Hypomania is not all fun and games.
While working on technical update to the DSM, 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?"
These are your typical road rage cases. Why was there no mention of that in hypomania? Dr Suppes wondered. A subsequent literature search yielded virtually no data.
The DSM defines hypomania as "a distinct period of persistently elevated, expansive, or irritable mood." Note that overlooked word, irritable. We’re not talking about letting the good times roll. In an irritable state, depression symptoms typically intrude into hypomania, what is called a “mixed” state. Unaccountably, although the DSM acknowledges mixed states in full blown mania, it is silent on the phenomenon in hypomania.
Many of us wind up spending a good deal of our lives feeling miserable in hypomania, and in a study published in the October 2005 Archives of General Psychiatry, Dr. Suppes provided proof. Drawing from patients in seven clinics associated with the Stanley Foundation Bipolar Treatment Network, Dr. Suppes found that the majority of hypomanic patients "met criteria for mixed hypomania," that is at least mild hypomania combined with at least mild depression.
Meanwhile, in a study published in Bipolar Disorders the same month, Hagop Akiskal, MD of the University of California, San Diego and Franco Benazzi, MD of the Hecker Outpatient Center (Ravenna) found individuals with “dysphoric hypomania” experienced more agitated depressions by a wide margin than “pure” bipolar II patients.
I see these individuals in my support group all the time, and I am often one of them. We tend not to feel comfortable in our own minds and own bodies, as if we need to crawl out of our skin. It’s as if our brains had a minor power surge and power outage at the same time. Predictably, we are not prime candidates for Miss Congeniality. This is where you want to throw Richard Simmons off the Carnival Cruise ship. Okay, many normal people feel that way, too, but in this state of mind you want to do it in waters frequented by sharks who are slow picky eaters.
The authors of both studies observe that because clinicians are under the misconception that hypomania is supposed to be euphoric, misdiagnosis is common. People who should be diagnosed as bipolar II instead are classified as having unipolar depression or some kind of personality disorder, then are put on the wrong treatments. (To learn more about treatments for depression, read our treatment guide.)
Not that we know the right treatments. There are no major studies involving treating patients with mixed hypomania, much less any mention in any of the treatment guidelines.
For this, the dark side of hypomania, we are truly in the dark ages.
To be continued …
Part V: How Little We Really Know
Published On: March 10, 2006
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