Manic episodes in bipolar I disorder play out differently for different people but often have scorching consequences. Learning about triggers, symptoms, and effective treatments is imperative.
When Keely describes her first manic episode, she lists what might be considered “classic” symptoms.
“I had lots of energy, a case of the giggles, and racing thoughts,” says Keely, 43. “I couldn’t sit still. I’d go to my office and sit down, and then I’d have to get up and pace the floors.
“I felt like Wonder Woman,” adds Keely, who lives outside of Boston. “No one could knock me down.”
For Julianna of Orange County, California, the trademark manic exhilaration quickly breaks down into agitation, irritability, and physical discomfort.
“I get like 24 hours of euphoria and then a feeling like ants in my pants—like I’m crawling out of my skin,” the 46-year-old reports. “I get very agitated and I pick on people.”
In this mind-set, Julianna can’t stand to see things out of place. She’ll yell at her husband for leaving his shoes in the family room, or dramatically sweep messy papers to the floor.
“I scratch my neck until it’s red,” she adds. “I feel so yecch.”
Psychiatry has established a central set of criteria to diagnose mania. But the list of symptoms in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) doesn’t fully reflect how mania can vary from individual to individual.
Just as episodes play out differently for different people, so does the course of episodes over time. Some people respond quickly to standard medications after a first manic episode and don’t relapse for years, if ever.
“There is a subgroup who, once they get on the right treatment, remain largely controlled—they might almost seem cured, but it’s because the treatment is working,” says psychiatrist Murray Enns, MD, a researcher and professor of psychiatry at the University of Manitoba in Winnipeg, Canada. “But not everyone latches on to the right treatment.”
For others, mania revisits despite the best interventions. It has taken Julianna years to find medication that keeps her relatively stable, but she still has manic episodes every couple of months.
Of course, that presupposes clinicians know what they’re treating in the first place. Clayton consulted psychiatrists and counselors over the years as abrupt, disruptive mood shifts cost the chartered accountant two marriages and numerous jobs. It wasn’t until 2006, while living in a homeless shelter, that he was accurately diagnosed and prescribed effective medication. Now 66, he’s a peer specialist in Calgary.
What’s in a name
The DSM lays out a list of core symptoms, starting with changes in mood and energy levels. Other diagnostic indicators include unrealistic self-confidence, a hyped-up buzz of ideas, talking more than usual, sleeping less than usual, and taking on lots of activities—including ones that are likely to have negative consequences.
Other fairly common symptoms aren’t noted. For instance, heightened senses.
“Colors may seem brighter, images more vibrant, sound more pronounced,” says Shefali Miller, MD, a clinical assistant professor of psychiatry and behavioral sciences at Stanford University.
That increased sensitivity can result in irritable reactions to noise. Cognitive changes—trouble with memory, obsessive thoughts—may also occur. Eating habits may veer toward voracious appetite or zero interest in food.
Some symptoms not mentioned in the core criteria are recognized in the DSM as “specifiers.” Thus an episode can be diagnosed as mania with anxious distress, say, or mania with psychotic features.
The longer mania goes untreated, the greater the risk of psychosis. In a psychotic episode, you have difficulty distinguishing what is rational and real from what is not. That may take the form of delusions—believing you have a special relationship with God, say—or hallucinations, either auditory or visual.
Clayton recalls “visions of becoming the Prime Minister of Canada” during one euphoric state. During Keely’s first manic episode a decade ago, she had a recurring hallucination, “clear as day,” of a female stick figure seated on a horse and holding a spear.
“It would just show up, but oddly, it didn’t scare me,” she says.
One-third of people with bipolar I experience elevated mood episodes with mixed features—symptoms of mania and depression at the same time. Research shows that there is a higher suicidal risk during such episodes.
Impaired judgment and impulsive behavior are hallmarks of mania, often leading to life-shattering consequences like losing jobs and deep-sixing relationships—sometimes due to the fallout from manic actions, sometimes simply by deciding to up and leave.
