The dividing line between mania and hypomania is not easy to demarcate (see Q 1.7); however it is worthwhile making this distinction because it affects decisions about treatment (Fig. 1.1). For this reason a different name is given to depression with mania–bipolar I–in contrast to depression with hypomania–bipolar II. There have been attempts to define bipolar III and IV based on family history and the effect of antidepressants but these have not really caught on.

Fig. 1.1 Prevalence of manic depression.

(Reprinted from Clin Appr Bipolar Disord 2002;1:10-14 by permission of Cambridge Medical Publications.)

1.4 What are the symptoms of mania?

The following example of a manic woman illustrates the range of symptoms and behaviours characteristic of mania (see also Box 1.1).

Mood: In order to make a diagnosis of mania there must be a change in mood. This is usually elevated and she feels elated, ‘great’, ‘fantastic’. Extreme terms are used to describe a state that few of us reach. She may well be feeling ‘better than ever’, and in an exciting and unique way ‘connected with the whole world’. It is common to have never had such a good feeling in the whole of her life. One of the major problems later can be that she doesn’t feel that this is an experience that she would like to avoid; in fact she feels just the opposite because it is a feeling that one would want to seek out. The closest comparison is to feelings that a great success or achievement (or winning the lottery) can produce or the high that comes from drugs such as cocaine. The elation is often infectious and others can (at first at least) feel more cheerful in her presence and find a smile on their face. She looks happy but in an active, excited way rather than displaying a calm peaceful serenity.

BOX 1.1 The symptoms of mania

There must be a change in mood–elation or irritability–together with usually all of the following:

decreased need for sleep

increased energy and activity

excessive talk, with pressure of speech and flight of ideas (see Box 1.2)

fast thoughts

distractibility and disinhibition (in speech, thoughts and action)

excessive confidence leading to grandiosity.

However, not uncommonly it is irritability rather than elation that is felt and apparent to others. She can’t tolerate any disagreement but finds arguments everywhere, as her plans are being thwarted by others who see how unrealistic they are.

Sleep: Sleep is reduced, but this is often not perceived as a problem but rather ‘I don’t need as much sleep as everyone else–and there is too much to do to spend all night in bed!’

Energy: Energy levels are high: ‘batteries fully charged and switched on’. She feels physically and mentally energised, active and strong. Overactivity is immediately apparent and she finds sitting for more than a few minutes very challenging, as well as a waste of time. She may run, dance and be constantly on the move. Increased energy also improves endurance and she may be able to walk long distances without getting tired and ignore the pain of walking barefoot.

Attention span: Attention can be intense but only for a short period. Concentration is poor because of distractibility, so that she cannot spend more than a few minutes on any task before setting off on another track. Memory is perceived to be good but may actually be poor because of the distraction and lack of focus. Afterwards she may have very poor recall of the events during the spell of mania.

Ideas and thoughts: These flow quickly, freely and fast; speech reflects this. The content is cheerful, confident and inventive until irritability and annoyance take over.

Self-belief: Overconfidence is the norm and this grows to grandiosity, claiming superior talents and achievements. Her self-belief may be very persuasive to those that don’t know her; some may go along with her plans initially, pleased to have found someone with such confidence in themselves, only to be very disappointed later. Grandiosity can become delusional with ideas of royal connections, riches, fame and natural gifts to the extent of superhuman powers (e.g. having control over the weather or ability to predict the future). Arrogance accompanies this, dismissing the views of others (unless they happen to coincide) in a haughty way. Some feel their intellectual powers are high and superior to others and start to talk in a foreign language even though their grasp of grammar and vocabulary may be limited. Physical limitations or disabilities are dismissed–‘I’ve cured myself of that diabetes’–or minimised or even perceived as signs of superiority. Mental wellbeing is reflected in a sense of physical wellbeing.

Speech: She will talk non-stop and be difficult to interrupt. Staying quiet becomes impossible and dialogue is not needed–monologue is fine. In fact she does not even need an audience: you can see her wandering about, chatting away. Talking may not be enough–singing, shouting and laughter all form part of expressing her joy to the world.

