Research report
High-risk behaviour in hypomanic states

https://doi.org/10.1016/j.jad.2013.02.018Get rights and content

Abstract

Background

Risk-taking behaviours during hypomanic states are recognised, however the high-risk nature of some behaviours—including the potential for harm to both the individual and others—has not been detailed in the research literature. The current study examines risk-taking behaviours and their consequences (including their potential for impairment) in those with a bipolar II condition.

Method

Participants were recruited from the Sydney-based Black Dog Institute Depression Clinic. Diagnostic assignment of bipolar II disorder was based on clinician judgement and formal DSM-IV criteria. Participants completed a series of detailed questions assessing previous risk-taking behaviours during hypomanic states.

Results

The sample comprised a total of 93 participants. Risk-taking behaviours during hypomania included spending significant amounts of money, excessive alcohol or drug use, dangerous driving and endangering sexual activities. Key consequences included interpersonal conflict, substantial financial burden and feelings of guilt, shame and remorse. Despite recognition of the risks and consequences associated with hypomanic behaviours, less than one-fifth of participants agreed that hypomania should be treated because of the associated risks.

Limitations

Study limitations included a cross-sectional design, reliance on self-report information, lack of controlling for current mood state, and comprised a tertiary referral sample that may be weighted to more severe cases. Findings may therefore not be generalisable and require replication.

Conclusions

Risk-taking behaviours during hypomania are common, and often linked with serious consequences. Whilst hypomania is often enjoyed and romanticised by patients—leading to ambivalence around treatment of such states—careful consideration of the impact of risk-taking behaviour is necessary, while the study raises the question as to what is ‘impairment’ in hypomania. Findings should advance clinical management by identifying those high-risk behaviours that would benefit from pre-emptive weighting in developing individual's wellbeing plans for managing the condition.

Introduction

The bipolar disorders (I and II) are associated with significant social and economic burden, viewed as highly costly behavioural conditions (Wyatt and Henter, 1995) and compromise quality of life (Awad et al., 2007). Bipolar II disorder—characterised by recurrent episodes of depression and hypomania—may be more prevalent than previously considered, with recent estimates in the order of 5% (Hadjipavlou et al., 2012). Whilst positioned by some as a ‘milder’ form of bipolar disorder (and, in DSM-IV as either not impairing or minimally impairing), the condition is characterised by a chronic course, with recurrent depressive symptoms, and contributing to similar levels of disability and suicide risk to that quantified in bipolar I disorder (Benazzi, 2001, Judd et al., 2003, Judd et al., 2005; Joffe et al., 2004, as cited in Hadjipavlou et al., 2012).

Risk-taking behaviours during hypomanic states are broadly recognised as integral to bipolar illness. DSM-IV criterion B states the possibility of “increased involvement in pleasurable activities that have high potential for painful consequences” (APA, 2000, p. 365), and with Criterion B7 indicating “there may be impulsive activities such as buying sprees, reckless driving, or foolish business investments” (APA, 2000, p. 366). Whilst DSM-IV diagnostic criteria recognise risk-taking behaviours in bipolar II disorder—DSM definition and formal criteria state that impairment is either absent in hypomania or slight—and not require hospitalisation. Such features—in addition to psychosis during manic episodes distinguishes bipolar II from bipolar I disorder, however the distinction is not clear-cut (Benazzi, 2007), while the very nature of clinically observed mood-related risk taking can suggest distinctive ‘impairment.’ The severity of risk-taking behaviours clearly varies—for example, over-spending can range from simply buying three pairs against one pair of needed shoes through to spending hundreds to thousands of dollars on personal items during shopping sprees, by excessive gambling, or by purchasing property without adequate funds and risking bankruptcy or financial ruin. Seemingly harmless gregarious and flirtatious behaviour can lead to unconstrained sexual activity, risking sexual infection or unwanted pregnancy and the potential breakdown of the individual's primary relationship. Whilst ‘marked’ impairment in functioning may not be recognised by the individual during a hypomanic state—and with a percentage reporting or experiencing enhanced functioning during such times (Judd et al., 2005)—a less positive intepretation may emerge following episodes and upon further reflection.

