Movement on an Energy Continuum: Bipolar Disorder, Mania and Manic Episodes
Although popular culture tends to equate mania with happiness and depression with sadness this isn't really the best way to think about what is happening in bipolar disorder. Bipolar Disorder involves not so much a swing between happy and sad states, as it does a swing between high and low energy states. When in a high-energy state, people appear happy because they are motivated and excitable, whereas in a low energy state, people feel sad, and lack motivation and enthusiasm. As the energy level of a manic episode increases, the early happy mood tends to degenerate into a more agitated and psychotic state which may be experienced more as terrifying than happy, but which is nevertheless very energizing. Similarly, as a depressive mood state increases, people may go from merely feeling badly about themselves to literally not being able to leave their bed. Thus, the happy and sad moods that are thought to characterize mania and depression respectively are results of different energy states and not necessarily primary features of the disorder.
The high and low energy states characteristic of bipolar disordered moods are often thought of as places that exist upon a continuum of energy levels. Manic moods are characterized by high energy states, while depressive moods are characterized by low energy states. As bipolar moods shift from depressed to manic and back to depressed again, part of what is happening, according to this way of seeing things, is that there is a smooth shifting of the bipolar person's energy state moving up and down the energy continuum. Each end of this energy continuum can be considered to be a pole, or end point (in the same way that the North and South Poles are the end points of the earth), hence the origin of the term "Bipolar" (meaning, involving movement between two poles).
Mania and Manic Episodes
Because high-energy manic states exist on a continuum, it is possible for someone to be a little manic or very manic. People who are very manic are said to be experiencing a manic episode. People who are only a little manic are said to be experiencing a Hypomanic Episode. The term 'hypo' means "under", so the term "hypomanic" translates to "less than fully manic".
There are defined criteria (in the DSM) that must be met in order to say that someone is experiencing a full manic episode. For example, manic episodes must be present for at least one week's duration before they can be diagnosed (although they may last far longer than that). Up to several months duration are possible.
A variety of symptoms are possible during a manic episode. At least three of the following symptoms need to be present before the diagnosis can be made:
- an inflated, expansive, grandiose (and possibly delusional) sense of self
- reduced sleep needs compared to normal
- pressured speech (talking so fast the words don't have time to get out the mouth)
- subjective sensation of racing thoughts (often called a "flight of ideas")
- distraction or derailment of thought occurring significantly more often than normal
- an increase in goal-directed activity (purposeful behavior), or physical agitation
- a marked increase in participation in risky but pleasurable behavior (such as unprotected sex, gambling, unrestrained shopping, etc.)
Manic episodes typically do not come on all at once. Rather, there is a progression of manic symptoms that occurs over a period of time. During an early manic phase of a bipolar condition, a person may become highly energetic, have a million ideas, become very talkative, stay up all night, feel sexually and generally potent, and become very productive. As the manic episode progresses and gains in strength, manic individuals tend to lose their inhibitions and whatever judgment they might normally have, and pursue one or more ill-advised and risky, but immediately pleasurable courses of behavior. Severely manic people may become sexually promiscuous, for instance, leading their becoming pregnant (or impregnating someone else) or becoming infected with a sexually transmitted disease. They may spend impulsively on shopping, travel, gambling, or drugs, causing massive credit card debts, and leaving a trail of bounced checks and large cash withdrawals from the ATM in their wake. In their enthusiasm to socialize, manic people may chatter on and on about things that are inappropriate to share with strangers, (e.g. personal beliefs, sexual experiences, etc.) They may also display inappropriate anger, or agitation, and even lash out and become violent in some cases. For example, a manic individual in a bar might pick a fight with little provocation. In the most severe cases of mania, hallucinations, delusions, and outright psychosis occur, further complicating the situation. The inappropriate and out-of-control behavior characteristic of people experiencing a manic episode makes the costs associated with mania sometimes devastatingly high.†