Mania (elevated mood)

Though most people know if they are having anxiety or depression, mania often occurs without us ever being aware of it.  Mania takes many forms: it can overlap with symptoms of depression (called a mixed state), or pass undetected as a brief, energized state that feels almost normal (called hypomania).  Yet it is common, affecting 30-50% of people who visit a psychiatrist, and is often the reason why people do not respond well to medications [1].

Mania often goes unnoticed because it turns down the part of our brain involved in self-awareness, called the frontal lobes.  This can feel good, freeing us from self-consciousness and self-doubt.  Trouble arises from the other changes it brings.  We can’t learn from our mistakes, remember the past or plan for the future very well in this state.  We may act on impulse: spending too much, saying too much, jumping in or out of relationships.

At first, mania brings good feelings, high confidence, creative ideas, and high energy.  This is the euphoric mania that is often described in textbooks.  Unfortunately this bright side rarely lasts more than a few days.  Gradually it transforms into impatience, anxiety, agitation and depression; painful sides of mania that are described below.

1) Anxiety

Surprisingly, anxiety levels are generally higher in mania than in depression [2].  Mania can activate the body’s fight or flight system, causing tremor, racing heart, muscle tension, and insomnia.  This can peak into a full panic attack. 

Manic anxiety usually worsens in crowds, during arguments, in over-stimulating environments, or after lack of sleep.  The body’s threat level is on alert, causing everyday worries (e.g. money, safety, health) to turn into paralyzing fears. 

It is a paradox that mania causes anxiety, because it can also cause a fearless state where people do dangerous things.  Actually, it is a terrible state to be in when anxiety and impulsivity overlap, and it has been linked to suicide and drug abuse.

2) Depression

Although mania and depression are thought of as opposites, the most common complaint of people in mania is actually “depression.”  In medical terms this is called a dysphoric mania or mixed state, and it is not actually a depression at all.  This brings out the difference between depression as a mood and depression as an emotion.  Emotions are normal reactions to life. and for many people it is simply depressing to live with mania.  Moods, on the other hand, refer to changes in the way our brain functions – they impact energy, concentration, sleep and appetite.

Biologically, mania and depression do represent opposite brain states, and usually respond in opposite ways to medications. 

3) Lability (“Emotional Swings”)

Severe depression actually makes people unable to cry and numbs emotions.  In contrast, emotions tend to be heightened in mania.  People may feel all of them intensely – tears, laughter, anger – and shift quickly from one to the other.  This reactive state is called “lability,” and though the dramatic sadness may feel like depression it is actually mania. 

 

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FrontalLobes.png The lines above show how the frontal lobes (our thinking and planning center) connect to the limbic system (our emotional center).  These lines of communication allow us to control our impulses and balance our emotions, except in mania when the lines shut down

 

4) Concentration (“ADHD”)

Mania can make your thoughts bounce like a ping-pong ball.  Manic thoughts pull you along with a powerful pressure, only to drop out and leave you distracted and forgetful. Thoughts can crowd together, or sound like multiple radios playing at the same time.

People with mania say it feels like ADHD, and indeed the two conditions have a lot in common.  Both cause restlessness, racing thoughts, distraction, disorganization, impulsivity, and irritability.  They make it difficult to prioritize tasks, stick to one thing, or shift flexibly when it’s time to change. 

Although the symptoms are similar, mania and ADHD are caused by very different brain changes. While stimulants, such as ritalin and adderall, can help ADHD, they may worsen mania, causing irritability, anxiety, depression, insomnia and paranoia.  Often people with bipolar disorder feel more mental or physical energy on stimulants, which may crash as they wear off.  In contrast, people with ADHD feel calmer and more organized on stimulants.  Even when stimulants do work well for people with bipolar, their benefits often wear off after 3-6 months.  

5) Excess

Mania can push your gears into overdrive, leading to high activity.  When the “orderly gear” engages, you are up all night rearranging the house.  The “generosity gear” can leave waiters with $100 tips, and the “perfectionism gear” can pull all your energy towards an unreachable goal. Mania is a common fuel for addiction, whether gambling, sex, food, shopping or drugs.

Usually, the brain will balance our behavior through a process called homoestasis; the common term for this is “satisfaction.”  While a non-manic person may be satisfied by buying one pair of shoes, a person with mania doesn’t have that brake and may buy twenty.  

