Finding the Threshold

In the bipolar community I feel like I’ve heard the word “hypomania” thrown around a lot and it seems that there is a bit of discrepancy about what the word means.

Hypomania is usually defined as “less severe mania”.

That’s a little broad, don’t you think? I mean really, what does that even mean? I suppose it is easy to say that there is a spectrum containing:

  • rational thought
  • hypomania
  • mania

but is there any viable definition of where hypomania ends and mania begins?

That question has been on my mind this week as I’ve attempted to get some solid footing on where my illness lands in the realm of the standard bipolar diagnosis.

I am often asked whether I have been diagnosed with bipolar type 1 or bipolar type 2.

The odd truth is that I don’t actually know. Is the issue that no doctor has ever been straightforward with me enough to tell me one way or the other, or is it possible that my swiss cheese brain doesn’t remember it happening? There are a lot of holes in my memory for some reason, I often struggle to remember pieces of years past (even more recent ones) and when dealing with long term memory my sense of time is completely warped. I feel certain though that if in the scope of my history I’d knelt on the linoleum floor and been dubbed “bipolar type 2” by some wrinkly old man wearing spectacles holding a ballpoint pen I would have remembered it.

Because that seems like an awfully important thing to forget.

Personally I feel like the diagnostic tools doctors have these days are frightfully inadequate anyway. If you knew some of the things I’ve been “diagnosed” with you’d laugh, trust me.

I have a lot more to say about that, but I think I will save it for another time.

Anyway, yes. I’d like to figure out whether I have bipolar type 1 or bipolar type 2 so, at the very least, I can answer that question when people ask it. Bipolar type 2 experiences depression and hypomania, while bipolar type 1 experiences mania as well.

So I can’t figure out which category fits me until I’ve come to some conclusion about the threshold between hypomania and mania.

I spoke with my therapist this week and out came the question:

Where does hypomania end and true mania begin?

What I want is a quantifiable answer.

  • Does it involve the moment one’s mind becomes severed with reality?
  • Or is it the instant manic symptoms slide out of one’s control?
  • Does hypomania become mania only when the effects become detrimental or self-destructive in some way to the individual? Work/school/relationships, etc?

PsychCentral.com says,

“A hypomanic episode is… not severe enough to cause serious impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.”

Ok, so one clear distinction is that paranoia, hallucinations, and delusions are symptoms only of mania; but these symptoms do not need to be present in order for a manic episode to be occurring.

This also suggests what I feared, that by having some kind of detriment is the very way by which mania is most often identified.

At this point I feel like I have a pretty good grasp on how depression feels for me and I can actively sense if I am becoming depressed. Likewise, I have taken mental notes while hypomanic to have a reference point and hopefully be able to sense when that is occuring as well. My fear really lies in mania because at this point I have no solid footing to cognitively discern whether I am experiencing mania or not, and from my past experience by the time I reach that point, I’ve already gone way beyond where I wanted to be.

But if having gone to that detrimental place is what is defining mania in the first place, how can one ever hope to catch it in time?

I also don’t know that I have ever had the capacity to recognize mania while it was happening. Most of these situations are blurred to me anyway, whether it is the swiss cheese brain or the mania itself that wipes these memories away I have no idea. Most of the resulting trauma is only recalled in mental photographs, but it might be that things are better that way.

I’m pretty unhappy with this definition. How helpful is it, really, for a very important (we’ll call it) “symptom” to be unrecognizable except in hindsight? Something that has to be reflected upon and recognized by someone who might not even remember it occurring?

Does that sound like a reliable way to make a diagnosis?

“Sexual promiscuity” is a symptom of mania. If hypomania is the same but less severe, how many random sexual partners does it take to be considered detrimental?

Yeah, still seems a little open-ended to me.

