Hypomania or Mania – Which was it?

I’ve had this post in the hopper for a while, and finally decided to publish it after reading another blogger’s post today about what she believes are the differences between Bipolar I and Bipolar II.  Basically, I believe she is incorrect.  But thinking about the real differences between Mania and Hypomania prompted me to write a post about how I believe my diagnosis of Bipolar II may be incorrect, and the thought process that drove me to the conclusion.

Last year, I was hospitalized for depression.  I was fed a whole slew of antidepressants and within three days the Drs were calling my miraculous turnaround a success story.  They promptly pushed me out the door and onto the street.  What they incredibly seemed not to realize is they let me discharge in a full-fledged manic state.

Yes, psychiatrists should know better – they should know that patients who show such marked improvement on antidepressants over such a short period are Bipolar and that a completely different intervention is called for.  There are many studies citing just how bad antidepressants are for BP, and many of those even go as far as crying out for elimination of antidepressants from everyone’s Bipolar cocktail.  But then there are those psychiatrists like the ones I came across, who are only interested in treating the immediate symptoms and turning over a bed in a ward.

Eventually, I did come down out of the clouds, was able to function on this plane again and found a psychiatrist who knew what to do with me.  Unfortunately, this was after a lot of damaging behavior on my part. My new psyc and I tried new drugs, tweaked my cocktail and fine tuned all meds.  Now, I’ve finally arrived at a place where I am basically OK.  At the end of all the med mixing, my psyc did say something pretty interesting.  That although I was diagnosed as BP II, I respond to med as a BP I would.  This got me thinking.

As far as I can discern from the DSM IV and the proposed criteria for BP in the DSM 5, the major difference between the two types of BP is to what degree the manic episode was debilitating to the sufferer.  This excerpt regarding mood severity is from the proposed criteria for a manic episode in the DSM 5:

The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. 

The italicization of the ‘ors’ is mine.  Because there sure are a lot of ‘ors’ in this full-blown-mania criteria.

This excerpt is from the proposed criteria for a hypomanic (or lesser-mania) episode in the DSM 5:

The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.

Again, italicization is mine.  Because this time, although there are still ‘ors,’ with the ‘and’ present, it changes the game.  Mania may have psychotic features, but hypomania does not.  Mania encompasses an impairment in day-to-day functioning, but hypomania does not.  Also, note that in both the DSM IV and the DSM 5, it explicitly states that when in a Mania, hospitalization is definitely in the ‘or’ category and is not necessary to diagnose a full-blown Mania.  This last piece of criteria is what I have seen misquoted time and time again – hospitalization is not necessary to diagnose a full-on Mania .

So, after digesting all the DSM IV and DSM 5 verbiage and ruminating on my behavior from both my personal view and contributions by second parties, it is the severe impairment piece that is the lynchpin to my suspicion I may be Bipolar I.

I can honestly say although I have never experienced psychotic features, my occupational functioning was hugely impaired – I was vibrating so much, I simply could not and did not work for the first two weeks out of the hospital.  It was during this time I also, ‘…engaged in unusual social activities and relationships with others,’ and to this day really don’t remember a large chunk of that period of my life.

For those of you familiar with the DSM, you may have by now spotted a hole in my thought process.

Episodes of Substance-Induced Mood Disorder (due to the direct effects of a medication, or other somatic treatments for depression, a drug of abuse, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Bipolar I Disorder. (DSM IV)

But, I had previously been diagnosed with BP and medication-induced switching happens.

As of late 2007, three recent studies have addressed the question as to whether antidepressants can induce switches into mania or hypomania. The bottom line: switching happens, but now often seems to vary widely, depending on the patient, and to some extent on the antidepressant chosen. (Read more here.)

Especially for those on the antidepressant I was given, bupropion (Wellbutrin ).  Even my psyc confirmed this.  There’s no doubt in my mind I am living proof that switching happens.  So, I am now back to the question of Mania or Hypomania.

Given the severe impairment I experienced while clearly displaying two of the four Mania criteria listed above, and a further five of the seven pieces of criteria listed in Part B in the DSM IV for a Manic episode, I now believe that what I experienced was a true Mania as a result of antidepressant ‘Switching.’