In one hot-headed moment, Julianna walked out on her marriage. The couple has since reconciled, but fractures remain. Julianna’s daughter, upset over how her mother treated her stepfather, has not spoken to her for a year.
“It was a rash decision,” Julianna admits. “Instead of going into [marriage counseling] I left my husband.”
A variety of studies suggest that lower impulse control and greater responsiveness to rewards may be characteristic of people with bipolar. For example, a 2014 paper in the journal Comprehensive Psychiatry found youth with bipolar scored higher on an impulsivity scale than those with major depressive disorder and those without any mood disorder.
Sheri Johnson, PhD, a professor at the University of California-Berkeley, leads research on the intersection between reward-driven activities and mania. Her Cal Mania (CALM) Program has found that goal-related pursuits and achievements can be a trigger for mania. Furthermore, the degree of sensitivity to rewards can predict increases in mania over time.
In turn, escalating mood intensifies the drive for pleasure and excitement. Deeply ingrained moral codes may get swept away in the rush, and people may act completely out of character: gambling, cheating on a partner, even stealing for the thrill of it.
The combination of impulsivity and grandiosity—feeling you’re invincible—can prove disastrous to one’s bank account. Individuals who are normally responsible with money can find themselves leaping into dubious investment schemes, launching business projects, or spending beyond their means.
“I recently spent money on pocketbooks—I have a collection in my closet,” she says. “I get to a point where I have to borrow money from my dad because I have no money left.”
Treat it right
It can be difficult for people on the upswing to detect changes in their own behavior—or to feel like their greater productivity and upbeat mood are signs of illness. In psychiatric terms, this is known as lack of insight.
Friends, family or co-workers are better equipped to notice changes like increased activity, greater inclination to socialize, less need for sleep, heightened irritability, and a general speeding up in speech and movement.
“If you’re euphoric, you feel very good but you could be making people around you very miserable by talking incessantly, moving constantly, leaping out of a moving car, or walking into traffic,” says Miller. “The family is stressed out while you’re on top of the world.”
Keely was working as a case manager in a psychiatric hospital when her manic symptoms emerged. Co-workers quickly diagnosed the episode based on her ramped-up restlessness and unusual liveliness.
“All the clinicians were concerned about how I was doing,” she says.
It’s essential to get psychiatric care as soon as possible, preferably before hypomania escalates to mania. For safety, a full-blown manic episode may require hospitalization because thinking becomes so distorted.
It’s also essential to maintain treatment after a first manic episode because it’s likely there will be future episodes, says Enns.
“With current treatments you can reduce the frequency, severity and duration of episodes,” he explains.
Enns recommends formulating a plan of action with your treating practitioner that goes into effect when symptoms first surface. You can work together on adjusting medications to address mood issues, sleep problems, and anxiety.
By carefully tracking your moods over time, you can learn to identify triggers for and warning flags of a mood episode. For those who experience abrupt onset, Enns notes, preventive interventions can be challenging.
When Keely begins swearing in everyday conversation, she knows mania is looming—even if she takes evasive action in the form of an extra dose of her antipsychotic.
“It seems as though I don’t have time to slow down or prevent a full-blown episode. It just happens so fast,” she says.
More than meds
Meds are just one thread in managing manic episodes. Clayton faithfully takes his medications, but still experiences mild mood shifts. Through counseling and peer support, he’s learned strategies like scaling back his social life when he’s experiencing hypomania.
Any skills that contribute to staying in balance will reduce the risk of mania. Psychotherapy can provide tools to better cope with life events and aspects of the illness. Self-care, including decent sleep and regular exercise, plays a huge role in stability.
“Even one night without sleep can lead to mania,” warns Miller.
Ryan adheres to his medication regimen, makes sure to go to bed early, and swims every morning at 5 a.m. Those changes keep his moods in check while he handles a demanding job as exhibit coordinator of the first children’s museum in Saudi Arabia and the equally demanding role of dad to a baby daughter.