Flight of ideas is the classic form of speech in mania (Box 1.2). Flight indicates the way ideas flow from one to another. The connections within the speech are usually apparent, in contrast to the thought disorder of schizophrenia which is much more obscure. But connections are too free and frequent so that distractions in what she sees or hears send her off on a new track. Alternatively, internal connections or personal memories may suddenly intervene. Playing with language is common as punning or rhyming takes over the flow for a while. The digressions mean that the goals of speech are quickly lost and so little is achieved in any conversation.

Appetite: Appetite may be little changed though she will lose weight because essentials such as eating are not given much priority, or poor concentration and distractibility leave everything half eaten.

Disinhibition: You may notice the disinhibition from a distance with flamboyant, bright, eccentric clothes and a home visit reveals a spectacularly decorated house. It is always interesting to visit a house in the summer which is decked out for Christmas because ‘I’m the second coming’. However, be wary of the conservatively dressed Englishman whose dress belies his extraordinary behaviour.

BOX 1.2 Flight of ideas

‘People are cleaning up the house, working very hard, there’s Flash on the floor, the dog doesn’t like Flash, there’s a flash in my eye as I’m looking at the trees, there’s not much oxygen from the trees, there’s water on the floor, agua run the water, don’t block the sink.’

The manic patient may do what the rest of us only think of–she may swear at the boss or alternatively tell him she’s in love with him, or head off to Paris on a whim with no bags required. However, involvement in areas which have a high potential for trouble–drinking, taking drugs, overspending and having sex–can be enjoyed at the time but are a source of shame on recovery.

Later stages: The fun of mania rarely lasts long and the initial infectious cheerfulness degenerates into unstoppable destructive irresponsibility. Others trying to bring her back to earth are dismissed, abused and ignored as the bank account gets emptied and exploiters strip her of her assets and dignity. Her ideas become obviously farcical and she becomes a figure of pity if not ridicule. Finally, someone takes action to get her behaviour curtailed and the indignity of the Mental Health Act assessment, with police backup to take her off to hospital as she will not recognise the extent of her illness, becomes the inevitable consequence. Lack of insight is the classic feature of madness and is to be expected in mania.

1.5 What psychotic symptoms accompany mania?

Psychosis is usually only found in the more extreme states of mania when the other symptoms are prominent. Psychosis refers to distortions of reality up to the point of losing contact with reality. The usual way to recognise psychosis is by the presence of delusions and hallucinations. However, sometimes activity is so bizarre (e.g. someone charging round a building site pretending to do battle training) that it is clear that reality testing is poor.

In mania, delusions are more common than hallucinations; both usually have a grandiose flavour and often come together. It can be difficult to tell when grandiose ideas tip over into delusions. When does thinking you are a good musician become so extreme an idea that it is delusional? The border is when the idea is fixed and is not retracted through logical argument. Some grandiose ideas are so eccentric that they are obviously delusional (e.g. the man claiming to be the Martian ambassador) and don’t need testing by argument. Challenging grandiose delusions can easily bring out irritability, if you are not just simply dismissed.

Paranoid ideas are the other type of delusion that is commonly seen in manic states. However, it can be difficult to tell when patients’ frustration with others’ lack of enthusiasm for their projects turns to paranoia. Paranoia always has a grandiose edge to it: ‘Why on earth would the CIA be interested in following you?’ Sometimes the mixture is more interesting–for example the man who has to leave the hospital as he is the only one who can tackle the drug traffickers who are in turn out to kill him. But remember paranoid ideas are common in a wide variety of psychiatric disorders (including confusional states) and are certainly not diagnostic of mania.

Hallucinations are most commonly auditory and usually second person (‘You’re the greatest’), rather than third person (‘Look at him, he’s so handsome’) which is more characteristic of schizophrenia. However, just because certain types of hallucination are present you should not dismiss the diagnosis of mania: so-called ‘first rank symptoms of schizophrenia’ are common in severe mania.

Visions can occur but are often overinterpretations of ‘fantastic sights’–for example a beautiful star-filled night sky is reported as a ‘choir of angels’.

Psychotic symptoms in mania are usually mood congruent, i.e. they reflect the underlying mood, either of elation or of irritability, rather than being disconnected and bizarre.

Confusion and visual hallucinations should prompt consideration of a possible organic (or drug-related) state but confusion can occur particularly in postpartum states.

