Research report
Are hypomanics the happier normals?

https://doi.org/10.1016/j.jad.2008.02.020Get rights and content

Abstract

Background

Not much is known about hypomanic states in subjects free of major and minor depressive mood disorders. Our aim was to identify and characterise a group of such “pure” hypomanics in relation to a normal control group.

Methods

Data were obtained from the Swiss Zurich study, a stratified epidemiological sample of young adults from the general population, followed from age 20 to 40. “Pure” hypomania was defined as a period of increased activity and decreased need for sleep with consequences (e.g. legal trouble or reactions by others). Minor and major mood disorders were excluded.

Results

Twenty-three subjects were identified as pure hypomanics. They overlapped minimally with and were clearly different from subjects with DSM-IV defined hypomanic episodes, most of whom had a bipolar disorder. Pure hypomanics were characterised by physical and social overactivity, elevated and irritable mood, as well as increases in extraversion, sexual interest, and risk-taking behaviors. They had higher monthly incomes and were more often married than controls. Subjective distress due to hypomanic symptoms was virtually absent. Quality of life and treatment rates for mood and anxiety were not different from controls, although sleep disturbances, substance abuse and binge eating were more frequent.

Limitations

The subsample identified was small. Due to the focus of the study on pathology, some positive aspects of hypomania may have been missed.

Conclusions

The existence of a group of pure hypomanics presenting a mixed picture of clinically relevant and irrelevant characteristics supports the concept of a continuum from normal to pathological mood states.

Introduction

The German neuro-psychiatrist Mendel (1881) was the first to use the term “hypomania” to describe a state with the typical characteristics of mania, but in a less pronounced form. However, an operational definition was not available until 1972 (Feighner et al., 1972) and today the definition is still in a state of flux.

The diagnostic and statistical manual DSM did not include hypomanic episodes until 1987 (American Psychiatric Association, 1987). The DSM-IV definition of hypomanic episodes requires a minimum duration of 4 days without marked impairment, while requiring a one week minimum duration for manic episodes. There are strong doubts about the temporal criterion of four days which has never been validated. An international expert group proposed a duration of two days (Akiskal et al., 2000). There are also doubts about criterion A (elevated, expansive or irritated mood), because many hypomanic subjects who are episodically overactive may deny mood changes and nevertheless manifest a manic syndrome (Angst et al., 2003). Goodwin and Jamison (2007) write that “euphoria might be a less reliable indicator of hypomania than overactivity”. A number of studies support the view that overactivity is the core feature of hypomania (Akiskal et al., 2003, Angst et al., 2003, Benazzi, 2007).

Compared to mild depression, hypomania (without depression) is clearly under-investigated. One reason for this is that the positive aspects of hypomania may prevent many individuals from seeking treatment; some may fear that treatment could erode their creative spirit. As a consequence, hypomanic subjects show up rarely at the clinician's.

The idea that creativity is intimately linked to madness has been common both among antic and modern thinkers (Kraepelin, 1921). According to this view, many outstanding personalities owed their productivity and intellectual or artistic achievements to being melancholic, manic-depressive or hypomanic. Systematic study of this phenomenon has been rare, but has substantiated the existence of a connection between bipolar disorder and creativity (Andreasen, 1987, Jamison, 1993). In particular, the case for a link between hypomania and entrepreneurial productivity, creativity and success has recently been made by Gartner (2005).

In general, the beneficial aspects of manic states have been neglected in favor of their more salient disruptive effects. In the present investigation, our aim was a more balanced evaluation of hypomania in a representative community sample. However, we were not primarily interested in hypomanic states as part of a bipolar disorder, but in subjects with “pure” hypomania, i.e. without major or minor mood disorders. The questions that motivated us were: can such a group of “pure” hypomanics be identified? If so, do pure hypomanics have the best of both worlds — i.e. only the best parts of being “abnormal” and normal? Are they just more energetic, active and happy, but otherwise clinically unobtrusive? Or do the benefits of hypomania come at a significant cost?

Section snippets

Sample selection and design of the study

The Zurich Study is based on an initial screening sample of 4547 subjects (M = 2201; F = 2346) representative of the canton of Zurich in Switzerland in 1978 (population 1.1 million). All subjects were screened with the Symptom Checklist 90-R (SCL-90-R) (Derogatis, 1977), a comprehensive self-report questionnaire of 90 questions, which covers a broad range of psychiatric symptoms. At screening, male participants were aged 19 (at conscription), female participants were 20 (at enrolment in the

Validation of hypomania definition

Nineteen subjects fulfilled the DSM-IV criteria for a hypomanic episode. Twenty-three were pure hypomanics according to the present definition (symptom + consequences), and 45 subjects had hypomanic symptoms without consequences (Table 1). Of the 19 subjects with DSM-IV hypomania, 17 were bipolar: 12 were bipolar-II cases, while 5 were minor bipolar cases. Therefore, since our definition of pure hypomania excludes mood disorders, there is only minimal overlap between the DSM-IV hypomanic group

Discussion

This study identified a group of pure hypomanics, i.e. individuals who experience hypomanic symptoms with consequences but who hadn't had any major or minor mood disorder up to age 40/41. This group had an appreciable cumulative population incidence of about 4%, i.e. 1 out of 25 people.

Our findings indicate that pure hypomanics are not simply normals with an extra measure of energy, productivity and happiness. Although physical and social activity was elevated in the hypomanics of our study,

Conclusion

The mixed picture of normal and more pathological features presented by pure hypomania supports the notion of a continuum between normal and pathological states that can only artificially be carved up into distinct categories. Hypomanics are disposed to be more socially and mentally active, more productive and more risk-taking. These features may make them more likely to make artistic and/or intellectual contributions. They may not suffer too much from their symptoms, even from more undesirable

Role of funding source

This work was partly supported by Grant 3200-050881.97/1 of the Swiss National Science Foundation (SNSF). The SNSF had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of interest

Prof. Dr. Jules Angst and Prof. Dr. Wulf Rössler have served on the advisory boards for Eli Lilly & Company, Janssen Pharmaceutica and on the speakers' bureau for Eli Lilly & Company, GlaxoSmithKline, AstraZeneca, Lundbeck Foundation and Pfizer. The other authors declare that they have no conflicts of interest.

Acknowledgement

This work was partly supported by Grant 3200-050881.97/1 of the Swiss National Science Foundation (SNSF).

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