A hypomanic episode is a distinct period of time that lasts at least four days during which the individual’s mood is consistently elevated, expansive, or irritable and is distinct from his or her usual nondepressed mood. Hypomanic episodes are characteristic of bipolar II disorder as well as features of cyclothymic disorder. They may also occur as a transitional phase from euthymia (feeling of well-being often associated with individuals with bipolar disorder when they are not having a manic or a depressive episode) to mania in cases of bipolar I disorder.
Hypomanic episodes usually begin suddenly with the symptoms rapidly increasing over the course of a day or two. A hypomanic episode may last anywhere from four days to several months, although some clinicians are beginning to argue that hypomanic episodes may be as short as two days in duration. However, because such research is based on the self-reports of patients (who tend not to be aware of their symptoms at first), there is not widespread agreement about this change in diagnostic criteria.
Hypomanic episodes associated with bipolar II disorder have the same demographics as that disorder. Hypomanic episodes can affect both adults and younger patients. In younger patients and adolescents, hypomania may be associated with such behaviors as school truancy, antisocial behavior, failure in school, or substance abuse.
Cultural differences can affect the experience and communication of the symptoms of hypomanic disorder, with different cultures interpreting such symptoms as irritability or inflated self-esteem in various ways. Some cultures and subcultures, for example, value such aspects of hypomania as decreased need for sleep, racing thoughts, or increased goal orientation as positive qualities of a productive individual, and do not regard them negatively.
Hypomania is not a disorder in and of itself. The causes of hypomania vary depending on whether it is a characteristic of bipolar I disorder, bipolar II disorder, or cyclothymic disorder.
During a hypomanic episode, the individual’s mood is consistently elevated, expansive, or irritable and distinct from his or her usual nondepressed mood. During this period, the individual must also display at least three of the following symptoms (or four if he or she is only irritable) to be diagnosed as hypomanic:
- inflated sense of self-esteem
- decreased need for sleep
- increased talkativeness or need to talk
- racing thoughts or flight of ideas
- easily distracted
- increased goal-oriented activity
- excessive involvement in pleasurable but high-risk activities (for example, buying sprees, sexual indiscretions, foolish investments)
In hypomania, these symptoms are associated with a clear change from the individual’s normal behavior and are readily observable by others. Hypomanic symptoms, however, are not severe enough to noticeably affect the individual’s functioning at work or in social situations, nor does their presence require hospitalization. To be classified as hypomanic, the individual’s symptoms cannot contain psychotic features or be due to the direct physiological effects of a substance (such as drug abuse or medication) or a general medical condition (for example, hyperthyroidism).
It is important to distinguish hypomania from euthymia in patients who are not used to a nondepressed mood state. In addition, although the two have the same list of diagnostic symptoms, hypomanic episodes are different from manic episodes. Hypomanic symptoms are less severe than manic symptoms and do not cause marked impairment of social or occupational functioning. However, approximately 5% to 15% of individuals experiencing hypomanic episodes will eventually develop a manic episode.
Many of the warning signs of a hypomanic episode such as increased goal-oriented behavior can also be normal and appropriate given the situation. Sometimes a patient’s good mood is just that. Some of the signs of a normal good mood that could distinguish it from hypomania include:
- ability to enjoy reading for a significant period of time without becoming bored
- ability to listen more than talk in a social setting
- no need to do something risky just to shake things up
- ability to complete tasks without repeatedly being distracted
- experience of appropriate anxiety about demands of life such as responsibilities, deadlines, and financial obligations
- ability to enjoy times of peace and quiet
- ability to sleep well at night for an appropriate period of time
- ability to accept well-meaning, constructive criticism without undue irritation
Cognitive-behavioral therapy (CBT) is regularly used to help patients test how realistic their thought processes and resultant behaviors are. The goal of such reality testing is to help patients weigh the facts more carefully than they would otherwise do and to seek the insights of others before acting on their beliefs. This approach can help patients be more independent in controlling their lives.
One of the tools used in CBT to assist patients in controlling their impulses during hypomanic episodes is keeping a daily journal of their thoughts. Such daily thought records are a structured method to help patients do a reality check on their thinking and actions. For example, patients can look for situations in which they overestimate their capabilities, rely on luck, underestimate risks, minimize problems, or overvalue immediate gratification.
Patients with hypomanic episodes can also be taught to test the validity of their thoughts and beliefs by consulting trusted others. By talking things through with a trusted and objective person, a patient in a hypomanic episode can be helped to test the reality of his or her thoughts and beliefs.
