Picture2Elsewhere we talk about some of the existential issues (who am I?) that most people struggle with when they seek help for depression or mood swings. Diagnosis (what does that mean?) highlights many of these issues. Am I just a diagnosis? What happens to my humanity when my subjective experience gets pathologized?

These are important issues, but there are very real advantages to getting the kind of thoughtful assessment that can lead to a diagnosis. For one thing, without “labels” (or, really, words) to describe our experiences it is impossible to figure out how to respond to the turmoil that shifting moods can cause.

For another thing, all of us need to be able to share our experiences with others, in order to get outside perspectives that can keep us from getting lost in our own thoughts. Our brains, as capable as they are, are also able to trick us.

Finally, there are certain disruptive or paralyzing states of mind that we may need help getting out of.

Types of Depression

There are many different types of depression. Usually assessing depression for diagnostic purposes begins with considering the distinction between “unipolar” depression and “bipolar” depression.

Unipolar depression is the term to describe people whose mood varies from minimally depressed to severely depressed. In general, people with unipolar depression also don’t experience as many or as rapid shifts in mood as those with bipolar depression do. 112076_f496

Bipolar depression is the term to describe people whose mood doesn’t just vary along a continuum of more or less severe depression, but who experience states of activation (or states of irritable depression) in addition to the classic lethargic depression.

Figuring out which kind of depression you have can be complicated. And one of the things that complicates this assessment is that many of us have associations with the term “bipolar” that make thinking thoughtfully about their experiences difficult. (“I’m not crazy, doc.”)

In many ways, these associations reflect an older view of bipolar disorder (which used to be called manic-depressive illness).

Twenty years ago most mental health professionals used the term bipolar disorder to refer only to the most extreme forms of the condition. Studies at the time found bipolar to be much less common than unipolar depression.

At the time, I found it odd that the seemingly milder form of bipolar (bipolar 2) was much less common than the type of bipolar associated with more dramatic energized states.

In the chart to the right you can see that a typical research study from the 1980’s found that unipolar depression was much more common than bipolar 1 depression and that was even more common than bipolar 2 depression.9-8-2013 9-22-31 AM

The finding that milder energized states (hypomania) were less common than more extreme energized states (mania) doesn’t fit with our understanding of how traits of all kinds get inherited (genetics). It is as if we found that extreme high blood pressure was more common than mild high blood pressure, or extreme high blood sugar (diabetes) was more common than mildly elevated blood sugar.

It now appears that what those studies were actually showing was that if you went from door to door interviewing people at random (which is how you do a study to try to figure out the rate of different conditions in the general population) people would only report having had more extreme energized states (because they could identify those states, if they had ever had them, as clearly abnormal or unusual). Milder forms were not identified by them as memorable, and so they couldn’t recall them when asked.

In addition, the studies were probably also tapping into feelings of shame and stigma associated with the term bipolar.

(An interesting illustration of that phenomenon is to be find in the studies done at the same time that found that in Japan, seemingly unique in the world, rates of depression were far lower than anywhere else, even though suicide was higher in Japan than it was in most countries – as it happens the problem was that the term used for clinical depression in Japanese implied that one was “crazy” – it was only after newer antidepressants started getting marketed that people became comfortable acknowledging these mood states and studies showed that rates of depression in Japan were comparable to rates in other countries). 

9-8-2013 9-44-09 AMMore recently, we have found out that mild states of activation are more common than more extreme states.

Studies now find that bipolar depression accounts for about a third of all depression.

And, of people with bipolar depression, those with the milder form of energized states (bipolar 2) are more common than those with the more extreme types of energized states (bipolar 1).

Interestingly, the change in proportions does not reflect much of a shift in rates of diagnosis of unipolar depression, rather what appears to have happened is that more people with bipolar 2 depression were discovered (I think you could think of this as a bit like the “coming out of the closet” phenomenon that took place as the result of gay activism several decades ago).

Energized States

The key to making the distinction between bipolar and unipolar depression is the presence or absence of distinct energized states. These states are known as mania or hypomania (where “hypo” refers to “a little,” as distinct from “hyper” which refers to “a lot” of something).

Mania is not usually something that is hard to recognize (although irritable mania may be harder to identify). Mania refers to a state of racing thought, not needing sleep, grandiose thinking (I can do anything), hyperactivity, and trouble staying on track (jumping from idea to idea) which those around you are sure to recognize as unusual abnormal (although it might not seem that way to the person experiencing the state).

Hypomania is the hard thing to notice – especially irritable hypomania.

To set the stage for a discussion of hypomania it is important to note that this is one of the very rare psychiatric terms that refers to a state that may not be associated with any impairment. In fact, hypomania may be a time of unusually productive energy.

John D. Gartner, a psychologist at Johns Hopkins University, has written about this in his book ”The Hypomanic Edge: The Link Between (A Little) Craziness And (A Lot of) Success In America” (Simon & Schuster). Gartner contends not only that most of today’s successful entrepreneurs and business people are hypomanic, but that many of our history’s leading figures, such as Alexander Hamilton, Andrew Carnegie, and Henry Ford, had the condition as well. The United States has more hypomanics than other countries, Gartner claims, and these people are largely responsible for the nation’s power and prosperity.

”Energy, drive, cockeyed optimism, entrepreneurial and religious zeal, Yankee ingenuity, messianism, and arrogance – these traits have long been attributed to an ‘American character,”’ Gartner writes. ”But given how closely they overlap with the hypomanic profile, they might be better understood as expressions of an American temperament, shaped in large part by our rich concentration of hypomanic genes.”

Whether hypomania is the essence of the American success, or a more mundane personal experience. The reason it is important to mental health professionals is that the treatment of depression in those who have also had hypomania is quite different than the treatment of depression in those who have not. Some traditional treatments of depression may actually make people who have had hypomania worse, more depressed, more desperate.

What is Hypomania

Hypomania, in essence is a noticeable change in mood and energy that persists for at least four days and that has some or all of the following characteristics:

  1. A period of enhanced self esteem, a stronger sense of personal value or importance, perhaps even the experience of being somehow central to some other purposes, a sense of being connected and related to others.
  2. A feeling of being tireless, indefatigable, unwearying, of being able to mount a sustained effort and of having unflagging energy. Often associated with doing well with less sleep than usual.
  3. A time of being animated, lively, talkative, friendly and willing to talk to those that one might not ordinarily be comfortable speaking to.
  4. A period when one’s thoughts are inventive, fanciful, original, imaginative, individualistic, unique, unusual, uncommon, distinct, different, and perhaps even moving at a rapid tempo or flying.
  5. A sense of being drawn to things that are often missed. Fascinated by things around one, seeing things in a new way, the colors may seem brighter, smells and tastes richer, an experience of pleasure in the senses.
  6. A time of being productive, energetic, prolific, successful, profitable, restless, perhaps fretful, possibly ceaselessly in motion.
  7. Having the experience of being adventurous, wild, engaging in an escapade or affair, being unusually athletic, a daredevil, bold, an adventurer, or a risk taking entrepreneur, intensely enthusiastic, perhaps being a big spender and not worrying about the consequences.

We like to ask the people we see to think back to a particular time in their life when some of these words seemed to apply to them. Describe that time. Would others have noticed that your behavior was different from your usual behavior (not necessarily in a negative way). And did you experience several of these types of experiences. If so you may have experienced hypomania.