Why haven’t I brought this up with my psychiatrist – the one who commented that my reaction to medication is more akin to someone with Bipolar I than Bipolar II?  Because by the time I was stable enough to reason all of this out, I’d relocated.  I need to find a new shrink.  I’m sad that the relationship with my wonderful Dr had to end, and even more sad that we’ll never have the opportunity to explore this hypothesis together.

I am afraid of having my diagnosis changed.  I am petrified the possibility of experiencing psychotic features may have grown. But, I have to put on my big-girl-pants, level with my new psyc and see what they have to say.  If I am truly BP I, what changes, if any, will have to happen to my treatment?  I am not sure.  But, I need to find out.  Because as we Bipolar sufferers know, BP just doesn’t get any better.  It degrades and worsens without the proper treatment.

I know this is an exceptionally long post, but if you’re still with me and if any of you have had the experience of having your diagnosis changed from BP II to BP I, I’d love to hear from you.

I find this incredibly uncanny, because I have been working on a similar post for the last week but haven’t published it yet.

I really didn’t realize the scope of the confusion about this beyond what I’ve been thinking about myself. I will probably post my thoughts on this (as I’ve already written them) today or tomorrow if you want to check them out, but I want to leave you in short with:

I feel you, for sure. I believe I was diagnosed as 2 but I have been questioning if I may be a 1. I’ve had reactions (like you) to antidepressants, (as well as one time that involved psychotic features) but I don’t think that is the reason I’m a 1. I am more concerned with my (at least) hypomanic episodes as they occur and when I am in the moment I can feel things, different things happening (my symptoms I suppose) but can’t pinpoint when those symptoms become mania. I’m looking for a foothold to be able to compare my symptoms from moment to moment so I can distinguish if (and when) the mania is happening (the way I do with depression).

Sorry for the long reply. Good post!

HI, ColonialPunk: No worries about the long reply – it’s great to know others out there are thinking along the same lines. I did bounce over and read your post – I can completely relate. And, I can understand your anxiety about wanting to have an accurate, more detailed diagnosis. The more I poke around, the more people I find who are confused about hypomania/mania/their own diagnosis. I’ll jet back over to your blog and post another comment to you…thanks for reading!

Awesome post. It prompted a couple of thoughts.

I’ve read the drafts they’ve had so far when it comes to various disorders and delays. When the DSM-V comes out, it’s going to change the game for a lot of people. It eliminates the sub-disorders in the ASD entirely, which I feel is not good for treatment. It lumps children of different functions together and targeting specific treatments may be difficult. As for psychiatrics, it eliminates something like 5 or 6 personality disorders.

Here are the good game changers. It adds over-eating to the eating disorders and changes certain criteria in other disorders to accomodate people who may stand on the fringe. That may include you.

Switching does happen, and it cannot be denied. The mania induced by a substance is NOT qualified under the “chemically induced” BP. I had a psychiatrist tell me this once when I was lamenting about how the Pdoc that diagnosed me with MDD in my teens screwed me. And he said, “How many BP people willingly go to the doc for a manic episode?” Unless it includes psychotic feature, probably few. Because the main complaint is depression, it is easily misdiagnosed. What he didn’t say is what I figured out later. Psychiatric professionals should be looking for switching with MDD patients because it’s a tell-tale sign of BP. But! – switching is often mistaken for recovery! Our society has things set up so hypomania or even non-psychotic mania is preferred!

Now that you mentioned it, I had the same problem with Wellbutrin when I first took it in combination with Zoloft for MDD. I thought it was side effects! I was shaking so bad I couldn’t move. I had these awful cold sweats and eventually, I began vomiting uncontrollably. That was the day I stopped it, and I wasn’t nearly at the dose I’m on now!

I’m probably lucky I didn’t suffer from seroitonin storm!

But you’re probably right. When the DSM-V comes out, you’ll likely have a Dx switch. And folks like you who prompted the change in criteria.

HI, Again, Lulu. You know, this whole DSM-5 is turning into quite a debacle. Reading the raging debates is like tuning into a soap opera, but the sad part is I think we can all see how it is going to ruin a lot of people’s RLs. You’re observation about our society being set up to prefer manic behaviors is dead-on. As long as you’re not psychotic, you can work more, produce more, have more fun, spend more money! More more more. Ugh. It makes it really hard to prompt people to even get to a Dr if they’re feeling manic. Thinking about it, how do you educate the public about Bipolar and urge people to seek medical attention for mania? I just don’t have an answer right now.