1.6 How much do people remember of their mania afterwards?

It is often surprising how situations that are burnt into the doctor’s mind because of the drama are dismissed rather lightly by patients afterwards. This is not universal, and certainly sexual indiscretions can weigh heavily on people afterwards. However, many bipolars have a very poor memory of their mania which can make collecting a retrospective history difficult. Even if you specifically ask about manic symptoms you may get a denial, unless you can discuss the specifics of their behaviour. Patients may also refer to these periods as depression, often because they do remember the depression that followed.

This poor recall can be a blessing for some but can also lead to patients not taking their problem very seriously when it comes to considering preventive treatment.

1.7 What is hypomania?

As the name suggests (Greek, hypo, under), hypomania is the same condition as mania but with a lesser degree of symptoms and more importantly less impairment and disability. In fact hypomania can be a very desirable state, with the patient feeling very well physically and mentally, having lots of energy, not needing much sleep, thinking fast with lots of ideas and feeling confident. Although there may be lots of ideas, productivity is often low: ‘I’ve got all the ideas but I can’t put anything into practice’. However, unlike mania, concentration can still be good and psychotic symptoms are not present.

The border between hypomania and mania is not clear and there are a number of different definitions. The most useful definition draws a clinical line so that if the symptoms are causing clear disability and last more than a few (e.g. 4) days, then this is mania. If symptoms are below that line then it is hypomania.

As you would expect, it is unusual for patients to present to doctors with hypomania, as it would not be seen as a condition requiring treatment even if they do recognise the change from their normal state. However, many (but not all) people who experience hypomania also have periods of depression which they find distressing and disabling.

Why do so many psychiatrists call patients hypomanic when they are clearly at an extreme of mental illness with manic symptoms? It may be that the term ‘manic’ is seen as rather derogatory and ‘hypomanic’ seems less worrying and extreme. Many of us hang on to the way we used terms when we were training and minding our language is a challenge for all of us!

1.8 What are the symptoms of depression?

Energy: Energy is low–‘the switch has been turned off’. The depressed feel tired all the time; even minor tasks can seem too much and some will spend the whole day in bed doing nothing. The lack of energy may be obvious to others as they see the patient just sit apparently doing nothing and sometimes hardly even moving. Speech can be very slow with long gaps and the patient seems to take an age to answer a simple question. This does seem to be an actual slowing of the thought processes and patients do come to the right answer if you wait long enough. Others may be very agitated, pacing around wringing their hands, sighing, not able to sit down and endlessly restless, not knowing what to do with themselves.

Memory and concentration: Memory is decreased, sometimes to the point that patients think they must be starting to dement because they cannot remember straightforward things like the name of a friend or what they have gone into the garage to get–though all of us experience this at times! This is at least partly due to concentration being poor. This can be a lack of attention–for example when reading, although the words on the page go in, they are not registered, and the patient cannot give an account of the content.

Negative thoughts: The world of the depressed is focused internally which can prevent events outside being either recognised or given much importance. Many of the depressed are distracted by their own unpleasant thoughts going round and round so that the only things they can concentrate on are the negative ideas that are dominating thinking. When depressed there is a strong negative bias to all the thinking processes. Unpleasant memories are much more easily recalled than pleasant ones, so that a patient may be unable to recall anything nice that has happened this year, whereas even apparently minor adversities are readily called to mind.

Depressives will almost certainly see themselves as worthless, useless and not worth bothering with–arguing with close family who are trying to get them to see how much they are valued. They see the world as an unpleasant hostile place that offers little solace. As Hardy wrote: ‘Happiness was but the occasional episode in a general drama of pain.’ Many depressives would have trouble even noticing the occasional episode of happiness. Their negativity can be quite infectious and the depressed can make others feel uncomfortable and so lead to them being avoided. The other habit that tends to alienate the depressed is their tendency to reveal a lot of personal details while portraying themselves very negatively.

Suicide: A negative view of the future is one of the drivers to suicide. The negative bias includes feelings that nothing can change and only bad things can happen from now on, and of only being a burden to loved ones. It is easy to see how, for a depressive, there is only a small step to thinking: ‘Everyone would be better off without me and I would be out of this mental pain if I was dead.’ Thinking about death is almost universal in depression and suicidal thoughts from ‘I sometimes just wish I wouldn’t wake up in the morning’ through to clear ideas of self-harm should be expected.

