My one quibble is that I don't think of this, or any other mental condition, as "either/or." I am not a psychiatrist or a student of psychology, but my inclination is to think in terms of a spectrum rather than either/or. I think that one can have mood swings that are very noticeable and somewhat debilitating but not extremely intense, and the decision about whether such a person needs treatment would be ambiguous.
Have not yet watched the video, but the posting itself strikes me as a good consumer's guide.
One question: Years ago I got the impression that the distinction between Bipolar Disorder I and Bipolar Disorder II was whether your illness was serious enough to warrant hospitalization, with (IIRC) hospitalization moving you up from II to I. Was that distinction ever a valid rule-of-thumb or was it just popular misunderstanding?
I mention this a bit - the way doctors have always discussed it with me, I is for people who go full out manic and II people top out at hypomania. But it's confusion and so I'm fobbing the question off to the DSM.
Freddie, the DSM uses your criterion 13, and there while there might be stealth indicators psychiatrists use to hint at one or the other, there aren't stealth criteria. If you have one proper manic episode you are Bipolar I, and psychosis is an automatic bump to mania from hypomania.. I think what you write in points 8 and 12 about mood state dominance is inaccurate and likely to lead to some confusion. (The majority of bipolar I people are also "depression dominant" in terms of time spent in depression vs mania.) Diagnostically it has nothing to do with how often you experience those states and everything to do with their intensity, and if psychiatrists are doing something else they are going rogue. Not that that never happens--I've also heard of people wind up with schizoaffective diagnoses because the schizoaffective/bipolar I line is fairly technical (as is the difference between hypomania and mania in the absence of psychosis) and some clinicians--wrongly!--round off to "presence of psychotic symptoms in bipolar --> a schizoaffective dx." And to point 14, actually, you can receive a bipolar diagnosis in the absence of depressive episodes, and some people do seem to present with manic episodes only.
When I say "depression dominant" or "mania dominant," I'm trying to refer to intensity, not to frequency. I will add a note to that effect. See if it looks any better now.
It's really only the intensity of the manic symptoms that's determinant. (How and why the mood-state space got carved up this way is probably an interesting story.)
Thanks much though Freddie, I'll stop nitpicking to say I'm always glad when you shine some light in this corner.
"aside from perhaps a few of the most advanced Buddhist monks"
--Smeh, they're the most messed up of us all.
To disavow all 'things' but then need special robes, special haircut, idols ... special markings--mysticism--for the purpose of setting themselves apart from the masses of humanity, positions, trappings, they become sought after things themselves, with what end goal, but to gain mystic respect, to master others in a hierarchical organization.
To engage in advanced naval gazing to the point of enlightenment?, or perhaps delusion.
There’s definitely an association. Alcohol is frequently used by people in states of depression and mania as a means of self-medication, and alcohol can exacerbate both depression and psychosis. I think my doctor told me that about 40% of people with bipolar have a diagnosable alcohol problem and about 50% have comorbid ADHD or another intellectual disorder. One of the reasons diagnosis is so complicated is that it’s rare for someone to just have one thing malfunctioning in their brain/body, and bipolar in particular tends to couple up with other health conditions.
"I think my doctor told me that about 40% of people with bipolar have a diagnosable alcohol problem and about 50% have comorbid ADHD or another intellectual disorder."
It's also true that medications used to treat inattention – or even stuffy sinuses – may have side-effects that might be mistaken for anxiety or inappropriate mood elevation. Checking for this is one of the basic responsibilities of medication management, but could get overlooked. (And may especially get overlooked if mental-health clinicians telegraph that patients who mention physical issues will get labeled with "health anxiety"/SSD: https://www.bmj.com/content/346/bmj.f1580/rr/638352#:~:text=In%20medicine%2C%20differential,are%20mistakenly%20diagnosed. )
The answer isn't always reducing medication, or just accepting a side-effect rather than treating it, but sometimes it is.
Thanks for opening up and sharing deep personal thoughts and experiences. I do think you're providing a valuable gateway to acceptance of mental health conditions.
