Subthreshold (Hypo)Mania As A Precursor To Bipolar Disorder

The new Bipolar Spectrum.

“There is growing clinical and epidemiologic evidence that major mood disorders form a spectrum from major depressive disorder to pure mania.”

Subthreshold mania can be seen as a precursor to Bipolar Disorder, subthreshold Bipolar Disorder is defined as “recurrent hypomania without a major depressive episode or with fewer symptoms than required for threshold hypomania” (Merikangas et al, 2007). Bipolar disorder should be suspected if prominent behavior problems, anxiety, and substance abuse were present during childhood in someone with recurrent depression and a family history of affective disorders. For example, the prevalence of anxiety in children may be prominent in early-onset Bipolar Disorder and may predate affective symptoms. Children with a parent with Bipolar Disorder are more likely to be at risk for early-onset Bipolar Disorder, along with anxiety, depression and other disorders.

Studies have shown that offspring of people with Bipolar Disorder are at high risk for developing Bipolar Disorder because they have a parent with the disorder and generally have significantly higher rates of subthreshold mania or hypomania (13.3% versus 1.2%) or what is known as bipolar disorder not otherwise specified (BP-NOS); manic, mixed, or hypomanic episodes (9.2% versus 0.8%); major depressive episodes (32.0% versus 14.9%); and anxiety disorders (39.9% versus 21.8%) than offspring of parents without the disorder. Subthreshold episodes of mania or hypomania (those that resemble but do not meet the full requirements for bipolar disorder in terms of duration) were the best predictor of later manic episodes.

It should be noted that the American Journal of Psychiatry has a multitude of studies that suggest that people who suffer from Major Depressive Disorder (MDD) have a higher susceptibility to Bipolar Disorder and that subthreshold hypomanic symptoms that are found in people suffering from MDD should be taken into consideration when diagnosing. Placing these people instead on a bipolar spectrum, hence altering their treatment plan by incorporating a mood stabiliser which can also assist with the present MDD.

 

 

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The ‘Poster Patient’ of Bipolar Disorder.

When you’re considered the ‘poster patient’ of Bipolar disorder…

I see all my doctors at regular intervals and I take medication daily. That’s the simple side of things, the easy routine and foundations that you are required to build. Depression and hypomania have accompanied me at different interludes, always waiting backstage for the next show to begin. I see myself as so dysfunctional. So haphazard and incapable of maintaining all the demons in check. I’m writing this post because I see myself as all those things, maintaining complete control of my emotions and rhythm is beyond my control, yet my psychologist insists that I’m a ‘poster patient’ for Bipolar Disorder, my ability to be functional when everything has turned on its head. I was so confused when she originally said this. I know my dysfunction, mismanagement and self-sabotage run deep, hence my confusion to the compliment. She referred to how she used me as an example to other patients about what can be achieved. The facts that she presented were right: I have completed a university degree and I am half way through another, I do have a full time job (I work full time as a secondary teacher), exercise, eat regularly and maintain some semblance of social interactions with friends. It hadn’t hit me that this is what is considered to make me less dysfunctional. My moods don’t generally have repercussions on my life, they are damn high mountains to climb over in order to find solace again, but the hike and lightheadedness of the ‘mood mountain’ doesn’t necessarily interfere with my outer world.

I don’t see these facts as things which make me more managed. I am dysfunctional. My ability to manage my life doesn’t make me any less so. As my depression deepened a few weeks ago, I started to have regular suicidal ideations again. Obviously the recognition that the severity of my depression was getting worse, I acted. I wanted to flip the switch. Anything had to be better than those tendencies, those ideations. I have done a lot of research into the vitamin 5-HTP, simply put it can potentially alter the levels of serotonin in your brain which can result in a hypomanic episode. High is much better than being low. Until you’re high….

Then it’s hell, again.

Without going into specific details of my episode, 5-HTP worked by flipping the switch. The worst part about flipping the switch is when you remember how horrible it is to actually be hypomanic at times. My memory had conveniently let myself forget. My mind has the useful ability to allow me to forget how bad things have been at both ends of my imaginary scale, the thermostat of my mind. It’s a protection mechanism, allowing me to move on and forget the consequences of all my subsequent moods. I took 5-HTP for three days before stopping when my head started to *whoosh*. I find everyone’s interpretation of ‘racing thoughts’ to be different, but then again, each episode I have had resulted in ‘racing thoughts’ which were different from previous occurrences. I see these in the following categories: Actual racing thoughts, when you have too many ideas at once – excitement usually accompanies this variation. Then there is the static or *white noise* head background pressure ‘racing thoughts’ which is usually accompanied by irritation and finally there is *whooshing*, when there isn’t an exact thought but your mind is just doing the simple cycle of the washing machine with your ears blocked, accompanied by a bit of depersonalization. It sounds absolutely nuts. Which it is.

I was never meant to be this broken, popping pills, waiting for the next mountain to climb.

At least I know that I can climb and conquer.

The Morning After I Killed Myself, I Woke Up.

*Thought this was a pretty epic story by Meggie Royer – for anyone who has thought about the day after it’s all over. 

I made myself breakfast in bed. I added salt and pepper to my eggs and used my toast for a cheese and bacon sandwich. I squeezed a grapefruit into a juice glass. I scraped the ashes from the frying pan and rinsed the butter off the counter. I washed the dishes and folded the towels.

The morning after I killed myself, I fell in love. Not with the boy down the street or the middle school principal. Not with the everyday jogger or the grocer who always left the avocados out of the bag. I fell in love with my mother and the way she sat on the floor of my room holding each rock from my collection in her palms until they grew dark with sweat. I fell in love with my father down at the river as he placed my note into a bottle and sent it into the current. With my brother who once believed in unicorns but who now sat in his desk at school trying desperately to believe I still existed.

The morning after I killed myself, I walked the dog. I watched the way her tail twitched when a bird flew by or how her pace quickened at the sight of a cat. I saw the empty space in her eyes when she reached a stick and turned around to greet me so we could play catch but saw nothing but sky in my place. I stood by as strangers stroked her muzzle and she wilted beneath their touch like she did once for mine.

The morning after I killed myself, I went back to the neighbors’ yard where I left my footprints in concrete as a two year old and examined how they were already fading. I picked a few daylilies and pulled a few weeds and watched the elderly woman through her window as she read the paper with the news of my death. I saw her husband spit tobacco into the kitchen sink and bring her her daily medication.

The morning after I killed myself, I watched the sun come up. Each orange tree opened like a hand and the kid down the street pointed out a single red cloud to his mother.

The morning after I killed myself, I went back to that body in the morgue and tried to talk some sense into her. I told her about the avocados and the stepping stones, the river and her parents. I told her about the sunsets and the dog and the beach.

The morning after I killed myself, I tried to unkill myself, but couldn’t finish what I started.
By Meggie Royer