Textmania: a Modern Manifestation of Manic Hypergraphia?

Continuing with the theme of reading and writing, a new study reports on the case of a 23 yr old woman with bipolar I disorder whose output of text messages was "1333.33% more" during a manic episode (Emeagwali et al., 2012):

The patient reported a dramatic increase in the quantity of both texting and sex-texting (or sexting) in addition to a decrease in quality of the message content. In addition, there was a substantial increase in the number of people with whom the patient engaged in simultaneous texting conversations. This case provides evidence for the need to consider non-traditional forms of communication when evaluating a patient’s communication pattern during mania.

How many texts per day are we talking about? At least 200, up from her usual 15-20 texts/day.¹ In the grand scheme of things, 200 is not all that unusual, because the mean number of text messages sent by young adults in the 18-24 age group is 109.5, according to a Pew Internet Survey.² The change in the patient's behavior is the critical factor here.

Hypergraphia (an overpowering urge to write) is probably seen more frequently in mania than in temporal lobe epilepsy, but the latter gets more attention in the medical literature due to the sometimes spectacular nature of the output (e.g., the novels of Dostoevsky, a 17 million word diary, and a copious collection of rhyming poetry). The neurological case studies are often illustrated with EEG traces showing abnormal spiking activity, along with examples of the person's handwriting (Kalamangalam, 2009):

The patient was observed to write for much of her waking hours. The document, a letter to her husband, numbered 29 pages by the time of her discharge from hospital and remained unfinished. The writing was cramped, dense, and used all the available space on both sides of the sheet, including the margins. The contents of the letter were rambling, though with specific details. She wrote about her hospital stay, often mentioning exact times, her intake of medications, and minor details of conversations with staff.

-- click on image for a larger view --

Fig 1 (left). Sleep EEG, bipolar longitudinal montage: a single spike maximum over the right anterior temporal region (arrow). Fig. 3 (right). Close up of page 16. The patient writes about her medication dosing, including minor details. (modified from Kalamangalam, 2009).


You don't see such reports in the psychiatric literature.³ There are no obvious manifestations of a manic episode on EEG or PET scans where you can say, in an individual person, "oh yes, this reduced gamma coherence and inhibition of theta activity in the lateral inferior prefrontal cortex, coupled with increased dopaminergic transmission in the midbrain, are clear indicators of mania." A PubMed search for mania OR manic AND hypergraphia returns one result, while a search for temporal lobe epilepsy and hypergraphia yields 22 hits.

There have of course been books on bipolar disorder and creativity, such as Touched With Fire: Manic-Depressive Illness and the Artistic Temperament by Dr. Kay Redfield Jamison. More specifically, Dr. Alice W. Flaherty covered the phenomenology and neurobiology of hypergraphia. In The Midnight Disease: The Drive to Write, Writer's Block, and the Creative Brain:

Flaherty writes compellingly of her bout with manic hypergraphia, when "the sight of a computer keyboard or a blank page gave me the same rush that drug addicts get from seeing their freebasing paraphernalia." Dissecting the role of emotion in writing and the ways in which brain-body and mood disorders can lead to prodigious — or meager — creative output, Flaherty uses examples from her own life and the lives of writers from Kafka to Anne Lamott, from Sylvia Plath to Stephen King [and Fyodor Dostoevsky].

And certainly the evidence for manic/hypomanic hypergraphia has been plainly obvious for as long as the internet has existed. There are thousands of bipolar bloggers and Tweeters and Facebook users and online journalers before that. Unlike PubMed, Google Blog Search returns 3,670 hits for bipolar hypergraphia and 4,230 hits for manic hypergraphia. And those are just the posts that use the term hypergraphia.⁴ One could envision a study on quantitative changes⁵ in written output on Twitter or blogs as a possible sign of bipolar cycling.

So it seems that contemporary psychiatrists are not all that interested in publishing case studies about their frantically writing patients, unlike the neurologists. Perhaps it's so commonplace that they just don't see the point?


Footnotes

¹ As you can see, the mathematical calculation quoted in the first sentence is rather imprecise.

² The median, which is less sensitive to the effects of gabby outliers, is 50 texts per day.

³ This raises the issue of Neurology vs Psychiatry and the Neurological/Psychiatric Divide.

⁴ For another interesting personal perspective see Bipolar 101 on HYPERGRAPHIA - the compulsion to write in bipolar disorder.

⁵ And of course qualitative changes in content and themes, when such writing hasn't been purged or accounts deleted at a later point in time...


References

Emeagwali, N., Bailey, R., & Azim, F. (2012). Textmania: Text Messaging During the Manic Phase of Bipolar I Disorder. Journal of Health Care for the Poor and Underserved, 23 (2), 519-522. DOI: 10.1353/hpu.2012.0062

Kalamangalam, G. (2009). Hypergraphia in temporal lobe epilepsy. Annals of Indian Academy of Neurology, 12 (3): 193–194. DOI: 10.4103/0972-2327.56323