Understanding mania and hypomania 1
Contents What are mania and hypomania? 3 How are mania and hypomania diagnosed? 4 What causes mania and hypomania? 5 What treatments are available? 5 How can I help myself? 6 What can I do if a friend or relative experiences mania or hypomania? 8 Useful contacts 10 2
This information is for anyone who has experienced mania or hypomania and for their family and friends. It describes the common symptoms associated with both and the impacts these can have on daily life, as well as their relationship to bipolar disorder. It then discusses what options for treatment and self-management have been shown to be effective. What are mania and hypomania? Mood can be thought of as a spectrum, with depression at the low mood end and mania at the other. Mania refers to periods of over-active, excited behaviour. Hypomania is often described as a milder form of mania. Although a hypomanic episode is not as severe as full mania, it can still have a serious impact on the way you normally live your life. For most people, mania or hypomania is experienced as part of bipolar disorder, but this is not always the case. Symptoms The following features are associated with mania and also occur in hypomania to a less severe extent: increased energy and activity feeling full of ideas with racing thoughts increased confidence and self-esteem decreased need for sleep talkativeness being easily distracted, and darting from one activity to another elevated mood, but sometimes increased irritability that can quickly turn to anger increased sociability and over-familiarity increased sexual desire and decreased inhibitions increased involvement in pleasurable activities with little thought for consequences, such as going on a spending spree or making reckless financial decisions lack of insight, or denial that behaviour has changed increased awareness of senses such as smell and touch. These symptoms are things people may experience from time to time, but for most people will not be considered severe enough to receive a diagnosis or require treatment. 3
How are mania and hypomania diagnosed? Hypomania A diagnosis of hypomania is made when you have experienced a number of the symptoms (listed on p.3) together for at least four days, and they are thought to be causing a problem for you and those around you. The disturbance caused by hypomania is not normally serious enough to cause major problems in relationships or work, and will not require hospitalisation. Mania The diagnosis would be mania, rather hypomania, if your symptoms have been present for a week or more, and your work and social activities are seriously disrupted, or you need a stay in hospital. If you experience full mania, you may also have psychotic symptoms, such as hearing voices, hallucinations or delusions, which are not present in hypomania. See Understanding psychotic experiences for further information. As part of bipolar disorder (manic depression) Some people experience mania or hypomania without experiencing depression, but this is not common. If you have been diagnosed with depression and then have a manic or hypomanic episode, this can result in a new diagnosis of bipolar disorder. There are different types of bipolar disorder, and the severity and length of your mania will determine the type you are diagnosed with. See Understanding bipolar disorder for further information. Problems with diagnosis Potential under-reporting Hypomanic and manic episodes can be enjoyable and exciting while they are occurring. If you experience an episode you might not see it as a problem and decide not to seek support at the time. If you later find you are feeling low or depressed and seek support from your GP or another health professional, they may not take your high mood into account in their assessment. This omission can lead to inappropriate treatment, such as the prescription of antidepressants which can actually act as a trigger for mania or hypomania in some people with bipolar disorder. It is therefore important to talk to your doctor about all symptoms or problems you have had to ensure you get a correct diagnosis and treatment. Length of a hypomanic episode Currently, symptoms have to be present for at least four days for hypomania to be diagnosed, but shorter episodes are common, and can be an indicator of bipolar disorder if you also experience periods of depression. There is an ongoing debate about whether this four-day period should be reduced to ensure hypomania is always noted by professionals. This could mean many people would see their diagnosis change from depression to bipolar disorder. Thyroid function Mood is influenced by the thyroid gland, which controls your metabolic rate (the amount of energy you use to keep your body functioning). In some cases, symptoms similar to mania or hypomania may be caused by an overactive thyroid gland, while symptoms similar to depression may be caused by an underactive thyroid. Both thyroid disorders can be treated. If you have experienced mania or hypomania and seek support from a doctor, they should check your thyroid function. More information is available from the Thyromind website (see Useful contacts on p. 10). 4
