The DSM-5 and Me: Mania
I’ve combed through the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5criteria for Bipolar Disorder more times than I can count. My misunderstanding of the criteria is part of what stood between me and treatment for nearly 9 years.
I recently had a good friend mention to me that she feels as if she’s becoming hypomanic. I sent her the diagnostic criteria and we talked briefly about what those symptoms actually look like in real life. I realized that I’m not the only one who struggles to look at their own symptoms, in light of the criteria in the DSM-5.
My experience is simply my experience. And while I do have severe episodes at times, I was able to survive all those years without treatment. A big part of this has been the luxury I’m afforded by my husband’s well-paying job. I get to stay home. I can fall behind on the laundry because I’m busy applying for a Master’s program in a field I’ve never been interested in. I can stay in my pajamas on days when I can’t even splash my face with water.
There are many whose symptoms are far worse than my own. There are also many whose symptoms are less severe than my own.
So let’s take a look at the established symptoms, and talk about how those manifest in my own life.
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently goal-directed behavior or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
Elevated mood — I’m going to break this down a little bit. I didn’t really start to understand what an elevated or expansive mood was until I started to pay attention to my moods in spring. I’ve always said I’m a solar-powered person. I would spend the late months of winter just as bitter as the wind. Then thaw out under the nourishing rays of the sun.
Nothing looks more like an expansive or elevated mood for me than spring mornings when we have company coming. I feel elated. Euphoric. The sun is shining, and it might be shining just for me. Mother nature is glorious and the perfect provider. We are all her children. We should all be worshiping her as the divine provider.
There is nothing that could possibly cloud my mood.
Goal-Oriented — Now, goal orientation for me is a little more nuanced. Looking back, there are cycles to this. In the Spring, I’m more impulsive. I may decide we need to change phone companies and not think of anything else for at least a week. I tell myself I NEED to complete this to quiet the buzzing bees in my brain. They’ll shut the fuck up if I just get this one thing done. For some reason, driving appeases them briefly. So I drive whenever possible. Might as well drive an hour and a half away to buy that new SIM card, why wait 2 days for shipping?
The kids want to make puppets. Let’s drive an hour away to the dedicated craft store so I can sew some puppets when we could just go to the Walmart 20 minutes away and get the same supplies. I channel creativity and motivation, but in a chaotic way. Refusing these impulses usually leads to self-destructive behavior.
Fall me is far more focused in this regard. She might sit down and organize 6 months’ worth of biweekly budget plans. She might obsessively research homeschool curriculum, before spending several hundred dollars on new supplies. She likes to apply for grad school and… start writing on Medium.
Duration — Lasting at least a week feels simple enough. But the whole bit about lasting MOST of the day, ALMOST every day is so important but so easy to miss. I’ve had days where I think my episode is over because I’m not feeling fully symptomatic. But that doesn’t mean I’m in the clear. I may actually sleep well tonight but go back to not sleeping at all tomorrow. I may spend the day sunken between the couch cushions writing about the sins and brain-washing of the pharmaceutical industry (not how I really feel) just to drive 2 hours away for a dozen guinea fowl.
B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
Inflated self-esteem or grandiosity
That guy at the park? He wants me. His girlfriend? Wants me? My husband? Wants me so bad it hurts because I’m a literal fucking goddess who embodies the sun as a gift to humankind.
Master’s Degree while homeschooling two kids? I’m going to absolutely kill it. I don’t know how or when I’ll fit the work in, but everything I submit is going to be magnificent.
I’m going to write a full memoir in 3 days and it is going to change everyone’s life.
Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
This one has been bad for me lately. From March to June I was averaging 2–3 hours of sleep a night. Two weeks ago, I spent a week and a half alternating between 5–6 hours of sleep and no sleep at all.