My experience was that my first manic episode was actually triggered by receiving SSRIs for a misdiagnosis of MDD, and I’ve heard similarly from a few other people with diagnosed bipolar. That’s one of the many reasons “response to medication” is such an important screener in diagnosis and why self-diagnosis checklists are incapable of capturing the complete story.
For me, mood cycling isn’t like quickly switching between emotions predictably. It’s more like rolling the dice every few weeks. Even numbers I’m fine, odd numbers I’m depressed, snake eyes I’m manic. I never know when it’s dice-rolling time but some events (substance use, breakups, life events) are more likely to kick it off. There’s a unique horror that comes from, even with perfect treatment compliance, just never knowing if today’s the day your brain decides to shit itself again.
I shall take this opportunity to give thanks that my mental fucked-up-itude is both manageable to the point where I cannot label it a disorder, and also the result of material intrusions into my brain from my environment and not an internal matter.
"People self-diagnosing as bipolar based on moving quickly from happiness to sadness are doing themselves a disservice and misunderstanding the diagnosis."
True. It's also worth noting that clinicians may do the same thing, especially when they're overworked.
"Psychiatric diagnoses such as bipolar disorder remain defined purely by their phenomenology, akin to migraine, Meniere’s disease, tinnitus... But it is hard to discriminate among possible conditions that fall within a differential diagnosis if the component elements of a defined syndrome are deconstructed and evaluated without considering the broader clinical context in which they arise. A young adult woman with high interpersonal sensitivity who becomes upset after quarreling with an intimate relation does not consequently 'rapidly cycle' all night. The businessman who rises to the occasion of increased work demands with gusto cannot volitionally summon up hypomania at will, nor does a manic episode typically end in convenient synchrony with the completion of an arduous work or social obligation."
^ That's advice written to clinicians, who don't always consider the broader context in which patient behavior arises. In fairness, many clinicians work under circumstances that aren't conducive to gathering context, even the context heading the patient's chart.
Allen Frances, chair of the DSM IV committee, now regrets having added bipolar II and Asperger's to DSM IV:
"We had excellent empirical evidence for including both bipolar II and Asperger’s in DSM IV, but both did more harm than good. Data drawn from research studies on highly selected patients in the hothouse environment of a university research clinic generalize very poorly to the hustle and bustle of primary care" (or even resource-strapped secondary care.)
"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."
Still, there is such a thing as too adversarial. Making snap social judgments about people is a normal human heuristic when bandwidth is low, and clinicians may do it, too. Whether it's a judgment that Black patients must just be seeking recreational drugs, or that women who believe the can succeed in STEM inherently have delusions of grandeur, or that the default assumption should be that patient reports that medication isn't helping shouldn't be believed, some clinicians may strike adversarial postures that make it more difficult, not less, for them to provide appropriate treatment, at least to someone like you.
And, if your problem is that you're down on yourself, inclined to lend too much credence to the least-charitable takes on who you are and what you're doing, you might be particularly vulnerable to putting up with this kind of inappropriate treatment. Being honest with yourself typically doesn't require accepting a cartoon version of yourself that's unrecognizable to you or to those who know you well, just because some official said so. But if you're down on yourself enough, you could be persuaded that it does.
Dr Frances wrote an entire book about his concerns around overdiagnosis after DSM V was released. I tend to agree with many of his concerns, but it's worth noting that he seems like he has a stake in defending his position here. He may not be a good objective source.
I don't expect Dr Frances to be objective. Psychiatry itself isn't on an objective footing yet. What I expect from interested experts is honesty, including honest dialog where interest counters interest.
In that respect, I regard Dr Frances's stake in defending his position as mostly good. DSM 5 did come with serious risks of compounding psychiatry's diagnostic inflation, and, given that risk, it makes sense for experts in the field to speak up about it, even if they stand to gain something by making it their pet issue.
When objectivity isn't a feasible standard, I expect honest advocacy, even if I don't entirely agree with it.
