Hypomanic Mood States
Recognizing hypomania as a disordered mood state in bipolar II disorder is very important. However, in practice it can go below the radar causing the diagnosis of bipolar II disorder to be missed. One reason is that patients will remember their depressions very clearly as the pain of them is not easily forgotten. However, may hypomania wash over and doesn’t have the same exaggerated and dramatic intensity as mania. By definition if one gets hospitalized with a disturbed elevated mood state it must be mania.
Hypomania can lurk in the background for a long time even though those close to the patient know there is something wrong. In this sense hypomania is insidious and can wreak a lot of havoc in one’s life before the diagnosis is made. I can think of at least 3 examples from my career in which chronic hypomania lead to financial ruin or nearly so.
Joe is a 55-year-old gentleman who has had a successful career in business. He never got depressed but always had more energy than anybody else to the extent that others found him exhausting to be around. His wife Alice for many years believed there was something wrong with him but could never get him to see a doctor. He got into investing in stocks and overestimated his prowess. Over the period of 5 years Joe lost about one million dollars. When he finally recognized what had happened, he fell into a terrible depression which took about three years of treatment before he finally got better.
Another patient, Margaret, 70 years old, had a successful antique business. She had had hypomania and depressions over the years but never got any treatment. As can happen her hypomania worsened and she began to slip into mania. She went to a house clearing auction in which most items for sale were routine and had no antique value. In her disturbed state she started to bid competitively on every item bidding way above its true worth. It got so bad that that other attendees would bid against her just to see how high she would go. At the end of the auction she had spent about $100,000 with no recompense available. In this instance the hypomania was not recognized or treated and eventually it moved over to the more severe form of mania. In that scenario her judgment was quite impaired, as indicated above.
More typically hypomania is bubbling beneath the surface without being destructive. It may become apparent over time the highs are followed by depressions. I may also be the case that when the usual antidepressant medications are used to treat depression they are not very effective and the patient may just feel agitated or irritable. These are then clues for the patient and the psychiatrist that something other than major depression are going on and the possibility of bipolar disorder must be entertained.