Hypomania

Hypomania is, in simple words, a long-term moderate agitation without signs of psychosis, but still outside the norm. A person draws attention to himself by talkativeness, active desire to communicate, initiative - to go somewhere, do something, etc. It is possible to notice distracted attention, however, disorganization of behavior and communication is not observed. The person may be joyful, even enthusiastic, or may be irritated and dissatisfied. His behavior and mood are not quite usual for him, but the height of the manic syndrome is clearly not reached. [1], [2]

Is hypomania bad or good? After all, in general, a person in this state is cheerful, energetic, productive and all radiant with well-being (not counting cases when the excitement is expressed in irritation and dissatisfaction). However, such an elevated mood coupled with physical activity can be a symptom of a mental disorder. Therefore, there is nothing good in this state.

Hypomania is in psychology a form of manic episode, a morbid syndrome indicating the presence of mental ill-health. The term translates as "low, small mania." And from small to large, as we know, is not very far. Therefore, it is undesirable to leave such "mild" mania completely unattended.

Epidemiology

Since hypomania is not a nosological unit and can be observed in patients with various diagnoses, not only psychiatric, but also in practically healthy people with low stress tolerance, its prevalence is unknown. In addition, people rarely seek help for the first episode.

According to morbidity statistics, bipolar disorder type II, which has a milder version of manic syndrome, affects from 0.4 to 2.4% of the adult population. [3] Women predominate among patients - up to 70%.

From all of the above, we can assume that hypomanic episodes are quite common. And many of them are overlooked by psychotherapists and psychiatrists.

Causes of the hypomania

The following pathologic conditions are generally considered as etiologic factors of hypomanic episodes:

• some mental disorders - bipolar type II, cyclothymia, schizotypal, post-traumatic;
• organic brain damage;
• hormonal imbalance during menopause, PMS, pregnancy, postpartum period, caused by increased thyroid function;
• prolonged intake or abrupt withdrawal of psychotropic drugs, narcotic analgesics, antiepileptic drugs, glucocorticosteroids and some other drugs;
• Gambling, alcohol and/or drug addiction.

Sometimes idiopathic hypomania is diagnosed, the causes of which have never been determined.

Risk factors

Many things can trigger the development of hypomanic syndrome, especially in people who have a hereditary predisposition to obsess about anything.

Constant nervous tension, chronic sluggish stress, sleep disorders, even seemingly harmless long-term consumption of low-calorie foods to remove excess weight or the change of season - the onset of brighter and warmer spring and summer months, not to mention regular uncontrolled use of tonics, energy drinks, herbal stimulants - ginseng, echinacea, gingko biloba in the form of tinctures, drops, dietary supplements, teas - can lead to the development of hypomania.

Endogenous lithium deficiency in the body is also called a risk factor.

The appearance of symptoms of facilitated mania can be facilitated by obsession with gambling, risky sports.

A change of residence, workplace, or marital status can also be a trigger for the development of the syndrome.

Being overly critical of parents, receiving frequent negative value judgments from them, or lack of attention can be one of the triggers for the onset of the disorder.

Episodes of hypomania can occur as a side effect of psychotherapy, particularly if deep emotional feelings are affected in sessions.

Since women are more susceptible than men, gender can also be considered a risk factor.

Pathogenesis

There is currently no precise description of the pathogenetic stages leading to the development of the syndrome, as well as the diseases for which it is characteristic. Although it is clear that its development involves both internal components - hereditary predisposition and personality traits, as well as the influence of the environment and external circumstances that act as triggers for the development of hypomania.

Researchers hypothesize that mood (affect) disorders are based on disorders of neurotransmitter metabolism and, consequently, neurotransmission. Serotonin, catecholamine, and melatonin theories explain much, but not all, of the development of affective disorders to which hypomanic syndrome belongs.

The emergence of molecular genetic diagnostic techniques, in particular, genetic mapping, has made it possible to establish the presence in patients with bipolar disorder of several genes that presumably increase the risk of developing this psychiatric pathology with inherent hypomanic episodes.

The possibility of lifetime diagnostics of cerebral structure (MRI and CT of the brain, nuclear magnetic resonance, etc.) has also expanded the understanding of the pathogenesis of the disorder. It turned out that patients with interhemispheric asymmetry, lesion of neurons of the anterior hypothalamus are prone to hypomania. They have desynchronization of circadian rhythms, in particular, the sleep-wake rhythm.

