A cheerful young woman comes in for a consultation and soon we come to a topic that can be remarkably frustrating for all: trying to explain the dangers of mania.
She is only mildly manic.
It’s true she often gets into arguments that don’t really make much sense and she has been smoking more marijuana and hooking up with an unusual number of young men, but she isn’t doing anything clearly dangerous.
And she is very charming and funny. And self-confident.
We all feel that we understand ourselves better than others do. How to explain to her that what’s happening is the progressive shutting down of the medial prefrontal cortex, the part of our brains that searches for evidence of risk and warns us away from doing things
that are risky. The brain cells that ordinarily monitor for painful outcomes are going to sleep. And the more energized, or manic, she becomes the less aware she will be of risks.
It is what is called a positive feedback loop. Because she is not aware of risk, she doesn’t really understand why she needs to pay attention to sleep, or take medications so that she can get to sleep. And, as a result, she gets more manic. And as she gets more manic she becomes even less aware of harmful consequences of her decisions.
This is why it is important to moderate mania before it becomes clearly excessive. By the time it is causing a person to make dangerous choices it may be too late to intervene. By then the manic person is no longer able to process evidence of potential risks.
Learning to live with hypomania and mania often means creating a plan for identifying when the “danger zone” is approaching. This is where some kind of memo to oneself (for example contained in the Wellness Recovery Action Plan) can be useful. Describing as clearly as possible what things are like when intervention is necessary.
When you are reaching a risky level of mania do you…
- Need less sleep – If so how much sleep is necessary. For many people sleeping 5 hours a night for more than one night can be a warning sign.
- Do you feel more energetic and more active – Do you take on new projects, clean the house from top to bottom, these are good things but several days of unusual energy can also be a warning sign.
- Are you more self-confident – As the risk monitoring part of your brain shuts down you will feel that you can tackle bold new projects, at first this is a blessed relief from the normal hypervigilance of that part of the brain, but are people you know now warning you to be careful?
- Do you feel more sociable (are you making more phone calls, going out more) – This increased communication with others is such a good predictor of mania that it is sometimes possible to predict mood shifts based only on call logs, or twitter or facebook posts.
- Do you want to travel and/or are you travelling more
- Do you tend to drive faster or take more risks when driving – This is obviously a sign that the risk part of your brain is less active.
- Spending more money or too much money is often one of the first signs that you are entering the danger zone.
- Planning more activities or projects and having more ideas, or feeling more creative doesn’t sound risky – But tackling too many projects leads to a bigger crash when it turns out that it isn’t possible to complete those projects.
- Feeling more flirtatious and/or being more sexually active is also something that in a small amount can be a positive – But too much can lead to risks.
- Other signs are thinking faster, making more jokes or puns when you are talking
Being more easily distracted – One of my patients would suddenly notice the “very loud” clock in my office when he started to get energized… Sense data becomes more compelling. Colors seem more vivid. Sounds richer. Again, a little of this can be wonderful. - Do your thoughts jump from topic to topic – Are these changes in direction becoming difficult even for you to keep up with. Do you find it annoying to talk to others because they seem so slow?
- Are you more impatient and/or do you get irritable more easily, in fact, can you seem exhausting or irritating for others – One of the risks of mania is that it can lead to burnout in even those who care for you the most, and it can be hard to recover some of those friendships.
- Do you smoke more cigarettes, take more drugs, or drink more alcohol – Many of these substances act synergistically to increase mania and impulsive decision-making.
Paying attention to these warning signs, and developing a plan for reaching out to others (your psychiatrist or therapist, or trusted family members) when they start to appear, so that you can benefit from their additional perspective on what is happening, can make all the difference between experiencing a mild period of increased energy without harmful consequences and a manic episode with long term negative effects on your life.