Clinically, risk-taking during hypomania is commonly reported by patients (albeit generally with guilt or shame after return to a euthymic mood or in a post-hypomanic depressed mood). Whilst such behaviours may be perceived positively in-the-moment (e.g. adrenalin rushes from driving fast, pleasure from sexual activity or gambling)—the associated risks and consequences are many. Moral indiscretions occurring during such times drive guilt, remorse and shame, and even suicidal intent. High-risk behaviours are also commonly clinically observed as contributing to interpersonal conflict, relationship breakdowns, financial hardship and potentially life-threatening outcomes (e.g. whether death by misadventure during hypomania or when the mood has normalised or moved to a depressed state).

High-risk behaviours and their negative consequences—including interpersonal difficulties and loss of relationships (Michalak et al., 2006, Angst, 1998, Tranvag and Kristofferson, 2008)—have been examined broadly as a general issue of relevance to the bipolar disorders. A higher prevalence of reckless activity has been reported previously in bipolar I versus bipolar II disorder as might be expected (Serretti and Olgiati, 2005), however articulation of the high-risk nature of such activities in bipolar II patients is lacking. By contrast, clinical and literary anecdotes provide rich descriptions of hypomanic behaviours and their associated risks:

“When you're high it's tremendous…Shyness goes…Sensuality is pervasive and the desire to seduce and be seduced irresistible”. (Jamison, 1995, p. 67)

“In hypomania…the elated mood leads to faulty judgement…hypersexuality may lead to venereal disease in men and pregnancy in women….” (Fish, quoted by Hamilton, 1974, p. 73)

On recounting his high school years, Stephen Fry commented:

“I was expelled from [high school]. I felt so intensely alive…in a constant state of edginess…I was so often alone, wandering the roofs…a mixture of risk and power when you are looking down on people [below]. The awful thing was the stealing…[it] gripped me…your heart is in your throat, and it is a real buzz…I progressed to credit cards from the jackets of my parents friends…I used the money in the most grandiose way…when I was about 17…going around London…bought the most ridiculous suits…drink cocktails…you are the centre of your own universe. After months of travelling the country using my stolen credit card, I was arrested”. (Fry, 2006)

Despite the high-risk potential and associated collateral damage, we are unaware of any studies examining in detail risk-taking behaviours associated with hypomania in those with a bipolar II disorder, and hypothesised that both the severity of such behaviours and their ensuing impact is underestimated. The current study therefore sought to explore in detail—both quantitatively and qualitatively—risk-taking domains and behaviours associated with hypomania in addition to the ensuing consequences, and as a corollary consider whether such behaviours are either not impairing or only minimally ‘impairing’ as defined by DSM-IV. Risk-taking behaviours were defined as those presenting both a potential risk to the participant (or those around them), as well as those that produced actual negative consequences, and our study was limited to those with a bipolar II condition.

Section snippets

Methods

Patients referred to the Sydney-based Black Dog Institute Depression Clinic for diagnostic clarification and treatment advice were invited to participate in research. Patients were requested to complete a detailed questionnaire booklet prior to attending the clinic, assessing demographic information, as well as their mood disorder and treatment history. Booklet questions reported on in the current study focused on behaviours undertaken when hypomanic, including any associated consequences.

Results

Of the 1020 participants (unipolar and bipolar) attending the Depression Clinic for whom clinician and MINI diagnosis were available, diagnostic agreement was acceptable overall (kappa=0.4, p<0.001) for diagnosing a bipolar II condition. The final sample with a concordant clinician and MINI diagnosis of bipolar II disorder comprised 93 participants, with a mean age of 33.6 (SD=11.6) years and with females slightly over-represented (63.4%). Participant characteristics are outlined in Table 1.

Discussion

The study had several limitations, including a cross-sectional design, and reliance on self-report information. The sample was characterised by a moderate level of depression at the time of assessment, which may have influenced responses (e.g. increasing the likelihood of viewing previous hypomanic behaviours in a negative light; over-endorsement of feelings of guilt or remorse). Participants were attending a tertiary referral mood disorders clinic, and the sample may therefore be weighted to

Role of funding source

Funding for this study was provided by NHMRC Program Grant (510135). The NHMRC had no further role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the manuscript for publication.