Symptoms of the hypomania

The first signs of hypomania rarely cause concern for the patient and others. There is no pronounced psychopathologic clinic, and the state of mental elevation or increased irritability is perceived as an individual character trait manifested in specific circumstances. In general, the patient's criticality of his behavior and mood is reduced. Hypomanic syndrome is characterized by egosyntonicity, i.e. The patient evaluates his unusual actions and feelings as normal, he is quite comfortable with himself.

Mood, motor and thinking activity are elevated - the manic triad is present, but it is not expressed in such a vivid form in contrast to mania. Psychosocial functions are almost unimpaired, the person is practically adapted in society.

Symptoms:

• staying in euphoria and self-satisfaction, demonstration of optimism and self-satisfaction, often not corresponding to the real state of affairs;
• Criticism from others is ignored or irritated;
• excessive physical and intellectual activity, initiative, often unproductive, generation of ideas and plans, not always logical and feasible - objections are not accepted;
• hyper-communicability, talkativeness, fast pace of speech, which is not always understandable, familiarity in communication;
• increased anxiety;
• hypersexuality;
• increased efficiency, low fatigue and reduced need for rest and sleep;
• a tendency to make risky decisions, impulsiveness;
• the tendency to lack detail in their grandiose plans, the intention to "embrace the vastness";
• persistence in achieving a goal and at the same time - switching to a new topic, abandoning what you have started;
• a "wolfish" appetite or lack thereof.

If one of the triggers for hypomania was a hormonal imbalance, the sufferer may have:

• the trembling in my fingers;
• hyperhidrosis;
• loss of visual acuity;
• hyperthermia;
• change in body weight;
• in women, menstrual irregularities.

A hypomania scale has been created (and more than one) to identify individuals prone to cyclical moderate hypomanic syndromes. Those who undergo psychological testing are given a certain number of points to judge the presence or absence of a problem. The scale's questionnaire is based on symptoms and personality traits of individuals experiencing hypomania or who have experienced this condition in the past.

How long does hypomania last?

The hypomanic episode itself usually lasts from a few days (at least four) to about two weeks. Then either remission occurs, or it is replaced by a depressive episode that lasts longer than the hypomanic episode. In a cyclical course, it is easier to notice abnormal behavior and seek help. Therefore, this may be the typical course of the disease.

However, sometimes hypomania runs continuously for a number of years, acquiring a chronic form. It is difficult to say how common the persistent course of the disease is, as it is often attributed to the characterological features of a particular person and is not sought for help.

Hypomania in children

It is even more difficult to recognize mild mania in children than in adults. Talkativeness in general is characteristic of childhood, elevated moods for no apparent reason, too. Even passion for any one activity, fantastic plans and persistence in their realization usually do not cause surprise. Perhaps that is why hypomania in children is almost never diagnosed.

Rather, the child's unusual nervousness, motor hyperactivity, and decreased need for rest may be of concern. If these symptoms go beyond the normal behavior of the child, for example, he began to sleep much less than usual, but looks energetic, or previously very well-mannered baby became swaggering and familiar with adults, then attentive parents may be surprised. But not the fact that they will run to a consultation with a psychiatrist.

Forms

Hypomania symptomatology can be classified according to different criteria, for example, according to the areas of mental activity in which disturbances occur. Changes are observed simultaneously in three (manic triad) areas of the psyche:

• affective - a mood disorder (not as intense as in true mania, without significant disorganization), including a pathologically elevated state of mind, optimism, enthusiasm, a sense of good fortune and mental comfort, a state called hyperthymia;
• personality disorders or autopsychic, manifested by rapidly changing thoughts and ideas (often obviously unrealistic), hyperproductivity, jumping from one project to another without bringing the previous one to a logical conclusion;
• somatopsychic - feeling of bodily comfort, limitless physical possibilities, quick recovery (little sleep, a lot of time spent actively).

Disorders do not always affect all areas evenly, sometimes the somatopsychiatric component predominates, overshadowing the first two. This complicates the diagnosis.

Hypomanic syndrome is also classified according to the type of underlying mental or somatic disorder diagnosed in the patient. If it is impossible to determine the type of primary disorder, the diagnosis of idiopathic hypomania is made.

The most common or most researched hypomania in bipolar disorder (bipolar hypomania) - the polarities are expressed in the cyclical alternation of the hypomanic stage and the depressive stage, after which the patient's behavior almost returns to normal. In the old classifiers, this disorder was called manic-depressive psychosis. Not particularly pronounced, weak symptoms of mania without hallucinations and delusions are observed in type II bipolar disorder.

Hypomanic episodes may also occur in cyclothymics, patients with schizoaffective disorder, and persons with alcohol, drug, or medication dependence. The latter often occurs in patients with bipolar or schizoaffective disorder who are prescribed psychotropic drugs. Wanting to get rid of distressing symptoms, a person begins to take drugs in increased doses, the consequence of which is hypomania from antidepressants.

