x Abu Dhabi, UAEFriday 19 January 2018

Mania's many new names are far from crazy: they'll help

Describe someone as a maniac or even as manic and the image of an erratic, wide-eyed, perhaps dangerous, individual comes to mind. Mania, however, has long been misunderstood.

Describe someone as a maniac or even as manic and the image of an erratic, wide-eyed, perhaps dangerous, individual comes to mind. Mania, however, has long been misunderstood. Mania is best considered on a continuum where many common mood fluctuations swing out of balance. The word mania comes to us from ancient Greek but its etymology is almost as muddled as its physiological origin. The Roman physician Caelius Aurelianus suggested that the word may have been derived from ania, meaning to produce great mental anguish. But he conceded that it could also have been taken from manos, meaning loose, suggesting that the illness was first defined by an apparent excess of relaxation in the mind or soul.

Arataeus of Cappadocia, a medical philosopher who spent most of his life in first century Alexandria, was the first to note the link between mania and depression, describing the condition as a form of sadness (melancholia) that transforms into excessive happiness. It wasn't until nearly two millennia later, with the birth of biomedical psychiatry and the categorisation of mental illnesses, that scientists began to advance an understanding of mania's different sides. The German psychiatrist Emil Kraepelin first described manisch-depressives irresein (manic-depressive insanity), which has survived in medical nomenclature as manic depression.

The American Psychiatric Association's latest diagnostic manual suggests several symptoms as characteristic of mania: inflated self-esteem, decreased need for sleep, more talkative than usual, increase in goal-directed activity, and my favourite, "excessive involvement in pleasurable activities that have a high potential for painful consequences". These symptoms must occur in the context of an abnormally elevated or irritable mood, and should be associated with significant impairments to social and/or occupational functioning.

Some people reading that list of symptoms may suspect they have had a manic episode, or at least a mild hypomanic one. That is the problem with categorical systems and with psychology in particular: reality is far from black and white. Manic symptoms, just like depressive symptoms, exist on a spectrum. Where different people and different cultures draw the line between disordered behaviours and normal behaviours varies considerably.

The identification of what is now called bipolar type II disorder illustrates this point. This is a form of bipolar disorder without full blown manic episodes. Instead, the sufferer experiences major depressive episodes and will also have experienced at least one hypomanic episode, characterised by an elevated mood, grandiose thinking, and rapid speech, among other symptoms. But Hagop Akiskal, a professor of psychiatry and director of the International Mood Centre based in San Diego argues that two categories of bipolar disorders aren't enough: there is a wider spectrum. This isn't just a matter for doctors to debate about at conventions - it affects how patients are be treated.

Dr Akiscal documented his clinical observation that occasionally when depression is treated with antidepressant medication it gives rise to an episode of hypomania. These individuals are also more likely to develop spontaneous episodes of mania or hypomania. He calls this Bipolar III. But he doesn't stop there. A person that is pretty much always hyper but who experiences a depressive episode is included in Bipolar IV. There is also depression with concurrent migraine, depression in the context of a familial history of mania, depression that responds to anti-manic medication, and something initially daubed "irritable hostile depression", which is pretty much it sounds like.

A categorisation of mania from "a little giddy due to lack-of-sleep" to "florid manic episode" may sound absurd, but it does help us to appreciate the everyday psychological mechanisms involved in mania. The authors Kay Jamison and Frederick Goodwin described it best: depression and mania are "magnifications of common human experience". A greater understanding of this will break down the stigma of confronting psychological problems and will also facilitate progress towards more effective therapies and interventions.

Justin Thomas is a psychologist in the department of health sciences at Zayed University in Abu Dhabi