What Is Depression?

As noted earlier, there are times in all of our lives when we experience feeling down, sad, or blue.  Although we may sometimes say that we feel depressed, this is often not the case. Depression is an illness that encompasses all aspects of life. It impacts the way you behave, your mood, and your thoughts. It affects your eating habits, your patterns of sleep, the way you feel about yourself, and the way you see, think about, and perceive things.

The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association [APA] 2000), or DSM, is a book that provides criteria for diagnosing the various mental illnesses. It defines a major depressive episode as a period of at least two weeks of depressed mood or the loss of interest or pleasure in most activities. In addition, to meet criteria for a major depressive episode, a person must experience at least four other symptoms from a list that includes things such as changes in appetite or weight; changes in sleep; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; recurrent thoughts of death; or suicidal thoughts, plans, or attempts. Major depression affects your ability to function in many aspects of your life.

Some people are able to continue functioning in at least some of their roles and can even sometimes mask their depression to such an extent that others don’t realize that they’re not feeling well. However, the longer you continue with this facade rather than seeking help, the more difficult things get and the more the depression will impact different areas of your life. Just because you can keep going like things are okay doesn’t mean that things really are okay and you don’t need help.

Sometimes you may find that you can get through an episode of depression without medications, while at other times you find that you just can’t function well enough without them. If you’ve had recurrent bouts of depression, you may find that some are less severe, and you can get by without taking antidepressants, while at other times the episodes seem much worse. Remember that major depression is an illness, and taking medication for an illness is not a sign of weakness. You wouldn’t question someone with high blood pressure taking blood pressure medications or someone with diabetes taking insulin. Instead of trying to tough it out, speak with your doctor to see if you need medications to help you through.

What Is Mania?

The DSM (APA 2000) defines a manic episode as a distinct period when there is an unusually and persistently high (or euphoric) or irritable mood that lasts for at least one week (unless the person is hospitalized, in which case it can last for less than one week). In addition, to meet criteria for a manic episode, the DSM specifies that at least three other symptoms must be experienced from a list that includes inflated self-esteem or grandiosity (a sense of being better or more important than others), decreased need for sleep, nonstop talking, distractibility, increased activity or agitation, and excessive involvement in pleasurable activities that are likely to result in negative or painful consequences (for example, using drugs or alcohol, engaging in risky behaviors such as gambling or sexual promiscuity, or overspending).

The experience of mania can be a double-edged sword: after you experience an episode of depression, it’s natural to enjoy lifting out of this low mood and experiencing feeling happy and energetic. At its extreme, however, mania can be incredibly dangerous and destructive. Manic episodes can lead to behaviors such as those listed above, which cause problems with family, friends, the community, and the law. Making these problems even worse is the fact that, during a manic episode, you may be unable to understand that you are ill because you feel great; this could even lead you to refuse hospitalization or other means of support.


What Is Hypomania?

Some people with bipolar disorder don’t experience manic episodes but do have times when their mood is somewhat elevated. This is known as hypomania, and people tend to experience these episodes more often than manic episodes for two reasons: full-blown manic episodes tend to be less common, and hypomania often comes before full-blown mania in people who do experience the severe highs. The symptoms of hypomania are the same as those for a manic episode, but according to the DSM they are less severe, last only a minimum of four days rather than one week, and do not include the delusions or hallucinations that sometimes occur in mania. Unlike manic episodes, when you are hypomanic, you usually remain aware of the changes in yourself, and you are therefore more able to prevent yourself from acting on the urges and impulses you are experiencing.

According to the DSM, the best way to differentiate between a manic and hypomanic episode is the degree of impairment caused. Mania is diagnosed when symptoms are present to such an extent that hospitalization is required to keep you safe or when symptoms are at least severe enough to be causing significant problems in your life (for example, inability to work or go to school; legal problems due to reckless behaviors such as dangerous driving; or relationship problems due to impulsivity, such as sexual promiscuity or compulsive spending). During a hypomanic episode, on the other hand, you may have some of the symptoms of mania and may experience the urge to engage in these kinds of destructive behaviors, but you are able to remain in control of yourself and not act on these urges.

