Treatment of Hypomania

1. Introduction

Hypomania is a milder form of mania, during which the person feels extremely happy, more energetic and powerful than usual, and more productive. The symptoms can be noticed by patients and their relatives, but they may not be as life disrupting as they are in mania. People are mostly happy during this period and may not be able to foresee risky situations and may stop using their medications.

In some cases, hypomania diagnosis can be missed. There are clinical difficulties in the diagnosis and evaluation of hypomania. Therefore, as studies on the diagnosis and treatment of hypomania increase, this period will be better understood. In this chapter of the book, it was aimed to evaluate the diagnosis and differential diagnosis of hypomania and to discuss the pharmacological and non-pharmacological treatment approaches in the treatment of hypomania in line with the current literature.

2. Method

While this chapter of the book was written, PubMed and Google academic databases were scanned, studies on the diagnostic evaluation and treatment approaches of hypomania, and treatment guidelines were reviewed, a large number of studies were scanned within this context, and the chapter was prepared by citing 14 studies.

The inclusion criteria for this chapter of the book were as follows: being treatment guidelines, being books with an important place in the literature, being publications with a higher number of citations, and being publications that will add new and interesting information to the literature on the subject. Case reports and publications with a relatively lower level of evidence were not included in this chapter of the book.

3. Hypomania diagnoses and differential diagnoses

According to the ICD-10, hypomania corresponds to mild mania and does not include a duration criterion. According to the DSM-5, hypomania is defined as a period of elevated mood that requires at least four days. The distinction between mania and hypomania is one of the most controversial points of classification systems. DSM makes this distinction in terms of severity and duration. Hypomania is defined as a clinical picture that lasts at least 4 days, does not require hospitalization, does not have a traumatic effect on the person’s life, and does not have psychotic symptoms; however, the change in mood and functional level is noticed by others. Reliability and therefore validity of hypomania diagnosis is low, in terms of both its duration and its difference from ordinary mood swings or mild mania. ICD-10, which distinguishes mania from hypomania as a difference in severity, is more understandable in this respect. [1]

According to DSM-5, the diagnostic criteria for hypomania are as follows:

• It is an elevated, grandiose, or irritable mood that is markedly different from usual mood and lasts at least 4 days

• Presence of at least three (or four if mood is irritable) of the following symptoms during the mood episode:

  • Increased self-esteem, grandiosity

  • Decreased need for sleep

  • Being overly talkative, pressured speech

  • Flight of ideas

  • Distraction

  • Psychomotor agitation, increased goal-directed activities

  • Participating in pleasurable activities whose probability of producing negative consequences is high

  • It is not due to the effects of a substance or general medical condition.

There is continuing interest in cases on the spectrum with less severe mood elevations as an extension of the bipolar diagnosis.

Bipolar disorder not otherwise specified (NOS), a DSM-IV diagnosis, includes any of the following: (1) recurrent subthreshold hypomania in the presence of intercurrent major depression, (2) recurrent hypomania (at least two episodes) in the absence of recurrent major depression, and the presence or absence of subthreshold major depression, and (3) recurrent subthreshold hypomania in the absence of intercurrent major depression, and in the presence or absence of subthreshold major depression.

The number of symptoms essential to diagnose subthreshold hypomania is two of the B symptoms (three required for DSM-IV, or four if mood is irritable). DSM-5 changed the diagnosis of ‘bipolar NOS’ to ‘other specified bipolar and related disorder’; however, this still covers the same group of disorders. The lifetime incidence of these disorders in the population is 2.4% [2].

On the other hand, Akiskal classified bipolar disorder as follows and specified hypomania in more than one group.

• BP-1/2 SchizoBP

• BP-I Mania

• BP-I1/2 Prolonged hypomanic depression

• BP-II Spontaneous hypomanic depression

• BP-II1/2 Cyclothymic depressions

• BP-III Hypomania with AD

• BP-III1/2 Masked BP with stimulant use

• BP-IV Hyperthymic depression [3].