My therapist also brought up a good thought, she told me to remember that every person is different. What one person does while experiencing a manic episode might be on a totally different scale from someone else. Spending a thousand dollars on a shopping spree might be detrimental to someone, while spending two hundred dollars on a shopping spree (mind you I don’t normally shop ever if I can help it and I have a huge amount of anxiety over money) would be detrimental to me. Especially if my entire monthly income to live off of is two hundred dollars, because if you look at it that way I just spent everything I had!

For my own peace of mind I’ve concluded that the two things I plan to focus on in particular while experiencing hypomania (to try to catch things before becoming full fledged mania) are:

  • The point at which one begins losing touch with reality
  • And the instant manic symptoms slide out of control

I already found myself (two weeks ago) face to face with that first point -I realized that I was very quickly becoming detached. It felt a little bit like my consciousness began to evaporate, and as I hovered above my body (who was still walking around talking) I decided I needed to go to bed, right then, and sleep.

(Sleep helps. Forced sleep -still helps.)

Needless to say, it is hard to figure out. I still don’t feel like I have compelling evidence that I have bipolar type 1 vs 2, but I do know that in the end it doesn’t really matter to me. Putting a number on it wont change much, and I’ve always had a way of being hard to put into neat little categories.

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13 responses to “Finding the Threshold

  1. Manic Muses has a wonderful post on this very subject, I suggest you check it out.
    http://manicmuses.wordpress.com/2011/10/20/hypomania-or-mania-which-was-it/

    Hope that helps.

    • Yeah! Actually I read her’s earlier today and I thought since I had been working on this one for two weeks and it was finished, just unposted -I decided to post mine too.

      Thanks!

  2. Great post, very interesting.

  3. Hi, again. Great post – I can follow your thought process and it looks a lot like mine. Is your treating doc a GP or psychiatrist? I think it’s vitally important to have the right, detailed diagnosis so if nothing more you can educate yourself more fully about the disease. It is really confusing to read all of the stuff out on the internet about hypomania/mania, especially since a lot of it is just wrong. Many of the symptoms for each are identical, and you’re right – it’s a matter of personal context as to what constitutes severity. The impairment piece to me, at first, looked like it could be pretty subjective. I think I’ve honed in on what day-to-day functioning impairment really looks like. Has this happened for you yet?
    Are you planning on asking your doc for a quantifiable answer? If you do, keep me posted. I’m very curious to see what they have to say.

    • My current situation with my doctor is a long and ugly story, suffice it to say that the WA state disability program really screwed me over. I had to stop seeing my psychiatrist to see a doctor on the disability program plan, and then they decided they couldn’t supply me with anyone because there weren’t enough doctors to go around. I haven’t seen a psychiatrist in 6 months, and I have no idea when I will be able to again (as I am pretty poor and can’t work enough to get insurance). The next chance I get though I will definitely ask more about this topic.

      I definitely understand what day-to-day functioning impairment looks like, I guess I just wasn’t thinking in that context. The manic episode I have been looking at the most for reference in my past happened when I was already impaired in the day-to-day functioning area from depression, so I hadn’t taken that into account.

      Also now that I really think about it I would say there have been times when I have lost my ability to effectively communicate with others, which I should think would classify in the “social impairment” area, right?

      Thanks for your input!

      • Happy Monday – I took a break from my computer this weekend…sorry for the late reply.

        “…times when I have lost my ability to effectively communicate with others, which I should think would classify in the “social impairment” area, right?”

        Obviously I’m no psychiatrist, but personally think that from what you’re describing, you’re on track. I spent Friday evening reading through case studies of BP I patients and the more I read, the more I get a sense of the nuances regarding ‘impairment’ criteria. It’s kind of a tricky business, this whole BP I vs BP II thing. Considering whether one’s impairment has been effected really relies on whether the patient is filling in their doctor with their whole history/truth and whether the doctor is really listening. Which really makes the whole thing somewhat subjective to begin with. (Which is really scary when you realize that unless you’re already hospitalized, the potency of the prescription relies on the whole Dr/Patient Dance.)