What causes mania or hypomania? Mental health problems are complex and it is generally felt that they develop through a combination of factors rather than one single identifiable cause. If you had a difficult or abusive childhood, or are going through challenging life experiences such as bereavement, domestic violence or unemployment, you are more susceptible to all mental health problems. High levels of stress, lack of sleep and stimulants such as drugs or alcohol are common triggers for mania or hypomania; however, on their own, they are unlikely to lead to more than one episode or to more long-term bipolar disorder. If you experience mania or hypomania as a feature of bipolar disorder, then you might have family members with the same diagnosis, suggesting a genetic link. Many people with the diagnosis, however, have no family history of it, and research has not so far identified a single gene that could be responsible. The fact that some people find symptoms can be controlled by medication especially lithium and anticonvulsants suggests that the function of the nerves in the brain could play a role. But, again, research evidence is not conclusive. (Also see Medication on p.6.) What treatments are available? For many people, the experience of mania or hypomania can cause significant distress, and there is no quick and simple treatment. You might find that you need to try a number of different options for treatment and also make changes to your lifestyle to manage your symptoms. Talking treatments The aim of most talking treatments is to help you to understand yourself better and develop strategies to reduce the chance of you experiencing hypomania or mania in the future. You should be given time and space to talk about your experiences in a calm and nonjudgemental atmosphere. You might be referred by your GP, following an episode, but the therapy is likely to be most effective when your mood is more stable. If you have experienced a mild episode of hypomania, your GP might refer you to your local Improving Access to Psychological Therapies scheme, where you are most likely to be offered a treatment called cognitive behaviour therapy (CBT). This is normally short-term and very practical, aiming to help you identify patterns in your thinking that can lead to hypomania (and depression, if you experience both), and develop ways to change these patterns. See Mind s booklet Making sense of cognitive behaviour therapy for further information. Longer-term psychotherapy, individual or in groups, tends to go more deeply into the origins of your problems in the past. It tries to help you understand the past in order to bring about change in the present. Psychotherapy is less concerned with making immediate changes to the symptoms you experience than CBT is. (See Mind s booklet Understanding talking treatments). 5
Interpersonal and social rhythm therapy is a more recent therapy. It was developed to treat bipolar disorder, and explores your reactions to events such as having an argument with a friend with particular emphasis on helping you to develop stable sleep and behaviour patterns. It is not yet well established or as commonly practiced as many other therapies, so finding a practitioner can be difficult. See the British Association of Counselling and Psychotherapy in Useful contacts. Talking treatments may be available on the NHS, through GP surgeries or hospitals (although waiting lists can be long), or from voluntary organisations or private therapists. Medication If your doctor is concerned that your hypomania might develop into full mania, or if you are given a diagnosis of bipolar disorder, it is likely that you will be offered treatment with drugs. You should be offered full information about the possible side-effects of these drugs before making a decision about whether or not you want to take them. Treatment with these drugs should be started by a specialist (psychiatrist) and not by a GP. Drugs licensed for mania, called antipsychotic drugs, are sometimes also used for hypomania. The most commonly offered drugs are called: olanzapine (Zyprexa) quetiapine (Seroquel) risperidone (Risperdal). Mood stabilisers are used to treat bipolar disorder and recurrent depression. These include: lithium (Camcolit, Liskonum, Priadel) valproate semisodium (Depakote) carbamazepine (Tegretol) lamotrigine (Lamictal). All these drugs can cause side effects. More information is available in Mind s booklets Making sense of anti-psychotics and Making sense of lithium and other mood stabilisers. How can I help myself? There are lots of strategies that can help you to manage your own mood, and reduce the unwanted effects of mania or hypomania. Using these strategies does not mean that you need to handle everything on your own they are often used in combination with other treatments and support from friends, family and professionals. Recognise your triggers If you are able to recognise the signs of an approaching episode and the things that trigger your symptoms then you can take action before things become more serious. However, a feature of mania and hypomania is a loss of insight into your behaviour, which can make recognising symptoms difficult. You may therefore find it helpful to talk to a friend or relative that you trust about warning signs and ask them to tell you when they see these. 6
