mental health mondays :: manic panic, part one

well, last week, i went through an exhausting, if not exhaustive, summary of recognising when depression and anxiety require outside help and what some of the options are. as promised, this week, we're turning our attention to depression's more alluring cousin, mania.

is it a good happy or a bad happy?

to start with, i'd like to return to my stock market analogy: the flip side of the sluggish or depressed market is one that is accelerated and expanding. generally that's the sort of positivity you want, but there's also a need to keep it in check. when a market begins to get overinflated, it gets wild and becomes risky and unstable. eventually the expansiveness becomes baseless and precipitates a collapse. most economists, and most psychiatrists as well, will tell you that these "manic" phases are actually far more dangerous than depressed ones.

the problem with mania is that it's not only a lot more difficult to diagnose, but individuals are a lot less likely to realise it's something that requires help. who the heck goes to the doctor because they're happy? or cranky? after all, manias are an extended period of elevated or irritable mood that can lead to unwarranted risk-taking and negatively affect one's social position and relations. the problem is, the person in the throes of mania doesn't realise how potentially dangerous or off-putting their behaviour is, because they are so incredibly overconfident and convinced of their own abilities. those who manifest the "cranky" (impatient, quick to anger) manias believe firmly that lack of progress or nay-saying is the fault of other people. it's virtually impossible to get someone in the midst of a true mania to admit that they're putting themselves (and potentially others) at risk.



some manias, the ones that we're most accustomed to hearing about, are easy to detect. these are the most extreme ones, where the individual completely loses contact with reality, where their delusions take on, for them, a reality. this doesn't generally require much deduction to diagnose, although it does make the point that individuals are not able to see the problem for themselves, which is the case for most manics. but the fact is that this represents the minority of manic episodes. people who are manic may seem fixated or paranoid, but their issues often don't announce themselves, except through side effects. mildly, a person may simply seem energetic and productive (called hypomania) and the state may not interfere with their daily life. doctors still need to be aware of it, because in order to treat someone, they need to understand the full scope of a person's problems.

the visible "side effects" of mania include insomnia or decreased need for sleep (probably the most common syndrome) with no corresponding fatigue, racing thoughts, becoming easily distracted, and engaging in risky behaviour- profligate spending, binge drinking or drug use, or sudden impulsiveness. one that doesn't get mentioned, but that i've witnessed first hand, is a sudden compulsion to travel (which can tie into the risky spending as well). there are no rules for what constitutes manic behaviour and it manifests itself differently in each person.

in order to qualify as a proper "manic episode", this elevated mood and its side effects need to continue for at least a week, but most people who've had them will tell you that it's not uncommon for them to last for months. externally, the person may just seem more outgoing and to exhibit self-confidence. we're socialised to think those are good things. it takes some serious observation, something most manic people can't slow down enough to do themselves, to see when something has become problematic.

normal vs. adhd brain activity

complicating things further is the possibility of confusing mania with adult attention deficit and hyperactivity disorder. adhd has gotten a bad rap, because it's associated with parents who'd rather medicate their kids than deal with them, but in fact, it's a recognisable disorder (there are studies indicating that parts of the adhd-affected brain are less dense than in a regular brain) and it looks very similar to mania. adults with adhd have severe difficulties focusing or concentrating, often fidget or grow impatient and exhibit poor social skills suck as interrupting people or not paying attention when others are speaking. the difference comes in that people with adhd alone (oh yeah, just to confuse things more, you can have mania and adhd at the same time, or one can morph into the other), the self-destructive, dangerous tendencies tend not to be present. so you can't really tell it's mania until it really starts to spiral out of control.

unlike depression, its comparatively well-studied opposite, mania is poorly understood. one going theory is that it results from the brain receiving too much serotonin (remember i said that, it'll come back later). or norepinephrine. or dopamine. or any number of other neurotransmitters. mania can cause sleep deprivation, but sleep deprivation can also mimic the effects of mania, so good luck with that chicken and egg combo.

so how can you tell if you're suffering from mania? the truth is, you probably can't, which is why it's good to seek a professional opinion. but there are a few clues you can follow by reviewing your behaviour when you're in a really good mood:

