She has enormous gifts and doesn't want her wings clipped. She has various personality issues. And her illness is affecting her judgment.

"We have the advantage of knowing the tragic outcome," I concluded. "Knowing what you know, are you happy just writing her a prescription and sending her out the door?"

Postscript: This first part of my talk - "The Problem Patient" - went fairly well, perhaps because the audience could spin my message in a way that assigned all blame to the patient. There was no way they could do that with the next two sections, "Problem Meds" and "The Problem Clinician," and I got a very different reaction.

More later ...