Keep a mood diary Keeping a regular mood diary will also help you to recognise changes in your mood which can be difficult to spot otherwise. There are a number of different approaches to mood diaries, but key features are to record information about how you feel, such as levels of stress, anxiety and energy, as well as information about external factors, such as how much you are sleeping or how much alcohol you are drinking. You may want to rate your mood from 1 to 10, as this will make it easier to look at your mood levels over longer periods of time; for example: Day Stress Low mood Energy Sleep Comments Monday 4 4 5 7 hours Relaxed day at work, nice lunch with colleague, quiet evening Tuesday 7 3 7 6 hours Things seemed busy today, stayed late at work and went to pub in evening Wednesday 6 2 8 5 hours Feeling really excited about things and think I achieved a lot today. But sister said I don t seem to be concentrating Over time, the diary will begin to show when your mood is changing, and the when the risk of an episode is increased. This is a very simple example to give a sense of what you might capture. Information about more detailed charts, that can to help you monitor your mood, is listed in Useful contacts on p.11. Write an action plan It is a good idea to make a plan of preventive measures that you will put into action if you notice that you might be becoming unwell. These will depend on your situation, but common examples might include: going to bed at the same time each night and prioritising good routine sleep patterns over other activities reducing alcohol, caffeine and other stimulants participating in calming activities such as gardening, meditation or yoga asking a close friend or family member to hold your credit cards avoiding or postponing making major life decisions avoiding situations that could lead to risky sexual encounters referring to self-help books which can help you to track your mood maintaining general wellbeing, spending time in nature and exercising trying to eat well and keep to regular mealtimes learning and maintaining the skills of mindfulness which help you to focus your thoughts (see Be Mindful in Useful contacts on p.10). These are just some possible self-management techniques and you might find that you are best able to control your moods by using strategies like these at all times. MDF the Bipolar organisation runs training courses see Useful contacts on p.10 for more information. 7
Support groups Talking to other people who have had similar experiences is often a help. There are support groups across the country for people who have experienced mental health problems. Mind infoline or your local library should have details of local groups, or some of the organisations listed at the end of this booklet may also be able to help. MDF the Bipolar Organisation maintains a network of local self-help groups that welcome friends and family as well. Both formal and informal online support is becoming more common. A number of charities and websites provide mental health information and safe forums where you can discuss your experiences. The internet can be a place of risk because of the anonymity it offers people. It is therefore recommended that you look for websites of organisations that you trust, such as Mind s Facebook page or the e-community run by MDF the Bipolar Organisation. What can I do if a friend or relative experiences mania or hypomania? Supporting someone with mania or hypomania can be challenging, because the person may feel that there is nothing wrong. They may be feeling very good about themselves and full of confidence and could get angry if you suggest that there is a problem. Building trust By giving your friend space to talk about their feelings when they are well, you can build their trust in you. If they feel that you have some understanding of their wishes, then it can make it easier to discuss changes in their behaviour. Important decisions It might be helpful to talk through any projects that your friend or relative is planning when they are unwell. Writing down the possible dangers and risks can help them to put big decisions on hold. Self-management You could offer to help the person if they are using techniques to self-manage their symptoms and