        I really hope you find a way to see another psyc soon, if for nothing more than to know you have a support network in place. For what it’s worth, the WA state disability program *is* crap. I know a few other people in your state in the same position. You’re not alone. [You can always mail me at manicmuses {at} gmail {dot} com if you want some more stories 🙂 ]

  4. Psycheducation.org has a Diagnosis Explanation using a mood spectrum. This page cleared things up for me.

    Really, there’s no definitive line. But, if you had to draw one, it would likely be at psychosis in the current diagnostic criteria. In the DSM-V, they’ve chosen to draw the line at functioning, which makes the line a lot fuzzier. But hypomania still stands – no psychotic features.

    Some people’s functioning may allow for a higher threshold of mania. What constitutes dyfunction? I’ve recently had dysphoric hypomanic episodes that made me have violent tendoncies. Did I hit people? No. Did I hit inanimate objects? Hell yeah! But did it stop me from my life? No way. In fact, it made parts of my life easier, even if it did hinder some social functioning. (I can’t go around threatening just anyone.).

    Hindsight will give you little perspective without a written record. Hence, we are here, on WordPress. I keep a personal journal so I can go back and make sense of it. What can really give you a better idea are observers on the outside.

    If I were to tell you about my own episodes, it would go like this. My depression is this black abyss that I fell into. I’m blinded and crippled from the fall. I have to force myself through my life. It’s the worst thing ever. But hypomania? (Again, I have to put out the disclaimer. I am in no way promoting mania or hypomania. This is just my own take.). It’s awesome. I am super me. I can take on the world! I have confidence, energy, and ideas. I usually feel great! But! – if you talk to the people around me, you’ll get a different picture. I am arrogant, pompus, often mean and merciless, and reckless. I am forceful and overbearing. Etc. All of the things I think are great really aren’t so wonderful.

    So, here’s the real answer: There is no answer. What is hypomania for one is mania for the other. The threshold exists at where you and the limits of your life put it.

  5. There are actually a great many criteria that differentiate mania from hypomania, I have no idea why people get so caught in the “A hypomanic episode is… not severe enough to cause serious impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.”

    It’s in conjunction with other things, such as length of time gone without necessity for or ability to sleep, activity levels in general, blah, blah, blah. I already wrote some of this on ManicMuses’ post on the topic, I won’t repeat it all, but if you’re curious you can read it.

    I will say to you this. Some doctors don’t tell their patients what their diagnosis is unless they are directly asked. Look at your insurance bill, there will be a number (courtesy the DSM-IV-TR), then likely something to the effect of the words: Bipolar I (or II), most recent episode depressed, then if you’re I something about the presence or absence of psychotic features.

    But then you could always just ask your doctor.

    I will belabor one point I made in my other comment, which is as far as I’m concerned, labels are for jelly jars. As long as you feel you’re getting proper treatment, take yours with a grain of salt.

    • Sorry, didn’t read the comment on the doctor situation – I try not to read other comments until after, I want to respond to your post, not what others have to say on it.

      I would say look for an old doctor’s bill if you really want to know.

      • Lol, hit the button by mistake! I was going to say if you really want to know what you are diagnosed as, “officially.”

      • Honestly I’ve collected 6+ diagnoses at this point, I’m searching more these days for tangible information that I can apply to myself to help me understand my past & future actions, as opposed to the singular (though technically educated) opinions of medical professionals. For the most part I have a very hard time trusting them after some of the things I’ve experienced and I haven’t met a doctor that I have enough of a history with to trust what they have to say without question.

  6. You shouldn’t ever trust what a doctor says without questioning. My favorite doctor I have known for about half my life, he is brilliant and thorough and right more often than not and I question the crap out of him. And he respects me for it.

  7. I only hope that the DSM-5, to be released in 2013, will do away with Bipolar NOS.

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