Research report‘Bright side’ and ‘dark side’ hypomania are associated with differences in psychological functioning, sleep and physical activity in a non-clinical sample of young adults
Introduction
There is a growing interest in research into hypomanic states because there is a reason to suspect that hypomanic and bipolar disorders may be underdiagnosed (Angst et al., 2010). In fact, the emerging data from several epidemiologic and clinical studies suggest that bipolar disorders, including hypomania, may in fact be as common as unipolar disorders (Akiskal et al., 2000). This holds both for clinical and non-clinical samples, and for adolescent and adult samples (see below).
The core features of hypomanic stages are: 1) overactivity (DSM-V: American Psychiatric Association, 2009, Benazzi, 2007, Gamma et al., 2008); 2) reduced sleep (DSM-V: APA, 2009; ICD-10: WHO, 2007), and 3) elevated, expansive or irritated mood (DSM-V; APA, 2009; ICD-10: WHO, 2007).
However, besides, Hantouche et al. (2003) first described that hypomania could be subdivided into so-called “sunny” and “dark” sides of hypomania: Whereas the sunny side of hypomania was related to the socially positive and advantageous facet, the dark side was associated with socially negative aspects. Specifically, the dark side of hypomania was linked with a cyclothymic temperament. Moreover, when hypomania and cyclothymia interacted together, the clinical picture of the patients suffering from unipolar and bipolar disorders (N = 427) was more complex, severe and recurrent. Thereafter, the publication of Hantouche et al. (2003) has stimulated a wealth of studies in which the subdivision between the so-called sunny and dark sides of hypomania has been further investigated in both clinical and non-clinical samples (see below).
Recent studies of clinical and non-clinical samples (Brand et al., 2007, Brand et al., 2010a, Brand et al., 2010b, Brand et al., 2010c, Brand et al., 2010d, Dilsaver et al., 2005, Holtmann et al., 2009, Kowatch et al., 2005, Pavuluri et al., 2005) suggest that bipolar II disorders (BP-II) may also be common among children and adolescents. Raman et al. (2007) reported that of 61 outpatients aged about 13.5 years and suffering from major depressive disorders, 12 (20%) were misdiagnosed as having a unipolar disorder. Regarding adolescents, Holtmann et al. (2009) investigated a sample of 294 non-clinical adolescents (mean age: 17.3 years; SD = 1.1) using the Hypomania Check List 32 (HCL-32; Angst et al., 2005). The authors observed hypomania in about 11.2% of the participants and distinguished between those who were ‘active-elated’ and those who were ‘disinhibited/stimulation-seeking’ and ‘irritable–erratic’. Importantly, whereas ‘active-elated’ (or ‘bright side’) hypomania was negatively associated with peer problems, ‘disinhibited/stimulation-seeking’ and ‘irritable–erratic’ (or ‘dark side’) hypomania was positively associated with conduct problems, hyperactivity–inattention and peer problems. In sum, both favorable and unfavorable hypomania features could be detected, each having a distinct association with favorable and unfavorable behaviors. Last, in a non-clinical sample of 103 adolescents (mean age: 17.9 years), higher total HCL-32 scores were related to current early-stage intense romantic love (Brand et al., 2007), to female gender, and to issues related to developmental tasks such as exploring and learning psychosocial and psychosexual behaviors (Brand et al., 2010a, Brand et al., 2010b, Brand et al., 2010c, Brand et al., 2010d).
Among adults, hypomania and bipolar II disorders (BP II) have been observed in both clinical (cf. Angst et al., 2005, Angst et al., 2010, Meyer et al., in press) and non-clinical samples (Angst et al., 2003, Gamma et al., 2008, Meyer et al., 2007). With respect to non-clinical samples, Gamma et al. (2008) showed that about 13% of the cohort (mean age: 40 years) presented a very mild expression of bipolarity between a bipolar disorder and normality. Compared to controls, these ‘pure’ hypomanics did not substantially differ with respect to quality of life or distress, though they earned more money and were more likely to be married. These observations were interpreted both as being related to hypomanic features and as favorable expressions of increased efforts with respect to vocational and social issues.
Meyer et al. (2007) investigated two different non-clinical samples. The first sample consisted of 695 German adults (mean age: 29.22 years; range: 17–67 years; predominantly academic staff members), the second sample consisted of 408 Swedish adults (mean age: 55.50 years; range: 35–65 years). Both samples completed the HCL-32. Results showed that, even with these non-clinical samples, the HCL-32 items could be divided between two distinct factors, the first describing ‘active/elated’ and the second ‘irritable/risk-taking’ hypomania. The two-factor solution was identical to that based on data from clinical samples.
To summarize, 1) there is evidence that hypomania is common both in the clinical and non-clinical population of children, adolescents, and adults; 2) the HCL-32 has proved to be an easily and readily applied self-report tool for assessing hypomania; 3) based on the seminal work of Hantouche et al. (2003), international and cross-cultural comparisons of the HCL-32 scores have revealed a robust two factor solution, distinguishing between ‘active/elated’ (‘bright side’) and ‘irritable/risk-taking (‘dark side’) hypomania (cf. Angst et al., 2010).
