Author: Thiago Genaro

 

I like to use metaphors with my patients. I think it helps translate some of the raw technical medical knowledge and helps draw parallels. I love it when my ophthalmologist explains the prescription of my glasses to me through comparisons and metaphors.

Let’s talk about the sea to address the topic of mania in the context of bipolar disorder.

“Eric” has been sailing since he was a teenager. He learned about boats, tides, wind, storms. Today, at 32 years old, he considers himself an experienced sailor. He has sailed around the Caribbean, along the Brazilian coast and has a special affection for the French coast. Even though Eric has all the technological navigation equipment on board, he feels safer encountering lighthouses on the high seas. On the French coast, there is perhaps the most famous lighthouse in the world: La Jument. The lighthouse is 1.2 miles from the island of Ouessant and is an imposing warning to navigators about rocks and corals on this side of the coast French. There were countless shipwrecks in the region.

In my practice as a psychiatrist, I see the importance of self-knowledge. I see better clinical evolution in patients who know themselves and understand what the cyclical evolution of bipolar disorder will be like. I think it is essential that both the patient and family members recognize the winds, tides and storms that will accompany this journey. I encourage periods of calm to be valued and celebrated!

When it comes to awareness, I have noticed that the patient recognizes the depressive phase more easily.

Recognizing periods of hypomania/mania can be a little more difficult. The increase in energy can be subtle, impulsivity can go unnoticed. Reduced sleep, irritability and excessive focus  on certain activities can occur. These symptoms can be attributed to external factors:

– “Work is busy!”

– “I’m studying a lot!”

– “I’m worried about my teenage son!”

No matter how well the patient knows themself, has a great psychiatrist, an excellent therapist and follows publications on bipolar disorder, there can still be a lack of an external perspective on the condition. Sometimes, an internal technological apparatus is not enough; an external La Jument Lighthouse is required to signal over corals and rocks at sea.

This external perspective can come from the mental health professionals who accompany the patient. However it could also be the wife, the husband, the son, the brother, the friend. It can be someone from the outside looking in.  A look that identifies and recognizes winds and storms. A look that contributes to periods of calm and tranquility.

Here are some things professionals, or family members/friends can look for to help identify an episode of hypomania or mania:

• Baseline Behavior: Understand their usual sleep pattern—some may naturally sleep only 6 hours a night. In hypomania/mania, this sleep pattern may change, with reduced sleep without noticeable fatigue. Ask family if there’s been a disruption in sleep.
• Increased restlessness and distractibility: With faster thinking, patients may become more talkative, forgetful, or make impulsive decisions (e.g., missing appointments, car accidents). Work productivity may decline, and ADHD-like symptoms could emerge.
• Changes in behavior and social interactions: While bipolar patients may be naturally outgoing, look for signs of excessive sociability, louder speech, or more invasive behavior. Increased self-confidence, arrogance, or indifference to serious matters can signal mania.
• Impulsivity and excessive energy: Watch for unusual patterns, like increased physical activity (e.g., extra workouts or sports) or risky behaviors (e.g., drinking more alcohol, taking on multiple projects). Impulsive actions like enrolling in multiple programs or gambling more frequently can also indicate mania.
• Distinguishing hypomania/mania from anxiety: Anxiety often involves fear and insecurity about the future, while hypomania/mania shows increased energy and impulsivity. These conditions often overlap, so it’s essential to consider both when assessing the patient.

For patients, considering Establishing an agreement with someone you trust, like the the Ulysses pact. In Homer’s work, the Odyssey, Ulysses sets up a strategy, together with the crew of his ship, to be able to hear the enchanting and dangerous song of the mermaids. Those who heard it brought their boats closer to the rocks, dying as they threw themselves into the sea, in the insatiable desire to join the beautiful mermaids. To protect the crew, Ulysses ordered each of his sailors to put wax in their ears. And in order to protect himself, knowing that he would be the only one to hear the song of the mermaids, Ulysses ordered him to be tied to the ship’s mast, so that, in a moment of impulse, he would not throw himself into the sea. Ulysses’ pact serves as a metaphor for several situations in medicine, including bipolar disorder. The patient may not recognize an episode of mania and may not want to schedule an appointment with his therapist or doctor. But it is essential to have an agreement with a friend or family member so that, as soon as an episode of mania is identified, the patient’s support network (psychiatrist, psychotherapist, other family members) can be contacted.

I really value this external view of the family. The patient most of the time does not realize that they are more restless, more agitated, with more energy. It is the spouse, the son, the brother who point out to me about this rock, about this coral.

And with this information, I talk to the patient’s therapist, anticipate the appointment and, if necessary, adjust the medication.

Having a Lighthouse in this ocean called Bipolar Disorder is a privilege.

Thiago Genaro is a psychiatrist in São Paulo, Brazil. He is part of the clinical staff of Conexa Saúde, Hapvida, MentalMe and Hospital Israelita Albert Einstein.

 

The content of the International Bipolar Foundation blogs is for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician and never disregard professional medical advice because of something you have read in any IBPF content.