I admit Dr Frances's interests and mine coincide somewhat, since I'm in one of the patient populations disproportionately threatened by the DSM 5's "SSD":
It's bad enough when medically *un*explained symptoms are assumed, absent other supporting evidence, to "prove" a mental disorder. Now medically *explained* symptoms may, too. Yes, I'm glad old lions of the field speak up against that, and other risks of diagnostic inflation, even if it helps them sell books.
I think he'd be a more effective advocate if his arguments were more objective and less rhetorical. I read part of his book for a paper a few weeks ago and found it full of exaggerations and misrepresentations of the sources he cited. But, as I said, I mostly agree with his conclusions.
If it's any comfort, my classes, teachers, and other students are all very skeptical of the DSM in general and specifically the diagnostic inflation we're talking about. I think that's a good sign for the future, at least. But the trouble for me is this: depression, bipolar disorder, schizophrenia, ptsd, anxiety - these do seem to be real. But they are listed alongside nonsense in the DSM that no one should take seriously. Apart from trial and error and clinical experience, how is anyone going to know what to believe? The whole thing is pretty messed up.
I hadn't seen SSD before. That one is especially awful.
"But the trouble for me is this: depression, bipolar disorder, schizophrenia, ptsd, anxiety - these do seem to be real."
Perhaps they're recognizable "types" that emerge from mutually-reinforcing networks of symptoms? (I'm choosing the following paper because of its pretty network diagram):
"Pain is not just a message from injured tissues to be accepted at face value, but a complex experience that can be tuned by your brain — and probably more than you think it can, and for weirder reasons..."
Appealing to predictive coding may explain mental illness. Excessive surprisal could create the delusions of salience leading to schizophrenia, for example:
"Bottom-up processing would become more powerful, unrestrained by top-down models... In extreme cases, the 'handshake' between exuberant bottom-up processes and overly timid top-down processes would fail completely, which would take the form of the sudden assignment of salience to a random stimulus. "Schizophrenics are famous for 'delusions of reference', where they think a random object or phrase is deeply important for reasons they have trouble explaining."
"Depression, traditionally viewed as a disorder characterized by negative cognitive biases, is associated with disrupted reward prediction error encoding and signaling... [D]isrupted generative predictions about the sensorium could lead to depressive symptomatology..."
About those "disrupted generative predictions about the sensorium"... I'll digress on what it's like to have a biopsychosocial predicament split into bio- or psycho- or social, with overworked behavioral-health services wishcasting the whole problem as psycho-, since maybe it sheds anecdotal light on systems models for behavioral health:
I grew up in a fluctuating but dull roar of noxious sensation I was expected to ignore, either because it was presumed treatable (atopy) or not recognized for what it was until now (EDS). If "MDD is accompanied by an inability to accurately predict forthcoming sensory information", well, then, that would be me. By world-historic standards, shifting, low-level, discomfort is hardly extraordinary. But, in a social milieu where such discomforts are presumed vanquished, the mismatch between presumption and sensation can be jarring. Well-meaning advice taught me that "healthy attitudes" ignore the dull roar and avoid predicting it, lest focusing on negatives become self-fulfilling. Ignoring a distractor can be mentally taxing. So can repeated, socially-invalid violations of sensory expectations. I may be innately prone to depressive glitches, but pressure to treat sensory discomfort as irrelevant to "health" likely didn't help.
Fatigue and distraction with physical causes can cause ADHD-like symptoms, and ADHD meds might reduce them. May as well call that "having ADHD". I certainly get depressed. While "yellow zone" asthma often disrupts both waking and sleeping, it doesn't normally trigger suicidality, for example.
It's most convenient to providers if mental illness is self-causing. Patients – particularly women – who report physical influences on mental state can't expect to be believed in a psychiatric setting: the presumption that psychologically-disruptive physical sensation is either psychogenic or salient only because of catastrophizing is often too strong: hypothesized somatizing and catastrophizing reduce the messy biopsychosocial stuff down to something "workable", just psycho-mediated. Besides, depression affected by unchosen shifts in physical state might present as... weird... Labile. Like there's gotta be some other mental kink, some secret anxiety, mania, or obsession, at work, too – if non-mental influences are discounted, as they often are. Nonetheless, conditions causing physical discomfort, not necessarily strong discomfort, but unpredictable, belonging- and agency-thwarting discomfort, remain suspiciously correlated with suicidality...