Hypomania screening assessment is performed using the Hypomania Checklist-32 Renewed Version (HCL-32-R).

Hypomania Checklist −32 Renewed Version (HCL-32-R):

• It is a self-report scale.

• Its first two items are rated on a Likert-type scale.

• It measures general mood and energy/activity level.

• Its third item consists of 32 statements answered as yes/no.

• Its cut-off score is 14 (70% specificity-sensitivity was determined).

• It contains different dimensions.

• It assesses exuberance/increased energy.

• It assesses risky behaviors/impulsivity [4].

4. Treatment of hypomania

Bipolar II disorder is a group of bipolar disorders in which major depression and hypomania episodes are observed. Hypomania is treated by providing treatment during the episode and preventive treatment to prevent hypomania from occurring. Pharmacotherapy of hypomania is presented in Table 1.

5. The role of psychotherapy

The number of studies conducted on the effectiveness of psychotherapy for bipolar II disorder is rather limited, and the number of studies directly measuring the effects of these treatments on hypomania is even fewer. In psychotherapies, attention is paid to mood cycles and recognition of these cycles, traumas associated with the illness can be targeted, and the psychosocial outcomes of the illness can be improved. It is unlikely to observe the monotherapy effect of psychotherapy in studies because patients receive psychotherapy as an adjunctive therapy while they use psychiatric medications. Among psychotherapy methods whose effectiveness has been proven are cognitive therapy, cognitive–behavioral therapy, psychoeducation, family-focused therapy, case management, and interpersonal social rhythm therapy [7]. These methods are presented in Table 2.

6. Role of interpersonal and social rhythm therapy

Preliminary evidence for the effectiveness of interpersonal and social rhythm therapy (IPSRT) in bipolar II disorder has been demonstrated [8]. IPSRT is the only psychotherapy which indicates that it is possible to treat individuals with bipolar II disorder with psychotherapy alone [9]. IPSRT is based on an instability model that identifies three interconnected pathways leading to relapse. These pathways are stressful life events, medication non-compliance, and social rhythm disruption. In addition, in this therapy, theories about the role of social and environmental cues in maintaining circadian rhythm integrity are gaining importance. In this theory, social cues that form the routine disrupt the sleep–wake cycle, which can lead to disruptions in mood such as hypomania, depression, etc. IPSRT comprises three main sections: psychoeducation, social rhythm therapy, and interpersonal relationships.

Therapists particularly draw attention to the history of rhythm disturbances, especially sleep disturbances, preceding the attacks.

It is often rather difficult to persuade individuals with bipolar II disorder to make significant changes in their daily routine such as going to bed at the same time every day, because initially, there is little apparent reason to make these changes. Effects of these changes in preventing hypomania are uncertain, because patients may perceive hypomania as a relief from depression and may not welcome this treatment proposal because hypomania is not accompanied by the negative consequences associated with mania. Individuals with bipolar II may have less insight into their symptoms than do those with bipolar I, and they may not recognize the symptoms of hypomania [10]. In order to encourage rhythm regulation, it should be emphasized that a period of depression may be followed by a period of hypomania and that the goal of this therapy is to improve general mood stability. Patients should be asked to reconsider that benign nature of hypomania, which is not as destructive as some patients think, and to view it as a kind of ‘experiment’ to see whether it is beneficial to general mood, energy, and motivation. If patients can observe the change in their mood when they fail to maintain a regular schedule, they may be more successful in maintaining rhythm stability.

Because of the subtlety of hypomania and the complexity of the mixed states, it may be difficult to assess the mood of individuals with bipolar II disorder accurately. Therefore, therapeutic gains may also be difficult. Assessing energy change rather than mood may be easier in following these patients [11].

Patients are taught to adjust the level of stimulation in their lives according to their mood, to increase stimulation when their mood is low and to decrease stimulation when they are vulnerable to hypomania. Some patients will paradoxically create chaos in their lives when they feel better, because euthymic mood is often experienced as ‘flat’. Hypomanic mood may motivate these individuals to make choices that further elevate their mood without being aware that their choices have the potential to lead to interpersonal chaos or more serious mood changes. Therefore, therapists should teach their patients to recognize the negative aspects of participating in stimulating activities and to identify appropriate activities that regulate stimulation.