Here are some other ways to tell the difference between a manic and hypomanic episode (Benazzi 2007):

• A manic episode usually lasts longer than a hypomanic episode.
  
  
• Mania substantially impairs your functioning, where as hypomania often actually improves functioning (for example, you have more energy and so are able to get more things done in a day), or at worst causes only mild impairment.
  
  
• When manic, your thoughts become speedy and disconnected, and your speech becomes fast and nonstop. In a hypomanic episode, the thoughts might be described as racing or crowded, but not to the same extent as in mania, and these thoughts are often also described as creative.
  
  
• Mania is associated with aimless overactivity, such as starting many different projects and not really getting anything done, whereas hypomania often leads to an increase in goal-directed activities—in other words, you are able to achieve more.

As with a manic episode, you may welcome hypomania as a relief from depression or simply because of the increase in energy and good feelings that hypomania often brings with it. You may feel that in this state you can get more done and are more creative, so you may be reluctant to seek treatment to bring it to an end. This makes it especially important to be aware that, while not a full-blown manic episode, it is possible for hypomania to turn into one if left untreated. For people who never experience full-blown manias, a hypomanic episode left unchecked often leads to a crash into a depression.

What Is a Mixed Episode?

The DSM defines a mixed episode as a period of at least one week during which the criteria for both a manic episode and a major depressive episode are met. Here, a person experiences rapidly changing moods such as sadness, anger, and extreme happiness, accompanied by the previously listed symptoms of a manic episode and a major depressive episode. The symptoms experienced in a mixed episode often include agitation, irregular appetite, insomnia, psychotic symptoms, and suicidal thoughts. Mixed episodes can be more difficult to identify because of the wide array of symptoms involved, but proper medical treatment is even more essential with these episodes, because the outcome for people experiencing them is poorer than for other forms of bipolar disorder (Strakowski et al. 2000).

What Is Psychosis?

Sometimes, severe episodes of mania or depression can result in symptoms of psychosis. The term psychosis basically refers to a loss of touch with reality. Common psychotic symptoms include hallucinations, when people hear, see, or otherwise sense things that aren’t actually there. Sometimes people are aware that these are hallucinations, depending on the degree of psychosis.

A second common symptom of psychosis is the presence of delusions, defined as false, strongly held beliefs that cannot be explained by the person’s cultural or religious beliefs and that are not influenced by logical reasoning (APA 2000). When a person is in a delusional state, he is unable to recognize that his beliefs are false, even when presented with evidence that clearly contradicts those beliefs. In my early years as a mental health worker, someone explained to me that trying to convince someone he was delusional would be like someone trying to convince me that I had never gone to university. To that person, the delusion is reality.

Once you have entered a psychotic state, the delusions you experience often prevent you from recognizing that you are ill and in need of hospitalization in order to become stabilized on medication. One common delusion, for example, is the paranoid delusion: the belief that others are out to get you. This can lead to ideas related to medical treatment—for example, that people are trying to keep you medicated in order to control you; that your medications are actually poison; or that you are being kept in the hospital as part of some kind of conspiracy. As a result, you may become distrustful of family members, friends, and mental health professionals who are trying to help you.

In addition, the hallucinations sometimes experienced in these states can be very frightening, further alienating you from people who are trying to help. Sometimes this can result in you becoming involved in the criminal justice system or being admitted involuntarily to a hospital. For example, I once worked with someone who was stopped by the police for driving dangerously while he was trying to get away from “devils” that were chasing him. In his terrified and incoherent state, the police assumed he had been using drugs and he was taken to jail. He was subsequently hospitalized involuntarily.

It’s important to remember that not everyone with bipolar disorder will experience psychosis.  While this information can be frightening, I have included it because the sooner a psychotic episode is treated, the quicker it will be resolved. One of the most important aspects of treating bipolar disorder is arming yourself with information so that you and your loved ones will be more able to recognize what is happening and get treatment quickly.


Excerpt from Dialectical Behavior Therapy Skills Workbook for Bipolar Disorder: Using DBT to Regain Control of Your Emotions and Your Life by Sheri Van Dijk, MSW