Conflict of interest

No conflict declared.

Acknowledgement

The authors would like to thank Georgia McClure for data entry.

References (38)

  • A.G. Awad et al.

    Quality of life among bipolar disorder patients misdiagnosed with major depressive disorder

    Primary Care Companion to the Journal of Clinical Psychiatry

    (2007)
  • F. Benazzi

    Course and outcome of bipolar II disorder: a retrospective study

    Psychiatry and Clinical Neurosciences

    (2001)
  • F. Benazzi

    Bipolar II disorder: epidemiology, diagnosis and management

    CNS Drugs

    (2007)
  • K.N. Chengappa et al.

    Relationship of birth cohort and early age at onset of illness in a bipolar disorder case registry

    American Journal of Psychiatry

    (2003)
  • S. Frangou

    Management commentary

  • S. Fry et al.

    The Secret Life of a Manic Depressive [Motion Picture]

    (2006)
  • G.M. Goodwin

    Management commentary

  • G. Hadjipavlou et al.

    Bipolar II disorder in context: a review of epidemiology, disability and economic burden

  • G. Hadjipavlou et al.

    Bipolar II disorder in context: a review of epidemiology, disability and economic burden

  • Cited by (47)

    • Towards tailored psychosocial intervention for BD-II: Lived experience perspectives on current and future management options

      2021, Journal of Affective Disorders
      Citation Excerpt :

      Differing perceptions of hypomania and depression have been reported previously: those with BD-II viewed hypomania as advantageous rather than problematic, whereas depression-related appraisals were catastrophic and driven by fear of relapse. ( Fletcher et al., 2013) While hypomania is not always viewed positively and has been associated with risk-taking, (Fletcher et al., 2013) interpersonal difficulties and a signal for an impending depressive ‘crash’, (Fletcher et al., 2013) these findings highlight the need for tailored interventions paying specific attention to the nuanced features of BD-II. Overall, strategies aligned with evidence-supported SM strategies for BD more broadly (Michalak et al., 2016; Janney et al., 2014; Jones et al., 2011), highlighting the complementary role of self-management alongside treatments delivered by mental health care professionals.

    • Measuring the consequences of a bipolar or unipolar mood disorder and the immediate and ongoing impacts.

      2018, Psychiatry Research
      Citation Excerpt :

      However, these items tended to be affirmed by the BP group at 1.44–2.27 times the rate of UP patients, suggesting that they are distinctly more characteristic of BP patients. Increased risk taking, accruing speeding fines and excessive spending are identified consequences of a hypo/manic mood (Fletcher et al., 2013) and consistent with the current data showing that 10.8% of BP patients had been arrested or charged by police when in a mood state compared to 4.2% of UP patients. Of the five items in the measure pertaining to positive outcomes of having a mood disorder, only one item – an enhanced capacity for empathy and compassion (e.g., for other people's suffering) – loaded highly on the central factor, and was endorsed by approximately two-thirds of the entire sample.

    • Risks of road injuries in patients with bipolar disorder and associations with drug treatments: A population-based matched cohort study

      2018, Journal of Affective Disorders
      Citation Excerpt :

      However, female gender, older age (i.e. over 80), residence in areas of the highest urbanization, and use of antidepressant at higher doses were associated with a lower risk of road injuries. Our finding that patients with BD were at greater risk for traffic injuries when compared to individuals without BD supports previous studies reporting on risk-taking behaviors in bipolar patients (Fletcher et al., 2013; Khalsa et al., 2008). Our results also support previous case-control studies that have described higher prevalence rates of BD among individuals arrested for driving under influence (Albanese et al., 2010; Freeman et al., 2011; Shaffer et al., 2007).

    • Cognitive and neural basis of hypomania: Perspectives for early detection of bipolar disorder

      2018, Bipolar Disorder Vulnerability: Perspectives from Pediatric and High-Risk Populations
    • Bipolar disorder and sexuality: a preliminary qualitative pilot study

      2023, International Journal of Bipolar Disorders
    View all citing articles on Scopus
    View full text