Hypomania and mania

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Mrs Evans had been diagnosed by the junior psychiatrist as suffering from mania. She had been brought into the emergency referral clinic by her son who had come home to find her sitting in the living room surrounded by new, expensive commodities she had purchased with her cheque book, even though there was not enough money in the bank to cover the outgoings. Mrs Evans was extremely happy about her new acquisitions but, when her son pointed out that she had done something wrong, she very quickly became petulant and started throwing things at him. In the ward round, after the junior psychiatrist had presented Mrs Evans' case, she was invited in to talk to the team. She immediately tried to sit on the consultant's lap and flirted with him outrageously throughout their short chat. The consultant tried to ask Mrs Evans how she was feeling and to talk to her about medication, but she seemed unable to concentrate on his words and her conversation leapt, seemingly at random, from one topic to another, each sentence ended by her characteristic giggle.

Perhaps the disorders that seem most clearly ones of happiness or positive mood are hypomania and mania. The central features are elevation of mood, hyperactivity, and grandiose ideas about the self (e.g., Cavanagh, 2004). Manic individuals often seem cheerful and optimistic when their mood is elevated and have an infectious gaiety. However, other individuals can be irritable rather than euphoric and their emotions are extremely labile so that this irritability can easily translate into anger. There is often diurnal variation in the individual's mood, whether it be irritable or euphoric. However, this variation does not normally conform to the regular patterns of other depressive disorders (see Chapter 7). Even in patients who are elated, it is not unusual for their periods of elevated mood to be interrupted by brief episodes of depression and, in fact, these "mixed state" presentations in mania, in which there may be a range of emotions present, seem to be much more typical than previously considered (Cavanagh et al., 2007; Cassidy & Carroll, 2001).

The manic individual's choice of clothing can often reflect the prevailing mood—there is an emphasis on bright colours and ill-matching garments. In more severe cases of mania, individuals often appear untidy and dishevelled. Manic persons are highly active, often leading to physical exhaustion. Furthermore, many activities are started but seldom finished as new activities become more tempting; speech is often rapid and copious and, in more severe cases, there is marked flight of ideas such that it is difficult to follow the train of thought of the manic person's discourse. Sleep is often impoverished or absent with early morning waking, appetite is increased as are sexual desires; indeed, sexual behaviour may be uninhibited.

Finally, manic individuals commonly experience expansive ideas. They believe that their thoughts and ideas are original, their opinions important, and their work of the most outstanding quality. Occasionally these expansive themes merge into grandiose delusions in which the individual believes he or she is a religious prophet or a famous person. Such grandiosity and expansiveness also manifests in extravagant behaviour; manic individuals often spend more than they can afford, and make reckless decisions, give up good jobs, or embark on schemes and ventures that have little chance of success. Such problems are compounded by impaired insight in most cases. Manic individuals will often see no reason why their grandiose plans should be reined in or their extravagant expenditure curtailed. Manic individuals rarely think of themselves as having an emotional problem or needing any kind of help.

In mania and hypomania, it appears that the individuals' dominant schematic models of self are highly self-serving, leading to the settting of unrealistic and optimistic goals. The achievement of these goals, or the belief that they have been achieved, is a source of joy and elation. There seems to be little or no access to the representations of the goals of others and, most notably, the shared goals of self and others—the social standards that are so important on setting limits on behaviour. Allied with this is the manic person's tendency to switch from periods of extreme gaiety to periods of intense anger or depression. It seems that different configurations of self-related schematic models come to dominate and regulate the system, such that at one moment everything is all rosy and the next it is all black. The tendency for mania and hypomania to co-occur with depression provides a difficult challenge that no biological or psychological theory has effectively accounted for (see also Chapter 7 on sadness). One might speculate that, first, if the self becomes predominantly organised around issues of success versus failure, appraisals of goal attainment versus goal failure for a highly invested domain are very likely to occur at different points (e.g., Johnson, 2005), so the person may swing between the emotions of joy, sadness, and self-disgust accordingly. Second, one of the findings that distinguishes bipolar disorders from other disorders of depression is the substantial genetic component in the bipolar disorders (Blackwood & Muir, 2004); perhaps this genetic component influences the development of the basic emotions early on, so that they are more likely to be unintegrated with each other. This proposal would suggest that this would be true not only for the basic emotions of sadness and happiness, but for the other basic emotions as well.

Spaars Model For Bipolar One Disorder
Figure 10.2 Jones' (2001) adaptation of the SPAARS model for bipolar disorders.

A specific application of the SPAARS model to bipolar disorders was proposed by Jones (2001) and further extended by Power (2005). As shown in Figure 10.2, Jones proposed that the starting point in bipolar disorders is often at the analogical level, for example through a disruption to normal circadian rhythms, through increased energy, the experience of a positive event, and so on. Positive schematic models of such changes can lead to positive feedback loops which further increase the analogical-level disruption, and also lead to a range of automatic appraisal biases at the automatic level. Power (2005) has further proposed that positive feedback loops can also occur through the coupling of emotions such as happiness and anger, and that the organisation of the components of the self-concept into extremes of positive versus negative valence further adds to the exacerbation and maintenance of the manic state, at times when a normal individual would down-regulate (Power, et al., 2002).

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Understanding And Treating Bipolar Disorders

Understanding And Treating Bipolar Disorders

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