From a systems view, the influence of unchosen physical state on mental state is unsurprising. Heck, it's unsurprising, period, at least in presumed-normal people. If someone presumed mentally-normal is a wreck the day after losing a night's sleep to a fire, that's not betraying "maladaptive decisions" to skip sleep or to find fires and alarms alarming, it's just... normal. Coping with life's vicissitudes while mentally ill takes better coping skills than while mentally healthy, but imperfect coping is normal, not always a sign of abnormal psychology even in the psychologically-abnormal: overworked providers seem extremely bad at recognizing this.
Since familiar mutually-reinforcing clusters of behavioral symptoms do repeatedly emerge in the population, some way of binning sufficiently-similar clusters into "types" makes sense. The bins are psychiatric diagnoses. Binning risks artificially severing what the clusters have in common, though, as well as severing the clusters from the physical and social influences we'd normally expect to influence behavior. The biopsychosocial model of medicine can't be truly bio- and psycho- and social if it's too quick to wall the psycho- part off from the bio- and social part.
I didn't mention mixed states, simply because I don't experience them myself so I don't have any insight to share. No idea on the percentage of rapid cycling - I just anecdotally encounter more people (in Zoom support group for instance) who claim to have it.
Your notes are excellent. With regard to hospitalization for depression, the ER doc takes it seriously, but the insurance companies long ago discovered the magic of "No." Even if admitted, your care in hospital may be rushed, and you'll likely do better in a day program or just outpatient visits. If you can get those, alas.
Thank you for the excellent post. If a patient has ever experienced an episode of mania, the diagnosis is bipolar type I, if not (i.e. they have experienced episodes of depression and episodes of hypomania, which literally means below mania) the diagnosis is type II.
This post is the deciding factor for subscribing. You have the compassion and grace to treat this subject with the responsibility and discernment it commands. A much welcome perspective.
>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.
A thousand yeses to this, but I have more thoughts.
Among lay people often no attention is paid to what bipolar disorder is--episodes of severe and persistent elevated and depressed mood over the lifecourse--to favor of a stereotype of some touchy asshole who's always flying off the handle. But on the flip side, the informed narrative can look a little too clean: mania, depression, normality, rinse and repeat. The mood extremes themselves often come with volatility and irritability, and irritability (heads up, fellow travelers, I've found this fact helpful) is often a leading indicator of an oncoming episode. And I think the relationship between macro-mood episodes and micro-mood instability is fairly well known. But having struggles with mood lability and irritability even when "euthymic" (in the relatively normal mood periods) is not uncommon and not necessarily a sign of a separate issue (although it could be, as far as determining that ever goes**). I say this based on my own experience, my anecdotal experience with other bipolar people, and some pubmed'ing I've done that supports the notion (cf. https://www.sciencedirect.com/science/article/abs/pii/S0165178107001941). So while mood swings are not at all used to determine whether someone has bipolar, and shouldn't be used as an independent indication that anyone is bipolar, bipolar people may be more likely to be mood-volatile, in a trait-like way the persists over macro-mood courses. But I'm usually loathe to mention this lest I add fuel to the idea that bipolar people are just moody jerks who will crank at you if you cross them. Or contribute to the swell of diagnostic inflation for that matter.
I feel like I need to add a bit on what I mean by macro-mood and micro-mood. Your mood can change a lot, from moment to moment, day to day, etc. But on the clinical mood scale most people will live their entire lives in what I was referring to as normality, in euthymia. People who experience depression will go further down the scale than most and people who experience mania will go further up the scale than most. But when you're briefly very sad or briefly very happy you aren't experiencing "mini depressions" and "mini manias". And a lot of very sad or very happy feelings chained together does not a mood episode make. Mania and depression are about dispositions to behavior, not feelings per se, and represent a shift the whole organism undergoes, with attendant changes in eating, sleeping, goal-directed and social behavior, and emotional patterns as well. Come to think of it, I might as well have just called the micro-moods "emotions" and spared myself this whole paragraph. Anyhow If you understand that you can feel down for awhile and not want to go out as much but also laugh at something funny during that time you understand the difference between mood and emotion I'm pointing at.