Mania can turn the volume up on our senses as well.  Sounds become louder and colors brighter, which can feel exhilarating, over-stimulating or even annoying.  In this sensory jungle we may hear things that aren’t there, like our name being called, or sometimes frightening hallucinations.

6) Relationships

Even when mania feels good, it can strain relationships.  You may become impatient with people who can’t keep up with or understand you.  When mania turns dark, arguments can escalate, often in a pattern like this:

Mania makes you mistrust other people’s intentions
You may have heard that 70% of communication is non-verbal. This is true: part of our brain constantly reads the non-verbal behavior of other people (called the amygdala). In mania, you will be much more likely to read others as threatening or menacing.

Mania causes you to lash out
Mania shortens the fuse on our temper, making it hard to think before we act.  In this, you will probably feel you are defending yourself, while the other person will feel they’re being attacked out of nowhere.

The other person gets afraid 
Unfortunately, mania tends to make the brain misread fear as anger, so the look of shock on the other person’s face can cause you to feel attacked and make you defend yourself even more. 

The forgetfulness of mania sets in
Mania impacts memory in many ways, including sequencing, which is how the brain keeps track of what came first in a series of events.  As an argument progresses, you may start to forget what you did to contribute to the fight. 

Confidence rises
Mania raises your confidence, making you sure that you are right and the other person is wrong. 

The other person gets angry
Somewhere in the time-line this is bound to happen.  When it does, the other person may start to act mean, irrational or even manic.  This only further justifies the anger inside you. Family therapists have found that the best solution for the other person is to step away from a manic fight – to go to a separate room.  Attempts to resolve the fight with words often lead to this viscious cycle.

Your focus narrows
Mania makes you single-minded.  In this pressured state, you stick to your guns and lose sight of the good things about the person you’re fighting with.  Most anger management programs teach people to step back from a fight so they can see the whole picture and act wisely – this is hard to do in mania.

Peace and satisfaction become hard to find
The other person may try to end the fight by offering peace or compromise, but mania is rarely satisfied, so the offering feels inadequate compared to the painful injustice you feel inside.

Studies have found that “getting even” can be addictive.  When we feel wronged by others, the dopamine (or addictive) part of our brain lights up at the chance to exact revenge.  This is true for everyone, but this dopamine system is even more sensitive to addictive rewards during mania.  When this is combined with the mistrustful, irritable, single-minded, uncompromising, forgetful state of mania, terrible fights can ensue.

7)  The bright side of mania

Many aspects of mania are desirable: the high energy, confidence, socially engaging, good humored, fun-seeking side.  Unfortunately this bright side of mania is short lived.  The good news is that people with bipolar disorder often have unique strengths that persist even after recovery from mania.  Research has found that they have greater emotional warmth, verbal abilities, empathy, spirituality, and open-mindedness. 

People who have been through mood episodes often have a more realistic view of themselves and the world around them.  Research has found that manic tendencies even make people better able to withstand stress.  They can see connections that the rest of us miss, and can find unique solutions to difficult problems.

To continue to the next section, click Bipolar II.

–Chris Aiken, M.D., Updated 5/25/12

 

References

[1]  The studies below all found that 30-50% of people who visited a psychiatrist had experienced mania or hypomania.  Amazingly, in most cases the doctors were not aware of the mania until they delved deeper.

Hantouche EG, Akiskal HS, Lancrenon S et al. Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multi-site study (EPIDEP). J Affect Disord. 1998 Sep;50(2-3):163-73.

Akiskal HS, Akiskal KK, Lancrenon S et al. Validating the bipolar spectrum in the French National EPIDEP Study: overview of the phenomenology and relative prevalence of its clinical prototypes. J Affect Disord. 2006 Dec;96(3):197-205.

Benazzi F. Prevalence of bipolar II disorder in outpatient depression: a 203-case study in private practice. J Affect Disord. 1997 Apr;43(2):163-6.

Kim B, Wang HR, Son JI et al. Bipolarity in depressive patients without histories of diagnosis of bipolar disorder and the use of the Mood Disorder Questionnaire for detecting bipolarity. Compr Psychiatry. 2008 Sep-Oct;49(5):469-75.

[2]  Researchers at Harvard identified the heightened anxiety during mania:

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 Jul;87(1):101-5.