Human beings are variable by nature. Life is inconsistent and we respond accordingly. Highs and lows are par for the course. However, we are all different, in our genetics, in our experiences, in our brain chemistry, so too are we different in the way we react to life's changing rhythms.
You can probably identify someone in your life who is unfailingly even-keel. This person seems to remain eternally steady in every circumstance, if mood is on a scale from 1-10, they are pretty much always hovering around a 5. This person might be described as having a "flat" affect, they are by no means the life of the party. By contrast, you can most likely also identify someone in your life who is constantly at the mercy of their every mood. This person spends a great deal of time ping-ponging between 1 and 10, with very little time spent mid-scale. This person might be described as a drama king/queen, they are intense and most likely draining to be around. If we look at these two people as the opposing ends of a spectrum, we can begin to see how the many variations of mood can manifest.
Most people find themselves somewhere in the middle of the spectrum. Their mood would look like a series of hills and valleys if plotted as a line graph, perhaps with a few mountains and the occasional canyon. When canyons and mountains or a perpetual plateau becomes the norm, it is time to evaluate whether there might be a mood disorder at play. In this article, we will be specifically exploring the mountain and canyon phenomenon better known as Bipolar Disorder.
The defining feature of Bipolar I Disorder is the Manic Episode. The occurrence of one or more Manic or Mixed Episodes distinguishes bipolarity from depressive and other disorders. These episodes are defined as follows by the DSM-IV-TR, the standard diagnostic manual for mental health professionals.
Manic Episode:
A period of one week (or less if hospitalization is required or psychotic features are included) or longer in which the prevailing mood is abnormally and persistently elevated, expansive, or irritable and during which at least three characteristic symptoms are present and cause marked impairment in functioning, require hospitalization to prevent harm to self or others, or include psychotic features. Characteristic symptoms are inflated self-esteem or grandiosity, decreased need for sleep, increased talkativeness, flight of ideas, distractibility, increase in goal-directed activity or psychomotor agitation, excessive involvement in pleasurable activities that have a high risk for undesirable consequences.
Mixed Episode:
A Mixed Episode lasts for at least one week and involves symptoms that meet the criteria for both Manic and Major Depressive Episodes. The disturbance is sufficiently severe to cause marked impairment in functioning, require hospitalization to prevent harm to self or others, or includes psychotic symptoms.
Manic Episodes are serious business. They dramatically disrupt a person's life and the lives of those around them. The key here is defining "marked impairment in functioning". When an episode leads to hospitalization, an arrest, a suicide/homicide attempt, it is fairly obvious to conclude that functioning has been markedly impaired. However, the consequences of mania can be more subtle and difficult to distinguish. Many times, mania is experienced as a pleasurable state (irritability is also possible and is often the result of the person's wishes being denied). The elevated mood can feel like a state of euphoria, causing the person to think they are doing great, better than great. This makes Manic Episodes particularly dangerous, as they often include unsafe behavior yet rarely cause the sufferer to seek treatment since they experience this state as pleasurable. Less overt indications of the occurrence of a Manic Episode include:
- Increased substance use
- Increased sexual behavior
- Unrestrained spending, making large, impractical purchases or engaging in foolish business investments
- Indiscriminate enthusiasm
- Increased energy despite a decrease in actual sleep
- Embarking on unusual projects, i.e. building a house with no knowledge of construction
- Excessive talking without regard for others, often accompanied by a theatrical presentation and abrupt changes in topic
- Distractibility, an inability to differentiate between relevant and irrelevant stimuli
- Increased sociability, to the point of being intrusive or domineering
- Excessive planning and participation in multiple activities
- Physical agitation or restlessness
- Reckless driving
- Impulsive travel
- Change in personal appearance, usually toward a more flamboyant or seductive appearance
- Lack of regard for ethical concerns
- Gambling
- Antisocial behaviors such as assault, physical threat, or hostility towards others
- Sharpened sense of smell, sight, or hearing
A person experiencing a Manic Episode most likely does not have awareness of the change in their behavior and affect. What difference they do discern they may regard as a positive change. Any negative consequences resulting from their behavior are likely perceived as happening to them, rather than being created by them. In other words, the loss of a job is seen as "my boss is just a jerk", the loss of a relationship is about "he didn't understand me", an arrest for shoplifting is explained as "they were out to get me", etc. A life that looks like a series of unending tragedies and victimizations, may actually be the catastrophic results of poor judgment exercised during intermittent Manic Episodes.
Mania can also manifest as a Mixed Episode. This means that manic symptoms and depressive symptoms are commingled with one another during the episode, causing the person to vacillate between extreme euphoria and hopeless dejection.
A third category worth mentioning is the Hypomanic Episode. This type of an episode differs from a Manic Episode in that it need only last 4 days, as opposed to one week, it cannot include delusions or hallucinations, and it is not severe enough to cause marked impairment in social or occupational functioning or to result in hospitalization. A Hypomanic Episode is basically a milder version of a Manic Episode. This is the defining feature of Bipolar II Disorder. In order to qualify for a Bipolar II diagnosis, a person must also have experienced one or more Major Depressive Episodes. As defined by the DSM-IV-TR, a Major Depressive Episode is as follows.
Major Depressive Episode
A period of at least two weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities. This must include at least four of the following: changes in appetite or weight, sleep, and psychomotor activity, decreased energy, feelings of worthlessness or guilt, difficulty thinking, concentrating, or making decisions, or recurrent thoughts of death or suicidal ideation, plans, or attempts. These symptoms must cause a clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The Greek philosopher Heraclitus said, "The only constant is change". Change is indeed the hallmark of our human existence. No one is constant in mood or in temperament, but when existence consists primarily of a violent vacillation between polar extremes, it may be an illness and not the fickle nature of life which is to blame. If you have a friend or loved one who fits this description or you are experiencing a number of these symptoms yourself, it is important to speak with a qualified professional. Assessment and diagnosis for Bipolar Disorder can be performed by a Marriage and Family Therapist, a Psychologist, or a Psychiatrist. There are a variety of highly effective treatments for Bipolar I and II Disorders. If you or someone you love is caught in a life of mountains and canyons, seek treatment and support. There is a more peaceful path awaiting you.
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