In the presence of a full range of symptomatology, the diagnosis is not very difficult to make. Clear hypomania allows you to help the patient, quickly and effectively relieving him of the unpleasant manifestations of the disorder.

At the same time, the productive form of hypomania has quite vivid and complete symptoms. In this case, the patient suddenly becomes energetic and active, thinks quickly and makes non-standard decisions. He has an improved memory and an almost imperceptible decrease in concentration. With productive hypomania, professional activity and adaptation in the environment do not suffer. The morbidity of the process can be noticed by such signs: previously this individual did not have such an irrepressible energy, he became more liberated and sociable, his communication with strangers is characterized by familiarity, in addition, all this occurs against the background of a disorder of sleep and wakefulness. Such hidden hypomania in the presence of pronounced symptomatology is diagnosed with difficulty. It often remains out of the doctors' sight until the symptomatology develops into true mania.

Hypomania is characterized by cyclicality. According to the nature of the process distinguish:

• remitting - it is characterized by alternating exacerbations and remissions, it runs in waves;
• with dual phases - a few days of euphoric symptoms are followed by a decline in energy and depression, then the patient returns to a virtually normal state, i.e. Remission occurs after two episodes of exacerbation with opposite polarity;
• Continuous (continuous) - the name already makes it clear that there are no periods of remission between episodes.

The first and second types are most common in type II bipolar disorder.

Sometimes hyperthymia with auto- and somatopsychic components extends in time for months and even years. In the case of such a course, chronic hypomania is registered. Prolonged syndromes usually manifest themselves in a productive form and are perceived both by the person himself and by those around him as features of character. In such cases, help is sought when the situation worsens and it becomes impossible to ignore mental illness.

Hypomania differs in its predominant manifestations:

• simple - when the patient is in an elevated mood, energetic, proactive, sociable, pleased with himself, this type is also called cheerful hypomania;
• adventuristic - similar to the previous one, but the patient clearly has a propensity for risky activities, risky decisions, rash impulsive actions fraught with negative consequences;
• Angry hypomania - a person is constantly irritated, dissatisfied with others and their actions, confident in his infallibility and rightness, behaves rudely with others, criticism is perceived as a personal insult and reacts accordingly;
• chicanery (querulant) - the "red thread" is the struggle for their allegedly violated rights in the form of writing complaints, filing lawsuits, visiting various instances;
• Dysphoric hypomania - misanthropy, intolerance, aggressive behavior;
• hypochondriacal - the patient is obsessed with the state of his health, inventing ailments, constantly visiting doctors, examinations, finding non-existent somatic symptoms.

All the above-described forms, except the simple, and especially the last three can be qualified as atypical hypomania, to which can be attributed variants with the presence of supervalue ideas, the feeling of pain, expressed hypersexuality and other manifestations that mask the clinic of the course of the disorder.

There is no such thing as mild hypomania. It is already a light version of mania, even to suspect and detect it is not an easy task at all.

Complications and consequences

Hypomania, as a rule, does not lead to such serious consequences as social disadaptation, loss of work, family, professional skills. A person in a euphoric state is almost impossible to spoil his mood, he is energetic, cheerful, sociable, efficient. Sometimes becomes very productive, offers creative ideas. He can arouse the interest of others in himself and his ideas. Hypomanic syndrome is often accompanied by creative activity.

Then the question arises: what is the danger of hypomania? Is it worth treating it if everything is so fine?

You don't want to ignore it. It can be a symptom of a mental disorder, a precursor to true mania, and this is not so rosy. Hypomanic episode, as a rule, is replaced by a depressive one. It's longer and more real.

In addition, during hypomania, criticism of one's behavior decreases, and the condition may worsen from episode to episode. Aggressiveness and irritability appear, the ability to concentrate decreases, relationships with others and coworkers begin to deteriorate, interests switch from one idea to another without bringing any of them to a logical conclusion.

Mentally unstable individuals subject to hypomania are prone to the use of alcohol and psychotropic drugs. Increased sexual activity against the background of rejection of criticism from the outside and increased self-esteem can also lead to trouble.

Diagnostics of the hypomania

Identifying hypomania can be difficult, [4] and as a result BSD is often misdiagnosed as unipolar major depressive disorder, [5] borderline personality disorder [6] or other disorders. Consequences of this misdiagnosis include inadequate treatment and worsening of the disorder, inappropriate use of antidepressant medications, and increased risk of suicide. [7]

If hypomania is suspected, a psychiatrist should be consulted. This is the main specialist who makes the diagnosis. If necessary, consultations with a neurologist, narcologist, endocrinologist and doctors of other specialties may be prescribed if somatic pathologies are suspected.

