Now That's Mania

For Mercy has a human heart

Pity, a human face:

And Love, the human form divine,

And Peace, the human dress.

William Blake

One advantage of workng inpatient psychiatry is that diagnoses present as closer to black or white, rather than as the infinite shades of gray encountered in outpatient practice. On an acute ward, to put it bluntly, the schizophrenics may be actively hallucinating and paranoid, the borderlines are flaming, and the melacholics are mired in despondency.

A floridly manic patient, pacing the halls 22 hours per day and talking non-stop, definitely shapes the ward milieu for better or worse, depending on whether the mania is irritable or euphoric. Like anyone who ever did much inpatient work, I recall any number of mornings when, even before turning my key in the lock, I saw or heard some ruckus through the unit door and instantly thought, "A manic came in last night." Mania is a force of nature; like a tornado, it is, when fully formed, unmistakeable.

But the last few years I have chosen outpatient settings, where diagnosis is endlessly slippery. Much has been written and protested recently about the alleged over-diagnosis of bipolar disorder, particularly in children, and presumably fueled at least in part by pharmaceutical advertising. I treat the 18 and over crowd only, but in coming years more and more young adults will obviously start coming in, trailing their dubious diagnoses behind them.

There are a few major clinical matters any psychiatrist wants not to screw up. Overlooking or minimizing suicidality is obviously a big one; missing bipolar disorder is another. The problem is that outpatients rarely present with unambiguous past diagnoses or crystal clear symptom reports. A chief obstacle is that several of the possible symptoms of mania are so common as to be, in psychiatry, what headache or heartburn is to primary care.

Consider the diagnostic criteria for bipolar disorder. Generally speaking, I don't know that I have ever evaluated someone with mood symptoms who, when asked, did not confirm "mood swings." Even those who clearly are recurrently depressed and not bipolar will report a subjective sense of mood instability (no one is equally depressed all the time).

So what constitutes a potentially manic mood swing? Unfortunately three of the possible symptoms--difficulty falling asleep, a sense of "racing thoughts," and distractibility (which could be experienced as poor concentration)--are ubiquitous in psychiatric work and can characterize depressive and anxious disorders as much as mania.

A hilarious aspect of a manic diagnosis is the duration component, described as more than a week or any duration if hospitalization is necessary. Herein lies the infamous circularity of psychiatric diagnosis, for in this instance a clinical treatment decision--to hospitalize someone--itself shapes the diagnosis.

Imagine that two people, each with a four-day history of obvious manic symptoms, come to the emergency room. They are clearly impaired and urgently in need of treatment, but they are not imminently dangerous to anyone and therefore do not warrant involuntary commitment. Patient A consents to voluntary admission and therefore "wins" the manic diagnosis; patient B refuses admssion and cannot technically be considered manic until three more days pass. In this case patient A, in granting, "Okay, I need to be in the hospital," is essentially and officially diagnosing himself with a manic episode. He needs to be in the hospital because he has a manic episode, but we know for sure that he has a manic episode only because he needs to be in the hospital.

What originally prompted this post was a fellow I saw a while back who, surprisingly and in a euthymic state, described what I consider a classic "outpatient mania." He was fiftyish and had no psychiatric history apart from a depressive episode of some kind a decade ago, in the context of specific marital and job issues. He had been hospitalized then but had pursued no outpatient treatment in the ensuing years. He functioned well and was asymptomatic.

In September he had the relatively acute onset of severe insomnia, but insomnia of a peculiar kind. He claims that over a ten day period he may have slept only four hours in all. Tired of lying in bed in vain, he got in the habit of getting up and working around the house all night.

He began to feel very productive at work, outperforming men who were decades younger. People started mentioning that he seemed to be talking a lot and was not himself. Finally he lost his job because his boss observed that he was plainly high on something, although crucially this patient had no substance abuse history (the latter frequently both complicates undisputed cases of bipolar disorder and muddies the diagnosis at other times).

This went on for three months, until at a certain point he developed the notion that the world was coming to an end in some Rapture-like event. He was variously wandering in roadways and speeding around in his car until he came to the attention of the police somehow, after which he was jailed briefly because of old issues pertaining to a failure to appear in court. By the time he saw me he was back to himself.

Obviously bipolar disorder is an immensely complex issue and beyond the scope of a post, a blog, or a book. It increasingly seems that like the vast and amorphous phenomenon of depression, bipolar disorder probably comprises multiple distinct disorders that we cannot yet sufficiently discriminate, and these are mediated by both biological and cultural pathways that are very difficult to fathom. It will be interesting to see how bipolar disorder looks in DSM-V.

There are a few moves in psychiatry that at times are absolutely essential, and yet that should be undertaken only when one is unequivocally sure. I would include among these: hospitalizing someone, particularly if involuntarily; recommending ECT; diagnosing schizophrenia; and diagnosing borderline personality disorder. Diagnosing bipolar disorder belongs with these as well.

For the many ambiguous cases one doesn't know after the first appointment, or after the third or perhaps even the fifth. One gets to know the person, and tries a few things to see what happens. At some point a provisional diagnosis inevitably, if implicitly, takes shape. Let's see, my motto should be: pragmatism, empiricism, contingency...