avoid triggers. You could help them to keep a mood diary or, if you live together, support them to start a regular sleep routine. Planning ahead It might be helpful to agree in advance what action they would like you to take if they have a severe episode. You might, for example, agree to look after their bank cards if they have a tendency to over-spend. You might also agree on which support services they would prefer to use; for example, going to a voluntary organisation rather than hospital. If your friend or relative is concerned about the treatment that they might be given if they become very unwell they may find it useful to make an advance decision. This is a legally binding statement that details the treatment they do not want receive. For further information, see Mind s legal briefing Overview and key decisions of the Mental Capacity Act. Depression As has been outlined above, many people who experience mania or hypomania also experience depression, so it is also important to look out for signs of depression following a manic or hypomanic episode. See Understanding depression and Understanding bipolar disorder. 8
Hospital admission (sectioning) Some of the suggestions in this publication might be helpful but, unfortunately, there may still occasions where your friend or relative is very unwell but does not want you to get involved. If the person is a risk to themselves or to other people, it may be necessary to seek compulsory admission to hospital. The 'nearest relative', as defined under the Mental Health Act 1983, has the legal right to request a mental health assessment from an Approved Mental Health Professional (AMHP). The AMHP will look at possible options and decide whether the person should be detained. (For more information, see Mind rights guide 1: civil admission to hospital and The Mental Health Act 1983 an outline guide) Your own health It is important to look after yourself as well. It can be distressing to see someone you care about behaving differently to normal, and putting themselves at risk. You might find counselling or a support group can help, giving you the opportunity to talk about what the relationship is like for you, the feelings you have about the person and what you can do to look after yourself. MDF The Bipolar Organisation offers support to friends and relatives (see Useful contacts on p.10). 9
Useful contacts Mind Mind Infoline: 0300 123 3393 (Monday to Friday 9am to 6pm) email: info@mind.org.uk web: www.mind.org.uk Details of local Minds and other local services, and Mind s Legal Advice Line. Language Line is available for talking in a language other than English. Be Mindful web: www.bemindful.co.uk Explains the principles behind mindfulness, and gives details of local courses and therapists British Association for Behavioural and Cognitive Psychotherapies tel: 0161 705 4304 email: babcp@babcp.com web: www.babcp.com Has a list of accredited behavioural and cognitive therapists British Association for Counselling and Psychotherapy (BACP) tel. 01455 883 316 web: www.bacp.co.uk For details of local practitioners Complementary and Natural Healthcare Council tel: 020 3178 2199 web: www.cnhc.org.uk Maintains a register of complementary healthcare practitioners MDF The Bipolar Organisation web: www.mdf.org.uk tel: 020 7931 6480 Support for people with bipolar disorder (including hypomania) and their families and friends. MDF The Bipolar Organisation Wales tel: 01633 244 244 helpline: 08456 340 080 web: www.mdfwales.org.uk National Debtline tel: 0808 808 4000 (freephone) web: www.nationaldebtline.co.uk Offers confidential advice concerning debts Thyromind web: www.thyromind.info Information about thyroid disorders and the importance of thyroid function tests as part of the assessment of a mental health problem 10
Mood Diaries There are lots of templates, websites and phone applications designed to help you keep track of your moods, and you might want to try several before you find the most useful for you. Mind does not endorse any particular one. Templates www.bipolar.com.au/common/pdf/mood-diary.pdf Websites www.medhelp.org/land/mood-tracker www.moodscope.com www.moodchart.org www.moodpanda.com Apps (for mobile phones) http://itunes.apple.com/us/app/moody-me-mood-diary-tracker/id411567371?mt=8 http://t2health.org/apps/t2-mood-tracker www.mappiness.org.uk/ 11
We re Mind, the mental health charity for England and Wales. We believe no one should have to face a mental health problem alone. Whether you re stressed, depressed or in a crisis. We ll listen, give support and fight your corner. First published by Mind 2005 Revised edition Mind 2011 To be revised 2013 This publication was originally written by Katherine Darton, Mind This edition was written by Beth Murphy, Mind Mind (National Association for Mental Health) 15 19 Broadway London E15 4BQ tel: 020 8519 2122 fax: 020 8522 1725 web: www.mind.org.uk Mind is a registered charity No. 219830 12