The psychiatrist collects the patient's medical history by interviewing him or her and people close to him or her about habits, lifestyle and rhythm of life, presence of mental traumas, diseases and harmful addictions.

Often already during the interview the doctor pays attention to the patient's agitated state, accelerated speech, inappropriate cheerfulness (irritability), jumping from one topic to another, boastfulness, etc. The patient is offered to take a test for hypomania. Answers are evaluated on a point scale. Depending on the number of points scored, the level of hyperthymic accentuation, impulsiveness, realistic self-esteem, presence of aggressiveness is assessed.

The hypomania questionnaire is designed to identify the patient's character traits, likely psychopathological manifestations, and personality accentuations. If a person scores high (each scale has its own gradation), hypomania is likely to be present. Although some people without mental disorders may have elevated scores. Scores below normal may indicate depression.

Diagnosis is usually not made at the first meeting and on the basis of the first test. Special techniques are used to assess the patient's thinking, memory, and ability to concentrate. The patient's mood and behavior, according to people close to him, are atypical, and this is noticeable to others.

Instrumental diagnostics of the brain (CT, MRI, EEG) allows to establish or deny the presence of organic damage to cerebral structures.

Differential diagnosis

In psychiatry, differentiation is problematic because it is based on the psychiatrist's observations rather than specific biological markers.

The main difference between hypomania and just a good mood is that the state of a person during the syndrome is not typical for him and it is noticeable to others. The duration of hyperthymia or irritable mood is at least four days, the person is too energetic for himself and practically does not need rest. The mood changes have behavioral consequences.

Mania and hypomania have differences, although its edges are quite thin, the main thing is the height and strength of the manifestation of symptoms. Hypomania is a mild, subclinical form of mania. There are no obvious signs of psychosis - delusions and hallucinations, a person is oriented in society, sufficiently organized, available for communication. Hypomanic behavior can be puzzling to others, but it usually does not lead to devastating consequences for the patient's life, professional activity and communication with people.

Mania is characterized by extreme manifestations of agitation, the presence of psychotic symptoms (delusions, hallucinations, paranoid thoughts), disorientation and disorganization, almost always requiring hospitalization. It is a life-threatening condition for the patient and those around him.

Hypomania and depression are two opposite affective poles. Hypomania is a rise in physical, mental and intellectual strength, while depression is a complete decline.

Treatment of the hypomania

There is no consensus on whether hypomania caused by external causes should be treated at all. Actually, the treatment is then reduced to the elimination of these causes. For example, drug-induced hypomania passes after changing the drug regimen; caused by hormonal imbalance - after its elimination; in case of lithium deficiency, diet and dietary supplements are prescribed.

It is much more difficult with hypomanic syndrome resulting from bipolar or schizoaffective personality disorder. In this case, long-term and sometimes lifelong medication is required, which is carried out according to the following scheme: symptom control → supportive therapy → relapse prevention:

• lithium salts are prescribed for the simple form of hypomania; anxiolytics, usually benzodiazepines, in the prevalence of outbursts of anger, aggression, irritability; valproate - to control attacks of agitation;

• If classical mood stabilizers (normotimics) are ineffective or cannot be used, therapy with anticonvulsants is used;
• If after three to four weeks of use of the above medicines no effect occurs, neuroleptics with predominantly sedative effect are used.

In complex cases, combine the use of antipsychotics with immunomodulators, calcium antagonists.

Prophylactic antiseizure treatment (mood stabilization) is carried out with a single normotimic. If a mono-drug is not effective enough, a combination of two drugs of this series may be prescribed. Administration is usually long term, at least five years, and sometimes permanent.

In parallel with drug therapy, patients are prescribed psychotherapeutic treatment. Regular sessions contribute to the patient's understanding of his condition, normalize the daily routine, improve the quality of life of the patient. The patient attends individual sessions, as well as - group sessions. Educational work is carried out with close people.

Prevention

Recommendations for preventive measures to prevent the development of the syndrome, the etiopathogenesis of which is unknown, have not been developed. To reduce the risk of hypomania, it is necessary to follow general recommendations - to lead a healthy lifestyle, do not start existing chronic diseases.

Forecast

In exogenous causes, the prognosis is favorable. If the hypomanic syndrome is part of the clinic of affect disorder, it is possible to maintain the remission stage for as long as possible if the patient fulfills medical recommendations, adheres to the regimen and timely diagnosis.