Physical manifestations: Some people have prominent physical symptoms when depressed, often exacerbations of prior physical problems such as worsening backache, as they become more sensitive to pain. Others will develop new physical symptoms such as headaches and other tension symptoms or stomach pains, or just feel generally unwell and tired. Depressed patients are likely to worry about these physical symptoms and what they mean, such as thinking that they must have cancer to explain the feeling in the stomach, nausea and weight loss, or that poor memory means dementia is on the horizon.

Appetite: Loss of appetite and consequently losing weight is the rule, although a few patients report an increase in appetite–often favouring sweet foods.

Sleep: Sleep problems usually occur and it is unusual to find a depressed patient who is sleeping well. The classic symptom is early morning waking when the patient wakes up, feeling bad and completely unable to get back to sleep or even to relax in bed and rest, despite feeling exhausted. However, initial insomnia is common, when the patient goes to bed tired but suddenly finds that sleep is elusive. Waking frequently during the night is also a common complaint. In fact we all wake a few times at night but don’t remember it because it is brief, but the depressed will wake and then stay awake, possibly because worry sets in. Nightmares are common and the pleasant release of dreams is rare. Some patients will oversleep and spend not only the night but much of the day in bed and asleep, feeling too tired to raise themselves.

1.9 What psychotic symptoms occur in bipolar depression?

Delusional ideas are congruent with the depressed mood, i.e. the content of delusions is very negative–‘My insides are rotting’. Depressives can feel so guilty that they think that they must have committed a terrible crime and need to be punished. It is unusual for the more bizarre delusions seen in schizophrenia to be present and the relationship of the delusion to the mood is usually obvious. Psychotic symptoms are usually only present when the other symptoms of depression are very obvious and severe: it is worth considering if the diagnosis is correct if psychosis is evident but only mild physical symptoms of depression are found.

Hallucinations are usually auditory, i.e. hearing a voice saying nasty things–for example hearing children in a playground shouting ‘Paedophile!’, or a voice saying ‘You’re going to burn in Hell’. Although other modalities of hallucination occur–for example smelling the body rotting–these are uncommon.

1.10 In what way are the symptoms of depression in bipolars different from those of unipolars?

The symptoms are very similar in bipolar and unipolar depression and any differences are not consistent. Bipolars are more likely to show excessive sleep and more lability of mood; they are also more subject to psychotic symptoms. Other common features are abrupt onset and sudden recovery.

The course of bipolar illness tends to be that patients have their first episode at a younger age and they are more likely to experience frequent recurrences. As a group, bipolars are more likely to have a family history of depression and also of bipolar disorder. However, even taking all these factors into account it is really not possible to tell when seeing a depressed patient if they are bipolar or likely to become bipolar. It can be surprising when patients whom you know well and have treated for depression suddenly become manic for the first time.

1.11 What is a mixed affective state?

The usual view of manic depression is of the two extremes of mood–very high and very low–which are seen as opposites. However, there is more in common between these states than it at first appears. Both states involve loss of sleep; overactivity is obvious in mania but it can also be present in depression in the form of agitation. The rushing thoughts of mania are apparent in speech but in depression the mind is often full of overwhelming negative thoughts going round and round that cannot be stopped. Both mood states lead to poor concentration, memory and distractibility. Psychosis can be evident in both states, though usually in different forms; disability is profound in both states when severe.

It is easier to understand ‘switching’ when the similarities between the two states are appreciated. Many depressions are followed by mania and vice versa. This is often put down to the effect of the medication but in fact it is a basic part of the illness course and was apparent well before the treatments we currently use were available.

It is probably better to look on mania and depression as closely related states rather than opposites and that they have more in common with each other than with euthymia (Greek, eu, good; thymia, mood)–normal mood (Fig. 1.2A). This makes the understanding of mixed states easier and the more you look for mixed states the more you will see them.

Fig. 1.2 A,The relationship of mania and depression to normal mood. B, Depression and mania are not best seen as opposite states.

Mixed states are the combination of manic and depressive symptoms at the same time (Fig. 1.2B). Sometimes it is just the presence of depressive ideas: feeling guilty and frightened in an otherwise clear manic state–dysphoric mania (Case vignette 1.1). For others the combination is so marked that you cannot say in which state they are in: