This is the fourth in our discussion of psychiatry’s diagnostic bible, the DSM. In May this year, an updated edition - the DSM-5 - will replace the current DSM-IV, which has been the last word since 1994. Last week, we had a look at bipolar depression and mixed states. This week we will look at the other end of the pole - mania and hypomania.
The DSM-5 will preserve the criteria for DSM-IV mania and hypomania just about intact, including the trademark symptom checklists, but is this adequate? Let’s look at the difference between mania and hypomania. Is there anyone among us who can make a convincing distinction?
The old and new DSMs, to their credit, red-flag the issue of functionality. Thus, for mania (from the DSM-IV):
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.
And for hypomania:
The mood disturbance is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
Basically, then, what distinguishes mania from hypomania is severity. The symptom lists are exactly the same (such as grandiosity and flight of ideas and so on), but one state is likely to wreck your life while the other may enhance it.
Could the DSM-5 have done better? This is not an academic exercise. Being microscopically attuned the severity of our (hypo)manias is critical to managing our illness. Could the DSM-5 have given us better indicators? Say what mania and hypomania actually look like?
Three years ago, when the DSM-5 published its first draft, I decided to have a go at my own "People’s DSM." This was a thought experiment on my part, basically: If I could light a match to the DSM and start over, what would I come up with? Here is my criteria for mania, which I subdivided into euphoric and dysphoric. Thus:
Subject may experience uncharacteristic feelings of extreme joy, superhuman positive abilities, and a sense of connectedness with the world, him or herself, and those around him or her. Subject may project a magnanimous "larger than life" presence.
Subject may experience uncharacteristic feelings of extreme irritability, superhuman positive and negative abilities, and a sense of disconnectedness with the world, him or herself, and those around him or her. Subject may project a hostile menacing presence.
And for hypomania:
Subject may experience uncharacteristic feelings of joy, enhanced positive abilities, and a sense of ease with the world and those around him or her. Subject may project a sociable charismatic presence.
Subject may experience uncharacteristic feelings of irritability, enhanced positive and negative abilities, and a sense of unease with the world, him or herself, and those around him or her. Subject may project an unpleasant mildly threatening presence.
I further subdivided mania and hypomania into behavior and thinking domains. For the sake of clarity, I have edited out what amounts to my symptom lists to highlight my differentiators. Thus, for mania:
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.
And for hypomania:
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
I am not about to suggest that my diagnostic criteria should replace the DSM. I simply raise my version as a talking point. If enough of us start talking, perhaps some clear ideas will emerge, the type that will help us through the day-to-day challenges in managing our illness. Let’s talk. Comments below …