Mania

Mania seems to be one aspect of bipolar that is both the best understood and the most misunderstood generally.  It is generally understood that mania is a strong indicator of bipolar, however it is misunderstood that all people with bipolar experience mania.  For example, to the best of my knowledge, I have not experienced mania.  This makes me less qualified to write a post on this topic.  However, since it would be remiss of me to discuss depression and bipolar without mania, here is a post drawn mostly from the literature.

Recognizing Mania
This description from the DSM IV is an objective description of mania which might be different from the subjective experience of it.

A) A distinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)
B) During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

1. inflated self-esteem or grandiosity
2. decreased need for sleep (e.g., feels rested after only 3 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 (at work, at 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)

C) The symptoms do not meet criteria for a Mixed Episode

D) 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.

E) The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment) or a general medical condition (e.g., hyperthyroidism)

It seems to me that mania is difficult to recognize without having repeated experiences with it.  Even when I saw mania in a close friend I had difficulty discerning their lack of judgement and impulsiveness.

Preventing and Treating Mania
Mania should be treated together with whatever other bipolar symptoms that one has.  This is typically done using drugs such as Lithium that act as a mood stabilizer.

It is not sufficient to treat mania only with drugs, as therapy and support from family and friends also plays a large role.  In this it is best if the person with bipolar takes charge, as attempts to force the person to comply will likely destroy the very trust needed for success.  One should try to identify triggers as much as possible and make contingency plans for future episodes. Involving family in contingency plans can help with determining when the family can make decisions on the behalf of the person with bipolar and when support is wanted or needed.  Or perhaps the person with bipolar might request for a family member to have control over their finances with a mutually agreed upon allowance, and with mutually agreed upon ability to revise the agreement.

These sorts of plans and frank conversations help prevent misunderstandings such as relatives refusing to make a monetary loan to a stable person because they mistakenly believe the request is a symptom of mania.  Or an even more harmful misunderstanding, relatives may unilaterally decide when a person with bipolar should be involuntarily hospitalized.  Planning helps with decide the conditions under which a person will voluntarily be hospitalized or when they might wish to request decision making help from certain trusted relatives.

Bipolar Episodes

The establishment subscribes to 2-3 types of bipolar episodes:

1. mania - high of euphoria, activity, grandiosity, impulsiveness, etc.
2. depression - low of activity, energy, negative thoughts, suicidal thoughts, etc.
3. mixed states - properties of both mania and depression, perhaps including psychosis

Believe it or not, there is still debate on whether the third type actually exists.  I have encountered prominent doctors at a university who subscribed only to the traditional bipolar I and II distinction in which bipolar I is thought to involve both mania and depression and bipolar II is thought to involve hypomania (baby mania) and depression.  These doctors would not discuss mixed states, but instead discuss schizoaffective disorder as the third disorder that can explain bipolar-like symptoms.

The first two types of episodes are what give bipolar its a name where the 'bi' refers to mania and depression, and the 'polar' refers to the presumed spectrum on which mania and depression sit at opposite ends.  It is fairly easy to see that the name bipolar comes from the traditional description of bipolar I and II.  The addition of mixed states is an acknowledgement that there is actually not a depression-mania spectrum for some people, and opens a diagnostic category for the people having episodic bi-polar-like symptoms that are not clearly related to schizoaffective disorder.

What are mixed states?
It is thought that they look different in everyone that experiences them.  And, one person might experience more than one type of mixed episode.  (Keep in mind that this discussion is not very scientific, as the definition of a mixed episode is still being developed.)  I like to think of it this way, and notice that my view is different from the traditional definition: mania is an episode centered around feeling good and depression is an episode centered around feeling bad.  I believe there are other feelings that can anchor an episode such as anger, or fear.  In each case, the trademark of bipolar is that these episodes take an emotion and make an extreme experience.  So that anger becomes a rage episode and fear becomes a paranoia episode.

These emotional episodes are called mixed, because they are said to have symptoms of both classical mania or depression.  For instance a rage episode might be considered energetic and may also involve suicidal thoughts.  Or a paranoid episode might be sleepless and may also involve difficulty with concentration.

Personally, I find the task of identifying both mania and depression symptoms in an episode to be difficult.  I would prefer to see descriptions of multiple types of emotion centered episodes.  But we will see where scientific discovery takes mixed episodes.  Hopefully we will see progress in the near future.

Does anyone else have thoughts about the distinction between mania, depression, and mixed episodes?