Mania

Dysphoria: The Dark Side of Bipolar Mania

Irritability and agitation in mania are destructive but often misunderstood.

Posted Jan 18, 2021

Mania in bipolar disorder (or hypomania in Bipolar II Disorder) is typically characterized by an intense experience of euphoria. Euphoric mania is often accompanied by grandiosity, inflated self-esteem, hyperproductivity, and a range of behaviors that reflect the feeling of being on top of the world.

“Bulletproof” may be another apt description. People in the throes of euphoric mania often pursue risky activities, including over-spending, substance abuse, sexual indiscretions, or errant business pursuits. Driven by the intense energy and sense of invincibility, euphoric mania is not only potentially destructive to an individual with bipolar, but threatens the well-being of the person’s relationships and reputation after the episode. This becomes especially true as the evidence of manic exploits is revealed along with the possibility of a forthcoming episode of major depression.

Episodes of euphoric mania are perhaps the most obvious aspect of bipolar disorder, especially when the high level of perilous behavior swings a wrecking ball squarely into a person’s life. But what is often not so apparent is the lesser-known side of a destructive manic episode: Dysphoric mania.

Dysphoria in bipolar disorder is characterized by increased energy and activity, as seen in euphoria, but the mood is dominated by excessive and persistent irritability. Agitation and restlessness often accompany irritability, and several typical manic symptoms, including pressured speech, racing thoughts, decreased need for sleep, and distractibility are common. In dysphoric mania, excessive involvement in high-risk activities often reflects nihilistic motivations or aggressive behaviors that are largely outside the person’s usual character.

People with bipolar disorder can have periods of mania that are either all euphoric or all dysphoric, but many have manic episodes that are mixed. It is not uncommon for someone with bipolar to start in a euphoric state but to eventually become dysphoric as the episode persists. This may occur as the individual becomes increasingly exhausted, yet cannot contain the ongoing excessive energy that disrupts sleep, relaxation, and replenishment of internal resources.

It is also not unusual for a person once in an excited euphoric state to sense eventually that their fantastic ideas and amazing persona are not gaining the desired attention from others. When grandiosity, hyperproductivity, spending sprees, and, if the episode has reached psychotic levels, paranoid delusions, are met with resistance from the world around them, the person in a dysphoric mania may retort, yelling, “You don’t get it, do you? You just don’t understand!” In a sense, the grandiosity of the euphoric period gives way to a tragic sense of isolation or beleaguerment during dysphoria.

The important thing to bear in mind is that the shift between euphoria and dysphoria can occur within the same manic episode. And given that bipolar disorder has high co-occurrence with suicidality and substance use disorders, I believe it is critical to further understand the role of dysphoric mania in bipolar diagnosis and treatment.

People in the post-stabilization phase of treatment will often remark that the dysphoric aspects of their bipolar mania produced the most distressing and destructive consequences of the previously untreated disorder. Short-term memory is frequently compromised during mania, but from what people can reconstruct, they come to understand how dysphoric mania created a sort of Jekyll-and-Hyde presentation to others around them. While violence is not a common product of dysphoria, much of the shame experienced by people with bipolar, as they achieve stability and are capable of personal reflection, comes from damaging expressions of hostility made possible by dysphoric mania.

Like much of bipolar disorder, evidence of dysphoric mania can often go unidentified. As I have noted before, the average length of time between the first bipolar mood event and the application of treatment specific for bipolar disorder is about 10 years (Drancourt, et. al, 2012). Additionally, most people with bipolar disorder are misdiagnosed at some point, and the majority of those are incorrectly diagnosed with unipolar depression (Hirschfeld, Lewis, & Vornik, 2003). There are likely several reasons why bipolar disorder is frequently unidentified and misdiagnosed. I believe that misunderstanding dysphoric mania is one of the biggest factors. 

Here’s why: Fundamentally, what I describe as dysphoric mania includes severe irritability and psychomotor agitation during the manic episode. This can also be present in major depression, whether the depressive episode is a part of bipolar disorder or not (APA, 2013). If someone with bipolar disorder presents to a mental health provider, and is in a state of dysphoric mania or describes a recent episode of dysphoric mania, what often is more salient in the presentation or description is the irritability and agitation commonly associated with a major depressive episode. Without a comprehensive assessment of all additional bipolar symptoms, along with personal and family mental health histories, there may be no recognition of an existing bipolar disorder. Instead, a diagnosis of major depression may be provided, and a treatment plan formed around that single diagnosis.

What follows is a disturbing series of events that can exacerbate bipolar disorder and the sense of hopelessness that may follow years of poor treatment. Many of my bipolar patients have commented that their dysphoric mania was once confused for major depression, which resulted in the increased use of antidepressant medications. In people with bipolar, the use of antidepressants without any mood-stabilizing agents can catalyze or exacerbate a manic episode (Viktorin, et. al, 2014). If the mania is predominantly euphoric, it may be more easily recognized as bipolar, and thus, the diagnosis and treatment could be immediately switched. However, if the mania is dysphoric and becomes increasingly so, the misbegotten conclusion is that the patient has a major depressive episode that is treatment-resistant or simply getting worse.

As a result, many people in this condition are given more antidepressant medications along with psychotherapy activities centered around depression improvement and not bipolar mood stabilization. Predictably, their undetected bipolar disorder gets worse. Some have reported to me that while their pre-existing depressive episodes may improve with antidepressants, they often experience manic episodes that are more agitating and consequential than ever before. Not until the irritability and agitation are viewed in the context of dysphoric mania do people with bipolar disorder have the opportunity to receive proper care.

This problem extends to those who have been diagnosed with bipolar disorder, but for whom dysphoria is misidentified as part of bipolar depression instead of mania. In this case, mood-stabilizing medications that are more antidepressive than antimanic are prescribed, unwittingly defying the typical bipolar medication algorithm. Commonly, a person with bipolar disorder would first be prescribed either a single medication or multiple medications that are more antimanic if the current or most recent mood episode is manic (Crismon, Argo, Bendele, & Suppes, 2007). If the person with bipolar exhibits dysphoric mania that is misidentified as an agitated bipolar depression, the meds provided may not be effective in bringing the mood closer to a baseline level. Similar to what we see in misdiagnosed bipolar patients, those diagnosed with bipolar require a clear assessment of their complete manic symptom profile to receive the appropriate treatment for the best outcomes.

To reiterate, irritability and agitation in dysphoric mania by itself is similar to that of major depression. But the similarities end there. Just as with euphoric mania, dysphoric mania is accompanied by increased energy and other typical manic symptoms, such as pressured speech, decreased need for sleep, racing thoughts, increase in goal-directed activity, and excessive involvement in activities with high potential for painful consequences.

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author, 124-131.

Hirschfeld R. M., Lewis, L., & Vornik, L. A. (2003). Perceptions and impact of bipolar disorder: How far have we really come? Results of the National Depressive and Manic-Depressive Association 200 survey of individuals with bipolar disorder. Journal of Clinical Psychiatry, 64(2), 161–174.

Viktorin, A., Lichtenstein, P., Thase, M.E., Larsson, H., Lundholm, C., Magnusson, P.K.E., Landen, M. (2014). The risk of switch to mania in patients with bipolar disorder during treatment with an antidepressant alone and in combination with a mood stabilizer. American Journal of Psychiatry, 171(10), 1067-1073.