- first up, think of the duration, especially in proportion to its cause. being relatively happy with your life should be normal. if you feel upbeat about things the majority of the time, that's good. getting really excited when something good happens to you is also both good and normal and, depending on how big a reason you have to be happy, that feeling can go on for a while (and it should- you deserve it). becoming so excited for weeks on end that you can't sleep or shut up, or that you're laughing all the time no matter what's going on around you, or you can't finish a sentence (or a blog post) without having your brain run off in several different directions with either little or no substantial reason is not normal. and, left unchecked, it's usually not good either.

- think of how you act when you feel "up". do you sleep a lot less? drink a lot more? do lots of drugs? buy things you don't really need? most important: do these things seem ridiculous and/ or dangerous to you when you're back down on planet earth? 

oh what- like you didn't see that coming?

- when you feel really happy, how often do you feel peaceful? people who are truly happy can relax at the end of a long day and say to themselves "life is good". people in the middle of a manic episode don't do that. even if you still feel happy, you'll notice that you're agitated- your feet are tapping, or you feel like going for excessively long walks, or you start chattering to yourself about nothing.

big bold type means i want you to pay attention to this warning: these next two are things i've observed, but i have never been able to find a medical study that stated the same thing. it's an opinion. i like to think it's an educated opinion, but take it for what it is.

- does your reaction to drugs and/ or intoxicants change? have you gone from a lightweight to being able to drink your entire circle of friends under the table without blinking? does half a cup of coffee set you off for days? something i've noticed is that manias change the way your body reacts to drugs. stimulants are a lot more stimulating. depressants don't slow you down so much. like i said, this is a theory, but it also makes sense. if your central nervous system is already stimulated, it stands to reason that it takes less to perk you up and more to calm you down. mania in general, i think, makes it easier to get ramped up and a lot harder to wear yourself out.

- it's well established that manics need less sleep, but i personally also like to pay attention to major shifts in sleeping pattern. my observations are that people with mania go until they collapse, sleep for a while, then get up raring to go again. going from sleeping eight solid hours to two is an obvious cue, but, i think, so is going from sleeping eight hours overnight to sleeping an hour out of every five, especially if you're exhibiting other symptoms.

oh, and by the way...

normal vs. bipolar brain activity

unipolar mania (meaning ups with no corresponding downs) is unreognised in modern psychiatry. if someone is manic, chances are that they have corresponding depressions. that doesn't mean that the depressions are as low as the manias are high- most people lean towards one side or the other- but exhibiting signs of mania generally puts you somewhere on the bipolar spectrum. that includes manifesting them both at the same time- being really worked up and really depressed, oh joy, which is a time when bipolar bears are at greatest risk for suicide.

this is one way that adhd can be distinguished from mania. adhd can and does manifest on its own, without depressive episodes. of course, just as often, depression is a comorbid condition with adhd, which puts us back where we started.

great, i'm a maniac. now what?

if you're seeking treatment for depression, you'll want to make whoever is treating you aware of these symptoms. this is especially important if you're taking medication for depression. why? remember when i mentioned before that the presence of too much serotonin or other common neurotransmitters in the brain is a suspected cause of mania? well anti-depressants work by increasing the availability of those neurotransmitters to your brain. that's right. taking medication for being depressed can actually aggravate any tendencies you have towards mania. this is why i always advise people to insist on getting a psychiatric evaluation rather than just getting a prescription for anti-depressants from a family doctor. unless you're full-on manic at the time, a g.p. can easily miss signs that depression isn't your only problem.

in fact, i recommend that anyone who thinks that they exhibit problematic signs of mania get themselves checked out by a specialist. why? because people with mania are not the most reliable self-observers. after all, they always think that they're in control, never more so than when they're the most out of control. it can't hurt to let people know, right?

therapy can be important in managing mania and particularly in recognising cycles that lead to manic episodes. however, unless your manic episodes are fairly mild, chances are you're going to need drugs to control it. sorry.

so in part two, we'll look at what those drug options are.