So, you’re still on Wellbutrin, too. How long did it take to get you up to an acceptable dose without the nasty side effects?

Surely, it is going to turn a lot of people’s world’s upside-down. And, it may lead to chosing down a lot of people who hardly meet diagnostic criteria but don’t need treatment. Isn’t one of the parameters in every disorder dysfunction? And because hypomania does occasionally cause me some dysfunction, then does that qualify me for BP I as well? I don’t think so. Only dyphoric hypomanic spells cause me difficulty. Those ones leave me ready to fight and any spark will set me off. But have I ruined a relationship or lost a job over it? Absolutely not. And I definitely respond to BP II meds.

When I first started Wellbutrin on the second round with Lamictal, I started at 150mg. It took about a couple of weeks to go from severely hypomanic down to just running on high. I wasn’t really back to an even state until three months after starting. I had another hypomanic fit in early April, but that wasn’t Wellbutrin’s fault, I don’t think. I was the musical director for a children’s play at the time and that was showtime. I even remember the day the fit started! I was screaming obscenities in the car coming home from work. It was a euphoric thing. I was relishing in the fact that I conquered the director when she tried to throw me under the bus. After that, I hit a short depressive spell, followed by a moment of even and then a ultra-rapid cycle that ended in depression. That’s when I came here and in August I went to 300mg.

I would guess I’m OK. I went through another ultra-rapid cycle in September that ended in hypomania. I’m not hypomanic right now, but I’m still running high. And now there’s the issues with panic. I’m not sure what that’s all about. Any ideas?

I was just reading about comorbid anxiety disorders with BP patients. It’s not very encouraging. “Non-serotonergic antidepressants (specifically bupropion) do not appear to be particularly effective.” “The risk of these complications is higher if the bipolar patient receives antidepressants during periods of euthymia or over long periods” The conclusion was certain antipsychotics (quetiapine worked and risperidone and risperidone didn’t) and anticonvulsants are a better choice than antidepressants. Benzos are of course affective but everyone is so afraid of them (“Who cares”, I say. We already have to take meds for the rest of our lives. If the benzos work, then use them.) Do you feel like you’re on enough mood stabilizer/lamictal?

This discussion is really interesting, but does considering yourself 1 or 2 really change anything? If your meds work, god forbid *anyone* mess with them. I know that on medication I often switched and my mania leaped off the charts (and I’m considered a 2). Ultimately, its between you and your doc to determine what the best course of treatment is for you.

Sandy – it’s great to see you online! I hope you’re doing well.

I think in the long run, knowing whether you’re a I or II is important. I’d like to better educate myself on the symptoms specific to BP I, but more importantly I’d like my family to be able to understand the differences and give my husband especially a heads up as to how severe a BP I mania can be. My East Coast Paranoia is surfacing here, but if he even starts to suspect I’m getting manic, I want him to get with my psyc more quickly than we did before. As for my meds…woah, Nellie! No doc on the face of the earth is going to touch my present cocktail until something goes out of whack again – and I know eventually it will.

Do you know which meds were switching you into mania? Was it everyone’s favorite, Wellbutrin?

I haven’t read the prior comments, but here’s my two – you quite probably did experience a full-blown mania (sounds like it to me), but it was medication induced. This is not uncommon among patients carrying a legitimate diagnosis of Bipolar II.

I have never been hospitalized, and on my first visit with my psychiatrist (whom I saw for five years), he diagnosed me as Bipolar II and sent me on my way with some Lamictal (fun stuff). By the next visit, after he had taken more of my history, he was practically shoving lithium down my throat because “Lamictal is not nearly a strong enough anti-manic for you” (of course we now know that it isn’t an anti-manic/mood stabilizer at all – score one for him).

I guess my question to you is have you experienced episodes of what you feel were full-blown mania that were not medication induced? I was never hospitalized, but on the strength of things I do (did) alone, I was classed Bipolar I. I kept things just enough under wraps, and I was never a direct danger to myself or anyone else, but I definitely developed psychosis, hallucinations, the whole she-bang. I’m just touchy in areas of trust and disclosure, so it may take a doctor a little while to recognize it in me.