Now, this is severe for me. And it might be for you. In the past, I would often be more on the 5 hours of sleep train. I think the key is that you have to be getting noticeably less sleep for you, and not really feel tired. It’s important to note that I yawn. My face and eyes sometimes feel puffy. But my brain and body don’t feel all that tired, and I couldn’t sleep if I wanted to.
Ambien, Trazadone, and Clonidine will often get me into that 6-hour category for a night, then not work the following night.
More talkative than usual or pressure to keep talking
This one really comes and goes for me. I usually feel myself do it. It sometimes presents as rambling, jumping from topic to topic, losing my train of thought. But, more often, it is a need to talk about many different things. A lot of short bursts of conversation, usually with too much detail.
Flight of ideas or subjective experience that thoughts are racing
This one, I didn’t recognize for a while. It does start as what feels like racing thoughts. But it morphs into something that I call static brain. Basically, my own brain is interrupting itself. I can’t finish a thought sentence if that makes sense. So instead of having useful and coherent thoughts, it’s just like the static on a radio.
Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
This one sort of lines up with my pressured speech. I can’t focus on what I’m saying, even though the words are tumbling out of my mouth to the degree that no one else can talk. Though, admittedly, I can mask that symptom a fair bit.
Anyways, I get drawn off onto different topics or provide an elaborate back story to a question… then forget where I was going. I usually need prompting.
The biggest sign though is that I can’t relax. I can’t watch tv. I can’t sit on the couch and enjoy a hot tea. I definitely can’t read.
Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
I’m reiterating this because it’s included under B but won’t say much since we did cover this in A as well. BUT. The inclusion of sexually goal-directed activity. Yeah.
Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
The biggest two for me are spending and drinking.
The spending is really specific to your own finances. I dug us into $6,000+ of debt in spring. We didn’t have that money but it didn’t totally bury us. At times in the past, this may have looked like $100 in supplies for a natural body care Etsy shop I wanted to start, despite never having made natural body care products. Or buying a $300 iPod. The whole grandiosity plays into this because I thought the Etsy shop would be the best natural body product to exist. Just me and this soap mold.
I might take the kids to the park, then swing by the liquor store for a 12 pack of drinks. I’ll drink at least two tonight as I cook dinner and the sun shines through the windows, speaking to me. The sun shines for me. I’ll get absolutely sloppy and overshare anytime we have visitors. I’ll continue to drink a few a night, and will often be tipsy before my husband gets home.
I don’t drink often outside of episodes, so this is a big red flag.
The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
This is another one that took me a while to get a grip on. I don’t work outside of the home, so occupational functioning didn’t get me in trouble. I would accumulate too many projects, and the acquisition of those projects would put me behind on housework. The kids would suffer because my obsessive focus on this or that would get in the way of anything beyond their basic needs being met.
There were no social issues (other than the oversharing), because my calm and quiet exterior are replaced by a charismatic and fun persona. At least, that’s my experience.
I have not needed hospitalization for mania. However, my husband and I both agree that we’d be less traumatized by my spring episode if I’d gone inpatient.
The episode is not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or another medical condition.
Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and therefore a bipolar I diagnosis.
I’ve never had this experience, simply because I got my Bipolar Disorder diagnosis at my first psychiatry visit. But, it’s worth noting here because a lot of people ARE diagnosed after a sting on antidepressants, and struggle to accept your diagnosis.
It bears repeating, if you discontinue the medication and the episode continues, it is a manic episode. And even if it doesn’t, that doesn’t mean you won’t have future episodes that aren’t triggered by medication.
So that’s the DSM-5 criteria for a manic episode. Early in my journey, reading those clinical descriptions left me a little bit lost. Okay, but what constitutes an elevated and expansive mood? When is it diagnosable? Things like that.
If you’re in the same place that I was, hopefully this helps. And if you have your own experiences with some or all of these criteria, please talk about it in the comments. Bonus points if you decide to write your own criteria story and drop the link in the comments. I love reading how these symptoms manifest for others. Including hypomania.