This is known as “lack of insight.” “We talk about onion and garlic symptoms,” says Youngstrom, using a metaphor he credits to the late Dennis Cantwell, MD.
“Onion symptoms would bug us when we’re having them and garlic symptoms bug everyone else around us first. Hypomania is a bunch of garlic symptoms.” From the perspective of people who are hypomanic, “They’re not talking too much, they’ve just got really exciting stuff that’s more interesting than anything anyone else is trying to say,” he says.
If someone doesn’t seek help because of stigma or some other reason, they’re not going to be diagnosed with anything.
And an initial diagnosis of depression may actually be correct in the early stage of the illness, because hypomania or mania may not emerge until a good while later.
Even experienced clinicians may have a hard time “unless the individual is in a flagrant episode of mania,” Frank says.
Primary care physicians may be getting more familiar with recognizing depression, but limited time with their patients and lack of comprehensive screening tools mean those elusive signs tend to go undetected.
“If you can’t really count on whether you’re going to be excessively energetic or optimistic or excessively pessimistic and not able to get anything done—if you can’t count on that stability, it makes life extremely difficult,” Frank says.
“By definition” gets back to those common criteria in the DSM, which is the standard reference clinicians use for figuring out how to label a set of symptoms—and thus how to treat the underlying illness.
Facing her is a Cubist image which conveys an uncomfortable mix of twitchy energy, irritability and a kind of wired-up unhappiness.
A tiny canvas represents symptoms that pass in days, while a mood that persists for weeks takes up a wall-sized tapestry.