We could get into the finer points of spending sprees and time gone without sleep, impulsivity and dangerous behavior, but for me the takeaway is this: A diagnostic label is only helpful insofar as it gets you the proper treatment (my “labels are for jelly jars” approach). If you don’t feel you are getting that, you may want to delve into your diagnosis. But Bipolar I or Bipolar II, any (competent) doctor is going to be much more careful about prescribing you something that could cause a mood switch than they were before.

After reading the comments I’m going to add this, and it will potentially read as really unfeeling, but I trust you and I have enough of a relationship that you know that isn’t how I mean it. If you’re questioning how to get someone to seek for help when they’re full-on manic, you have not experienced full-on mania. The only reason I ever sought for help with it was because after years of treatment and my manias being purely dysphoric, I realized that mania inevitably led to a depressive crash in me. Even after that, I still only call my shrink when I’m starting up and haven’t hit full mania yet.

Which brings me full circle to your question: because when you’re manic you absolutely do not believe there is a thing in the world wrong with you, and pretty much nothing and no one can convince you otherwise. And the harder they try, the more you push them from you as the “crazy” ones.

Incidentally, Wellbutrin wasn’t the worst offender for me, it was pretty innocuous (relatively speaking). For me it was Prozac.

Ahh hell. In hypomanic episodes I don’t think there’s anything wromg with me! I guess that’s what I was trying to illustrate. Mania, hypomania, they work in the same way that there are, at the very least, some incredibly delusions you wouldn’t otherwise believe. I think I’m starting up with the hypomania again, or continuing or something. I caught myself saying and thinking some radical stuff. I’m glad my husband is here to keep me in check. Or else, I may have ended up in the slammer for vandalism yesterday. (I was going to play a joke on a friend when I saw their car parked in the lot where he works. Well, C.S pointed out that someone might get suspicious and call the police. I fought him tooth and nail. I called him a wuss and told him he got soft over the years!)

The difference between mania and hypomania? I guess severity if I’m here talking about it. But it’s true. T.D’s therapists told me that the Dx is not important in it’s name or label. It’s about treatment and services. (Because I’m not entirely convinced T.D has PDD-NOS. But he still responds to standard OT for ASD).

Yes – treatment and services…so, if the person is responding to the treatment as if they have a diagnosis different from what they were given, isn’t that just another way of arriving at the correct diagnosis?

Hi, Ruby – Took the weekend off…sorry for the late reply.

LOL – no, your comment doesn’t read as unfeeling at all. It’s what I was hoping to hear – honest input from a BP I person!

I spent Friday evening reading through case studies of BP I and reviewing what has gone on in my history for the last 25 years. Without going into the dirty details on a public forum, yes, I have been experiencing full-blown manic symptoms for a long time. The reason I’m feeling some urgency about getting my act together is to get off on the right foot with the new psyc, whom I’ll have to see within the next month. (I’m not looking forward to the Russian Roulette that goes on every time a change of Dr’s is forced, but that’s another topic. ) Since my dear, sweet husband is the one who has to execute the interventions when I get too depressed or manic-y (I never initiate because I’m always in denial about how bad things can potentially become), I just want everyone to be on the same page going forward.

I do find it very encouraging you’ve never been hospitalized for mania, and especially that psychotic features can exist without necessitating a trip to the ward. All of this research and input from folks like you (thanks!) has reset my understanding of mania. It’s one thing to read about the symptoms in a clinical manual, but it’s quite another to talk to others who have BP and be able to dissect the finer points.

Prozac! Evil, evil stuff. I was given the Big P after I had my son and I will never, ever, ever touch that stuff again. Can you take any antidepressant at this point?

ManicMuses, I cannot smell and anti-depressant, even in the presence of a mood stabilizer and anti-psychotic, without going full-on nuts (pardon the term). I have tried everything from SSRIs to MAOIs, and all classes in between.

The one thing that really helped with my depression was liothyronine, a prescription thyroid supplement. I took it for several months without nasty effects on my mood, even though my thyroid was normal. Then I became so hyperthyroid it could have easily killed me. We tried it again, in the Spring, in a lower dose – after five days I was in the ER with thyroiditis. But I’m weird like that. Otherwise it was a dream for my depression.

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