Here’s a video answering one of the most common email questions I receive. In the beginning of the video I say it will be brief; as usual, that’s a lie. I also look like absolute shit, sorry. This is not medical advice and I am unqualified to give such advice. Talk to a doctor. Here are some notes.
Ugly realities of the American medical system notwithstanding, you should do your very best to discuss your symptoms with a psychiatrist who has the potential to diagnose you.
The brain has a self-deceiving quality that, aside from perhaps a few of the most advanced Buddhist monks, afflicts us all. Doctors are only human and imperfect at diagnosis, especially in mental health, but they are able to see us from outside of ourselves, which is essential. Our minds aren't really made to audit themselves.
You should go into your psychiatrist appointment with honesty - that is, if you believe you have bipolar disorder, you should feel free to share that fact - but without an agenda, and be ready for your doctor to diagnose you with something else or with nothing at all.
Diagnosis for psychiatric conditions can be an adversarial process, by design. This is not always pleasant, but it is what’s best for patients and doctors alike.
You can find a lot of resources online about what the symptoms of bipolar disorder are. Remember that they are fundamentally subjective, and that experiencing some elements of such diagnostic lists is perfectly common among people who are not bipolar. Everyone experiences mood swings. Mood swings as conventionally described are not indications of bipolar disorder.
The single greatest misconception of bipolar disorder is that it entails moving very rapidly from one emotional state to another. While I encounter more and more patients who claim to experience “ultra-rapid cycling,” a great majority of bipolar patients experience their mood changes slowly, over the course of weeks or months. Moving quickly between emotional extremes is not a common symptom of bipolar disorder. People self-diagnosing as bipolar based on moving quickly from happiness to sadness are doing themselves a disservice and misunderstanding the diagnosis.
Depression is a persistent “down” state. It was long believed that depression is associated with reduced serotonin levels or function but this belief is increasingly contested. As with so much about the brain and its disorders we don't really know. Bearing in mind that this newsletter is not the DSM and is not attempting to give you medical advice, depressive symptoms include a sense of hopelessness/meaninglessness, an inability to experience pleasure, intense pessimism, difficulty getting out of bed, lethargy, mental slowness or fogginess, irritability, and a lack of interest in things that you used to enjoy. Typically people talk about this condition as being independent of events - if you're persistently sad because a loved one died, this is unlikely to be a symptom of clinical depression.
If your depression is dominant, meaning that you experience it more often or to a greater degree than your manic phases [edit: DSM says intensity of mania/hypomania is determinative], you are likely to be diagnosed as Bipolar Type Two. This diagnosis will require that you also experience hypomanic states; if you don’t experience those states, you’re likely experiencing major depressive disorder/clinical depression. This is in no sense a lesser, less serious, or less “cool” diagnosis. Depression kills a lot of people, as does bipolar disorder.
Hypomania and mania are excitatory states. It’s believed that mania is associated with greater dopamine levels or dopaminergic function but as with so much about the brain and its disorders we don't really know. Bearing in mind that this newsletter is not the DSM and is not attempting to give you medical advice, bipolar mania is associated with elevated feelings of energy, an inability to focus on one task at one time, feelings of grandiosity and self-importance, reduced amounts of sleeping, reduced amounts of eating, speaking at an elevated speed, feelings of paranoia or being oppressed, feelings of euphoria or elation, lowered risk aversion, and at an extreme delusional beliefs, which is to say beliefs that have no basis in reality. Typically people talk about this condition as being independent of events - if you're persistently excited because you won the lottery, this is unlikely to be a symptom of mania.
Some bipolar people experience elation or euphoria while manic, but this is not universal. Personally, my manic states are extremely unpleasant experiences; I am constantly agitated, intensely irritable, and profoundly paranoid, sometimes to the point of delusion. I experience a constant “buzziness” and I feel that my skin is somehow ultra-sensitive. I grind my teeth.
A common feature of bipolar mania is grandiosity - a sense within the bipolar patient that they are of world-historic importance, that what we do is freighted with importance. This can contribute to the paranoia, as important people are people with enemies. This grandiosity can compel people experiencing bipolar mania to avoid treatment, as they feel that their current mindset contributes to their importance, again even without feelings of elation or euphoria.
If your mania is dominant [edit: DSM says dominant in terms of intensity, not frequency], and in particular if it leads you to psychotic states, you are likely to be diagnosed with Bipolar Type One.
My understanding is that the Type One/Type Two distinction is less about “mania dominant I, depression dominant II” and more about the intensity of experiencing both states. However, in my experience as a patient and working with more than a dozen doctors and at many different facilities, very often the casual working definition seems to be bipolar I = mania dominant, bipolar II = depression dominant. Consult the DSM for the official definition.
As far as I am aware, there is no DSM-defined diagnosis of only mania independent of any depressive phases. [edit: Not that it never happens that people have mania with no depression, but rather that there isn’t a monopolar mania diagnosis that’s anywhere near as common as a monopolar depression diagnosis.] For myself, depressive periods lessened in intensity as I aged, while manic phases did not, but I still get regular depressive cycles. It's difficult to know if there's been some neurological change over time or if I've just gotten better at handling depression with experience.
The borders between the two major types of bipolar disorder are, like so many things in psychiatric medicine, less certain than you would like to be. I am bipolar I, but I have had doctors in the past who have suggested that I am bipolar II, based on a long period of not reaching full-blown mania. I have had other doctors who have said that anyone who has experienced psychosis from mania is necessarily bipolar I. This leads us perhaps to 10(a), which is that for many bipolar patients the mood cycle is not consistent - that is, sometimes you peak out at an elevated but pre-manic state, sometimes you peak out at hypomania, and sometimes you peak out at I-am-God-and-my-enemies-are-trying-to-destroy-me mania. This can complicate diagnosis.
Many people instinctually associate psychotic disorders with anosognosia - the inability of the mentally ill to perceive that that are ill. But this is not universal, and my research indicates that a majority of bipolar patients don't suffer from it. You can be quite fucked up by mania and understand in some sense that you're ill. Unfortunately, this does not guarantee that you'll accept treatment.
Positive reaction to medication is probably one of the few tangible signals you’ll ever have that your diagnosis is correct. Litihium in particular exacts a serious price in return, but it works for a large portion of the bipolar population. Antipsychotics are also a real bitch physically but are very effective at reducing or preventing psychosis.
If you’re truly manic, you’re likely to be able to get admitted to a psychiatric facility based on that fact. (Although it will still be a huge pain in the ass and potentially very expensive.) If you’re truly depressed, you’re unlikely to be able to get admitted to a psychiatric facility based solely on that fact, unless you’re rich or you threaten suicide. This has nothing to do with whether the depression is as “real” as mania and has everything to do with the incentives for people who make these decisions and the path dependence of psychiatry. You may feel compelled to invoke the magic words to get taken seriously in the average ER: “I believe I am a threat to myself and to others.”
I have written about the experience of trying to get emergency psychiatric care here. I have written about the side effects of bipolar medications here.
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