Another method that can help hypomanic patients test reality is to have them rate the relative risks of the options that they are considering by listing the productive potential and destructive risks of their alternatives. If patients are unable to think of examples of destructive risks for their plans, the therapist or other objective outsider can help by giving them examples and helping them to develop their own list of potential risks. Similarly, lists can be made of the benefit to others versus the cost to oneself or the benefit to oneself versus the cost to others.
Patients can also be helped to more realistically evaluate their thoughts and plans through role playing or playing “devil’s advocate.” Such techniques can be used to do a hypothetical trial run to see what possible consequences might be incurred if an unreasonable risk is taken.
To help reduce impulsivity and recklessness in hypomanic patients, psychotherapists use various different techniques. One technique is to institute a “wait 48 hours before acting” rule to help the patient avoid spur-of-the-moment reckless actions. It is also sometimes helpful for the patient to try to foresee the possible negative consequences of their proposed actions through imagery by describing the bad things that could happen if they took their proposed course of action. Because hypomanic patients are often overly active, it is sometimes also helpful to have them schedule their activities to help them focus their attention on what is important so that they do not become overextended. Hypomanic patients can also be taught listening skills that can help them focus and break the vicious circle of constant activity and to listen to others. Similarly, patients can be taught anticipatory problem-solving skills that help them recognize the symptoms of a building hypomanic episode and to reduce the stressors that put them at risk. It is also helpful for hypomanic patients to minimize or completely avoid situations that are apt to trigger a hypomanic episode such as daredevil hobbies, exaggerated acts of generosity or intimacy with relative strangers, unsupervised expenditures of large amounts of money, or situations that require the use of a lethal weapon. Hypomanic patients can also be taught to help control or adjust their moods through relaxation techniques and breathing control exercises.
In addition to CBT approaches in controlling hypomanic episodes, several biologic management strategies may help patients. These include:
- optimizing the dose of mood stabilizer or antimanic medication
- encouraging good sleep practices
- discontinuing antidepressants
- including lorazepam or clonazepam (1-6 mg/day) as clinically indicated
- including mood stabilizers such as lithium, divalproex, or caramazepine in the treatment regimen as appropriate
In most cases, such biologic treatments can be used on an outpatient basis.
There are a number of warning signs of hypomania. If patients can be taught to recognize such early warning signs, they have a better chance of using various techniques to help lessen the possibility of acting out and the negative consequences of inappropriate actions that may be associated with hypomania. Attending to such warning signs also can give patients and their doctors more time to adjust medications or arrange for greater supervision to reduce the potential harm from inappropriate behavior.
Some of the typical early warning signs of an impending hypomanic episode include:
- disruption in sleep patterns (for example, decreased subjective need for sleep)
- decrease in anxiety without cause (such as ignoring a deadline or less concern about owing money)
- high levels of optimism without appropriate sound planning and problem-solving (for example, belief that everything will turn out all right even though nothing has been done to make that a reality)
- increased desire to be with others along with relatively poor listening skills (for example, talking at length to someone who is obviously anxious to leave)
- decreased mental concentration (such as difficulty following through or becoming more disorganized than usual)
- increased libido to the point where it affects other areas of life (for example, dressing more provocatively than usual, or inappropriate talk of or joking about sex)
- increased goal-directed behavior to the point where the individual appears driven
According to CBT, if the patient can be taught to recognize the signs of an impending hypomanic episode early enough, he or she will have the time necessary to put into practice the various techniques already discussed to help avoid the negative consequences of potential risky actions.
Bipolar II disorder —One of a group of mood disorders in which the individual has one or more major depressive episodes and at least one hypomanic episode.
Cognitive-behavioral therapy (CBT) —A form of psychotherapy used to help patients modify their behavior by testing their thought processes.
Cyclothymic disorder —A mood disorder in which hypomanic episodes and depressive episodes both occur over the course of at least two years during which time symptom-free periods last no more than two months.
Euthymia —A feeling of well-being often associated with individuals with bipolar disorder when they are not having a manic or a depressive episode,
Mania —Excitement, overactivity, and inappropriate physical and mental restlessness, often accompanied by impaired judgment.
Psychotic —Behavior characteristic of any of a number of severe mental disorders in which the accuracy of perceptions and thoughts is incorrectly evaluated despite of evidence to the contrary, affecting the individual’s interaction with external reality.
Role playing —A technique used in psychotherapy in which the patient acts out a situation to test attitudes, relationships, actions, and their potential consequences.
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Ruth A. Wienclaw, PhD
hy·po·ma·ni·a / ˌhīpəˈmānēə/ • n. Psychiatry a mild form of mania, marked by elation and hyperactivity. DERIVATIVES: hy·po·man·ic / -ˈmanik/ adj.
—hypomanic (hy-poh-man-ik) adj., n.