The Dark Side of Hypomania
While working on the American Psychiatric Association’s latest DSM version of bipolar disorder (IV-TR), Trisha Suppes MD, PhD of the University of Texas Medical Center in Dallas carefully read its criteria for hypomania, and had an epiphany. “I said, wait,” she told a UCLA grand rounds lecture in April 2003, “where are all those patients of mine who are hypomanic and say they don’t feel good?”
The DSM defines hypomania as “a distinct period of persistently elevated, expansive, or irritable mood,” but the overwhelmingly standard misconception is one of unadulterated exuberance. Ask your typical patient about hypomania and he or she will fondly recall those life-of-the-party and unbelievably productive moments and reply, “if only I could put it in a bottle and sell it.” And a psychiatrist off the record may add, with a hint of envy, “if only I could buy it.”
But what about road rage and other destructive behaviors? The DSM recognizes “mixed” states in mania where highs and lows simultaneously run riot in the brain, but nowhere does it acknowledge a parallel phenomenon in hypomania. Does mixed hypomania exist and how common is it? Dr Suppes decided to find out. The results of her seven-year investigation appear in the October Archives of General Psychiatry.
Drawing from patients in seven clinics associated with the Stanley Foundation Bipolar Treatment Network, Dr Suppes and her colleagues gathered prospective data on 908 bipolar patients (most by far with bipolar I). Of 14,328 visits by patients, 1,044 involved hypomania. Examinations of the patients in this state found that the majority (57 percent) “met criteria for mixed hypomania.”
By “mixed hypomania,” patients must have met the researchers’ threshold for at least mild hypomania (corresponding to a YMRS score of 12 or greater) combined with at least mild depression (corresponding to an IDS-C score of 15 or greater).
Patients with bipolar I were far more likely to experience hypomania than those with bipolar II, though the likelihood of mixed states within each diagnosis remained about the same. Women were significantly more likely to experience mixed states than men (72 percent vs 42 percent). Women in the study with no hypomania had a 41 percent probability of experiencing depression. This increased to 66 percent with mild hypomania and 81 percent with moderate hypomania, then dipped back to 67 percent with severe hypomania.
Although there was no association between hypomanic and depressive symptoms in men, the authors of the study concluded that “men are far more likely to be irritable and agitated when hypomanic.”
Dr Suppes and her colleagues observe that one reason bipolar II patients are misdiagnosed with depression is “the expectation that hypomania is predominantly euphoric.” Patients tend not to report mixed episodes and psychiatrists often fail to ask the right questions. The result, they say, may lead to inappropriate treatments, such as antidepressant monotherapy which may induce increased cycling.
Read on …
Dysphoric Hypomania
The unofficial title of Dr Mood Spectrum belongs to Hagop Akiskal MD of the University of California, San Diego. Entering “mixed” to his name on PubMed turns up 47 published articles. His latest one, in the October Bipolar Disorders, reinforces Dr Suppes’ study and adds new insights.
From a sample of 320 bipolar II patients, Dr Akiskal and frequent collaborator, Franco Benazzi MD of the Hecker Outpatient Center (Ravenna) focused on 45 who presented with both hypomania and major depression. This meant that euphoric mood was absent. Instead, hypomania was based on the often overlooked DSM criteria for irritable mood plus four hypomanic symptoms.
The authors define this hypomania-major depression double-whammy as “dysphoric hypomania,” which roughly corresponds to Dr Suppes “mixed hypomania,” but sets a higher threshold involving more severely ill patients.
Comparing these patients to the “pure” bipolar II patients in the study found that those with dysphoric hypomania experienced more agitated depressions by a wide margin (86.6 percent vs 5.8 percent) and evidenced more atypical features (such as mood reactivity). Hypomanic symptoms included racing thoughts, distractibility, being more talkative, excessive risky activities, and increased goal-directed activity. Women were more likely to experience dysphoric hypomania than men.
Clearly, these individuals require urgent attention. Unfortunately, say the authors of the study, this “dark facet” of hypomania “is likely to be relegated to the domain of erratic personality disorders.”
Based on their previous work and the work of others, the authors propose a continuum of mixed states that includes:
DSM-IV mixed state (dysphoric mania).
Mixed mania (mania with a few depressive symptoms).
Dysphoric hypomania (hypomanic episode plus full major depression).
Depressive mixed state (major depressive episode plus a few hypomanic behaviors. A landmark 2001 study by the same authors found at least two hypomanic symptoms in 73.1 percent of bipolar II depressions and 42.1 percent of unipolar major depressions. Three or more hypomanic symptoms were found in 46.3 percent of bipolar depressions and 7.8 percent of unipolar depressions.).
Agitated depression.
Think road rage, tall, venti, and grande, potentially dangerous in any brew. How safe are you?