However, surprisingly, little is known about the relations between hypomanic states, psychological functioning, sleep, and physical activity in the non-clinical population of young adults. Nonetheless, we hold that, at least for four reasons, trying to fill this gap in knowledge may be important. First, early adulthood is a period of transition between adolescence and more stable periods of adulthood; this period of transition may be particularly critical for longer lasting decisions related to peer interaction, romantic relationships, family planning, vocational career and life style choices. As a result, some decisions may be accompanied by increased emotional turmoil and mood changes (cf. Arnett, 2007, Arnett et al., in press). Second, findings from research focusing on cerebral development suggest that complete myelinization comes to its end at the age of about 24 years (cf. Giedd et al., 1999, Higgins and George, 2007). Thus, from the point of view of cerebral development, adolescence seems to reach its end during early adulthood. Third, following Steinberg (1996), late adolescence may last until the age of 21 and to early adulthood, although, in most European countries, 18 year-olds have full adult rights and from the view-point of criminal law are fully responsible for their behavior. Fourth, it is conceivable that general practitioners and counselors have to deal with young adults' issues related to hypomanic states and mood changes. Against this background, the present study may shed more light on the topic of hypomania and mood change during early adulthood within the non-clinical population of young adults.
Five hypotheses were formulated. First, following Gamma et al., 2008, Brand et al., 2007, we expected better psychological functioning1 among participants reporting ‘active/elated’ hypomania, compared to those reporting ‘irritable/risk-taking’ hypomania or no hypomania. Second, and complementary to the first hypothesis, we anticipated poorer psychological functioning among participants reporting ‘irritable/risk-taking’ hypomania, compared to those reporting ‘active/elated’ hypomania or no hypomania. Third, as reduced sleep is a further core symptom of hypomania, and as sleep difficulties are related to poor psychological functioning (Baglioni et al., 2010) we anticipated greater sleep difficulties in participants reporting ‘irritable/risk-taking’ hypomania, relative to participants reporting ‘active/elated’ hypomania, or no hypomania. Fourth, following the DSM-V (APA, 2009) and prior research (e.g., Gamma et al., 2008, Benazzi, 2007), following which overactivity is a stem criterion of hypomania, we anticipated that greater physical activity would be apparent among participants reporting hypomania, compared to those reporting no hypomania, and specifically, we expected an increased activity among participants reporting ‘irritable/risk-taking’ hypomania, compared to those reporting ‘active/elated’ hypomania. Fifth, we expected that participants reporting ‘irritable/risk-taking’ hypomania would also report mood, which is more negative than usual, compared to those reporting ‘active/elated’ hypomania or no hypomania.
Section snippets
Sample
The participants were 862 students (M = 24.67, SD = 5.91 years) from the German speaking North-Western part of Switzerland (223 men: M = 24.48, SD = 4.78 years; 639 women: M = 24.74, SD = 6.26 years), who were recruited from the University of Basel (sport science: n = 250, psychology: n = 83, and medicine: n = 223) and from the North-Western University of Applied Sciences (psychology: n = 66, tourism: n = 17, pedagogy: n = 127, and gymnastics: n = 96). Participants were informed about the purpose of the study and the
Results
The comparison between the three groups (NHG, AE-HG, and RI-HG) revealed significant differences on various dimensions, as subsequently reported in more detail (see Table 3).
Discussion
The key findings of the present study are that, in a non-clinical sample of young adults, about 19% were in a self-reported current state of hypomania, and that among these, a considerable proportion (57.6%) were in a so-called active/elated state of hypomania. Compared to other participants, those reporting an active/elated state of hypomania also reported better psychological functioning and greater physical activity. By contrast and in general, participants reporting a risk-taking/irritable
Limitations
Several limitations warrant against overgeneralization of the findings. First, participants were exclusively recruited from universities, and consequently the sample is not representative of young adults or adults as a whole. However, with regard to psychological functioning, there is evidence that students are as much at risk for developing psychiatric symptoms as are other populations (Bayram and Bilgel, 2008, Wilding, 2004). Second, results were exclusively gathered from self-reports; thus,
Conclusion
A distinction between ‘bright side’ and ‘dark side’ hypomania would seem justified given that, in a non-clinical sample of young adults, the general pattern of the results indicates that ‘bright side’ hypomania is associated with positive psychological functioning and physical activity, whereas ‘dark side’ hypomania is associated with negative psychological functioning and poor sleep.
Role of funding source
The study was financially supported by the Basel Scientific Society (Freiwillige Akademische Gesellschaft (FAG) Basel, Switzerland (SB)). The FAG had no influence on data collection, data entry, data analyses, the interpretation of the data or the writing or the submission of the manuscript, or on the journal chosen for possible publication.
Conflict of interest
All authors declare that they have no competing interests.
Acknowledgements
We thank Klara Spalek, Daniela Beutler, Mirjam Jenny, David Fasler, Patrick Winiger for data entry, and Tobias Krieger MSc, for data entry and data management. Moreover, we thank Nick Emler (Surrey, UK) for proofreading the manuscript.
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