Another essential change: Sobriety. Although alcohol often acts as a depressant, for Ryan it’s tied closely to mania.
Ryan dates the onset of his manic episodes to 2005, when he was a Peace Corps volunteer in northern Thailand. Far from home and quartered in a rural village, he began drinking heavily.
“The isolation of the assignment exacerbated the loneliness, and the primary outlet was alcohol,” he recalls. “I engaged in a lot of risky behavior that could have really ruined my life.”
The whole cycle “started really spinning out of control” after Ryan and his wife settled in Saudi Arabia, affecting his reputation in their small community and straining his marriage.
Ryan, 35, marvels that his wife “stuck by me” despite behaviors like getting unreasonably angry, inappropriate contact with other women, and crashing his car after a night of drinking.
Those who have family support are fortunate. Keely lived with her father for two years after her initial manic episode. She was touched that he accompanied her to doctor’s appointments to learn as much about the illness as he could.
Julianna enlists her husband to help mitigate the consequences of her manic phases. He has durable power of attorney for her psychiatric care. According to a plan they agreed on together, he makes sure she doesn’t drive and takes away her credit cards.
“The trick is to stick to the agreement,” she admits.
Learning better ways to cope with stress—a notorious trigger for mood shifts—is an important preventive measure. For many, meditation can be a powerful force for maintaining calmness and clarity.
And if you’re feeling too antsy to meditate? That’s when Keely turns to adult coloring books.
Julianna, a Buddhist, meditates three times a day. The practice helps her stay motivated to do the hard work of staying well.
“When I [meditate] I am always thinking about others in my life and how they need to be treated,” she explains.
In the past, Julianna didn’t fully appreciate how her behavior affected others.
“I hurt my husband, my daughter, my in-laws,” she says. “Everything used to be about me.…. I’d rather do the work than feel the way I do when I feel manic, and avoid hurting the people I love.”
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Mania by the book
The Diagnostic and Statistical Manual of Mental Disorders, the standard psychiatric reference in North America, tells practitioners what to look for in order to diagnose a manic episode:
A distinct period of unusual and persistent elevated, expansive or irritable mood that lasts at least one week, requires hospitalization, or results in psychosis.
A sustained increase in goal-directed activity or energy levels.
Noticeable difficulty at work, at school, or in social activities or relationships due to the mood disturbance.
Three or more of the following symptoms (or four if the abnormal mood is irritable):
Inflated self-esteem or grandiosity
Decreased need for sleep (for example, you feel rested after only three hours of sleep)
Unusual talkativeness and rapid speech
Increased goal-directed activity (such as taking on new projects) or agitation
Doing things that have a high potential for painful consequences, such as buying sprees, sexual indiscretions, or risky business investments.
Hypomania means “below mania” in Greek. In a hypomanic episode, the mood changes and symptoms last four to six days and do not cause significant disruptions in usual pursuits.
Mania in context
Although bipolar disorder was once known as manic-depression, the current designation “bipolar I” is given when someone has a manic episode—no matter what has occurred on the depressive side.
A bipolar II diagnosis means someone has experienced at least one episode of depression and an episode of hypomania. A subgroup of people with bipolar II—about 5 percent over a five-year period—may go on to have a manic episode, according to psychiatrist Murray Enns, MD. This would change their diagnosis to bipolar I.
A small fraction of those with bipolar I experience only manic episodes when destabilized. Most experience the full trifecta: mania, hypomania, and depression.
The various mood states often abut, so that hypomania may transition into mania and mania quite typically dive-bombs into depression.
While manic episodes can have severe and dramatic consequences, depressive episodes may prove more debilitating over time.
“In any given year, people with bipolar I and bipolar II spend up to half their time with some degree of depressive symptoms and only 1 percent or 2 percent in mania,” Enns says.
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