What is manic depression (bipolar disorder)?

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.

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.