The Primacy of Mania - Re-thinking Bipolar Disorder

by M.C.
(Criminal Justice student, Texas)

What if bipolar disorder is not primarily characterized by the mood swings from depression to mania?

What if our understanding of how most people with bipolar disorder spend the majority of their time in a depressed state is deeply flawed?

What if mixed states are actually easily explained, and far more frequent than has previously been realized?

There is an important theory of bipolar disorder, advanced by Greek psychiatrist Athanasios Koukopoulos in 2006, that argues for "The Primacy of Mania".

According to Koukopoulos:
"Circular mood disorders have been the focus of increasing attention and research, but the issue of a possible intrinsic link between the phases of the manic-depressive cycle has never been investigated. The general assumption is that mania and depression are manifestations of two different phases of the same process without questioning whether one of the phases gives rise to the other."

The primacy of mania argument is that there IS an intrinsic link between mania and depression. Further, it is MANIA that is the PRIMARY neurophysiological event, and the depression is simply the consequence.

This turns much of the established wisdom on its head. For a start, if depression only ever arises as a consequence of mania, then our existing definition of mania is narrow and cliched - a much broader and accurate understanding of the manic state needs to be formulated.

To some extent this has already started to happen, with irritability and other states of agitation, anxiety, stress, and excitation beginning to be seen as mania, or at least as hypomania.

Why would mania always give rise to depression? According to Dr Koukopoulos:
"excitatory processes are harmful to the nervous system while depression is the psychic expression of this impairment and a period of reparation".

This would explain why it is mood stabilizers rather than antidepressants that have the most pronounced preventative effect. Even though it APPEARS that most people suffering from manic-depressive illness are primarily plagued by depression, the fact is that only drugs with anti-manic properties are truly helpful in the long term. In fact, there is a strong belief at the moment that anti-depressants may do more harm than good as sooner or later they contribute to a switch into mania.

If we reconceptualize bipolar disorder to admit the primacy of mania this makes sense - prevention will never be found in medications that, in any sense at all, will in some way stimulate or contribute to excitation of any kind.

Personally, I like the implications of this theory, especially as it moves away from a too narrow definition of mania and a too broad definition of depression.

I am going to experiment with this approach in my own life by:
1. doing more meditation
2. getting more exercise
3. drinking less coffee
4. avoiding stress, and
5. generally pursuing calmness.

It is so hard to pull out of depression - it would be great if depression could be minimized not through a frantic search for "happiness" or "pleasure", but through avoiding mania, even in its most suble forms.