Don't fall into the trap of these 3 myths about mania in bipolar disorder...
Bipolar disorder is riddled with misunderstandings, from the myth of manic happiness to the idea that all antipsychotics stabilize mood.1 Some of those misconceptions derive straight from the DSM, and in this article I will address 3 that often get in the way of making the diagnosis.
Patients with mania are often able to keep up a high level of activity while sleeping very little, such as 3 to 6 hours per day. That is a fair description, but the DSM went beyond the purely observable by inserting the subjective term, “decreased need,” into the sleep criterion. Interviewers would do well to avoid that term, as most manic patients want nothing more than to get some sleep. And they are right. A good night’s sleep usually calms the uncomfortable agitation they struggle with. Instead of asking “Do you ever have a decreased need for sleep?” ask patients, “Are there times when you still keep going despite sleeping very little, even if you wish you could get more sleep?”
“I felt infinitely worse [during mania] than when in the midst of my worst depressions,” wrote Kay Redfield Jamison.2 Here, the DSM has kept up with reality, somewhat. In 2013, DSM-5 dropped the word “pleasurable” from the manic criteria, but they still recommend screening for mania by asking patients if they ever felt “very cheerful or happy” (they suggest following this up by asking if the patient was ever hospitalized for this good cheer).3
Euphoria does occur in mania, but it is usually brief and followed by a more lasting state of impatience, anxiety, and agitation.4,5 There is little pleasure in all that, which is why most manic patients answer “depressed” when asked to describe how they feel inside.5 To avoid diagnostic confusion, mood experts recommend asking about high and low energy rather than happy and sad emotions when screening for mood disorders.6
Serious mental illness takes a toll on a person’s self-confidence, whether it be autism, addiction, or bipolar disorder. For this reason, asking a patient if they ever have times of feeling “confident, on top of the world,” is likely to draw a blank stare. Mania causes people to lose control over their life, their mind, and basic bodily functions like sleep and energy. This is not a recipe for confidence. On the rare occasions where mania brings a subjective burst of confidence, the patient is unlikely to acknowledge it, as only a humble person would recognize that their confidence is excessive.
DSM-5’s hyperconfident criterion is better understood through actions than subjective report. Manic confidence causes people to take on risks, talk over people, and gesticulate with dominant posturing. They make unreasonable demands and experience their own ideas with an undue sense of certainty that is a frequent cause of argument. Instead of asking about confidence, look for times when the patient acted in such bold ways or, better yet, ask their relatives.
Observable behaviors are a more reliable guide to psychiatric diagnosis than subjective report, and the DSM-5 criteria does a poor job of differentiating between the two. This problem is particularly relevant to mania, where there is often a stark contradiction between the patient’s inner and outer world. Manic patients may stay up all night, engaged in daring pursuits of pleasure, but all the while feeling insecure, dissatisfied, and exhausted.
Structured clinical interviews go a long way to improve diagnostic accuracy, but they don’t overcome this basic flaw, as most of these instruments simply translate the DSM criteria into yes/no questions. Clinicians can improve on those by interviewing family and asking about behavioral examples of mania, like “road rage; excessive, lengthy texts; staying up all night organizing the house or working on projects; suddenly starting or ending relationship or changing jobs.”
1. Vieta E, Sachs G, Chang D, et al. Two randomized, double-blind, placebo-controlled trials and one open-label, long-term trial of brexpiprazole for the acute treatment of bipolar mania. J Psychopharmacol. 2021;35(8):971-982.
2. Jamison, KR. An Unquiet Mind: A Memoir of Moods and Madness. Vintage, 1996.
3. Kotin J, Goodwin FK. Depression during mania: clinical observations and theoretical implications. Am J Psychiatry. 1972;129(6):679-686.
4. Nussbaum, AM. The Pocket Guide to The DSM-5 Diagnostic Exam. American Psychiatric Association; 2020.
5. Simon NM, Otto MW, Fischmann D, et al. Panic disorder and bipolar disorder: anxiety sensitivity as a potential mediator of panic during manic states. J Affect Disord. 2005;87(1):101-105.
6. Kotin J, Goodwin FK. Depression during mania: clinical observations and theoretical implications. Am J Psychiatry. 1972;129(6):679-686.
7. Benazzi F, Akiskal HS. The dual factor structure of self-rated MDQ hypomania: energized-activity versus irritable-thought racing. J Affect Disord. 2003;73(1-2):59-64.