Grandiosity and entitlement levels of individuals with bipolar II disorder may be high [12]. Although grandiosity is a symptom of hypomania, the individual may have high levels of grandiosity at baseline, regardless of mood. Most patients are open to having these behaviors pointed out by a supportive therapist with whom they have a close therapeutic relationship. Therapists are likely to be faced with maladaptive interpersonal patterns while they establish a therapeutic relationship; thus, they must know how to recognize, tolerate, and manage these difficulties.

Individuals with mixed moods display high levels of emotional reactivity, which can lead to difficulty downregulating arousal levels even when they are not in an acute mood episode. Therefore, therapists may benefit from other helpful strategies such as breathing exercises, distraction, and self-soothing to reduce the rapid shifting of emotions.

Patients should be asked if they use legal and illegal drugs and alcohol and should be informed about the effects of these substances on mood. Among these substances, most common ones are alcohol, prescription drugs, street drugs, nicotine, and caffeine. Caffeine can increase energy in people who are generally low in energy, so caution should be taken as it can cause hypomanic symptoms.

IPSRT can be used in combination with medication used in bipolar II disorder and may be useful in preventing hypomania and other episodes. It is also clear that more experience with psychotherapy is required [13].

7. Cognitive interventions in hypomanic episode

During a hypomanic episode, the person may have unrealistic positive beliefs such as ‘I am better than everyone else,’ ‘I can do whatever I want,’ or ‘I will be strong and energetic from now on’ about themselves, the world, and the future. In addition, he or she may have such beliefs that the illness can pass by his or her own will or that there is no need for medication. It is attempted to regulate cognition by targeting beliefs and cognitive distortions related to this.

8. Behavioral interventions in hypomanic episode

Activity programming can also be effectively achieved during the hypomanic period. Behavioral patterns in this period differ from those in the depressive period. It may be beneficial to reduce the activities that are rewarding for the person in hypomania. The following behavioral suggestions are also useful:

• Increasing the amount of sleep: A decrease in the amount of sleep is a symptom of hypomania and affects the elevation in mood. The aim is to ensure that the person sleeps more than they think is sufficient, close to the amount of sleep they have in the euthymic period. Activities such as going out at night and participating in night entertainment that delay going to sleep should be restricted in the program.

• Tightening money management: Monthly and weekly budget arrangements can be made in cooperation with the patient. Taking measures to limit the person’s access to financial sources may be useful. Limiting shopping expenses above a certain limit may be useful. Restrictive measures can be taken on bank accounts. For the effectiveness of these periods, communication with the patient should be continued during the hypomanic period. Interventions should be repeated in each attack.

• Slowing down the making of important decisions: It is recommended that the patient should make decisions likely to create major material and spiritual changes in his or her life only after two consecutive nights of adequate sleep. It is also recommended that decisions should be made after at least two reliable people are counseled before any decision is made. When this approach is explained to the patient, the decision-making mechanism of large companies or the referee system in scientific research can be given as examples.

• Reducing impulsive behaviors: A person in an elevated mood is advised to think for five seconds before he or she takes an action while arguing or joking with others and to visualize two different outcomes of this action. For example, in response to a dirty joke, they are asked to imagine the other person smiling or distressed.

• Stimulus regulation: The aim is to avoid stimuli that may be associated with elevated mood or dysphoria in the person’s activity program. These stimuli may be specific places, people, or conditions or may be related to a specific friend, or they may be focused on a specific area such as writing an article, or physiological states such as hunger or fatigue [14].

9. Conclusion

In the present study, it was aimed to ensure the correct recognition of hypomania, which is a mood episode that is often overlooked by researchers and clinicians, and to present pharmacological and nonpharmacological treatment approaches. It is thought that this chapter is important because it is expected to provide guidance to future studies in the field of hypomania.