[**"Maybe my mood swings are caused by something else, like ADHD or child abuse hx...but wait! Maybe my bipolar is just a manifestation of the child abuse! Maybe there's a lurking temperamental variable mediating an interaction between the two!" I have to make fun of myself because I start to feel very silly very quickly discussing diagnostic categories assembled by committee like they have independent causal powers.]
I definitely resonate with the idea of people thinking having bipolar is somehow 'cooler' then having depression, my thought is that it might be less common and therefore adds to your 'unique' experience of mental illness. Depression is 'basic' but bipolar makes you more extreme?
I'm diagnosed as bipolar 2. It was actually quite a shock to me because I went through a period of very typical depression. Then I started to experience what I didn't understand at the time was mania. I just believed I was better.
When I got to my senior year of college I went through in retrospect a very manic episode that lasted about 4 months. I spent a ton of money on credit cards, was using substances constantly, was extremely irritable, wasn't sleeping, ended up taking 25 credits in my last semester of college because I believed I was extremely intelligent and could do much better than all these other kids in college who were only taken a pitiful 14 credits. I was convinced that I was just a better artist and student than everyone else and definitely had a period of deep grandiosity. I was young, 21, and didn't really have a lot of information about bipolar disorder so I assumed that I was just healed from my depression and had become myself again. Then right after my graduation I crashed overnight into one of the most depressive periods of my life.
I had taken anti-depressants before and they had never worked. When I finally went to another psychiatrist after college I was told that maybe I should try mood stabilizers because this sounded like bipolar disorder. I was horrified because I associated bipolar with people who were REALLY crazy vs depression was sort of just a justifiable disorder. Taking lamictol changed my life and I began to accept that maybe I did have bipolar disorder and this was something I would have to own and live with. It was very difficult for me but I recognized that being able to function was superior to being shamed by a label and therefore not taking care of myself. The diagnosis is difficult to deal with and I still do feel shame occasionally, especially because my family. I have never understood the pride of putting it as the first line of your dating profile, but everyone is different. I think being more aware of symptoms is helpful and allowing people to not feel shame about their diagnosis is important, but this disorder is something I would never wish upon anyone, no matter how seemingly 'cool' it makes you.
Can you rewire your brain? Can you rewire how your body works? Would that begin to alleviate symptoms if you could step back from your thoughts and emotions and feelings as they arise? Have you ever looked at how you breathe or do you believe that you know how to breathe. Do you think breathing effects your mind? For instance, which way is your diaphragm moving on the inhale? If it moves up that's your body telling your brain that you're in fight, flight, freeze, fawn, flop. What if you had more control over your breathing. Breathing affects all your physical systems, even the flow of fluid in your spinal cord.
Where does thinking occur? Are you trapped by your inability to manage your thoughts or is there a way out? Are you your thinking? Do you identify your self by the thoughts you have? Is there anything more powerful than thinking, or is thinking actually a weak force? If you had zero thoughts would you have emotions? Do you know the difference between emotions and feelings?
Where do you place your ego? What is its job? Is the ego creative? Or does that come from somewhere else? Does your ego convince you to speak or act in a way that you know is wrong but you believe that it's protecting you?
Do you feel safe? How do you measure safety? Can you feel safe ever if you have no real way to control your thoughts or emotions or your body? Take a big breath and observe. Is your inhale smooth or staticky? Long or short? Slow or fast? Do you breathe differently when you're manic or depressed? Are you storing past emotions in your body and are they then being triggered, unconsciously?
Do you know what attention is and how to use it? Same question for intention? Do you use your imagination? Can you control it? If not, what if you practiced controlling it? The same way you could practice breathing consciously. How might you approach breathing so that your mental/emotional state would be positively affected? Are you breathing two-dimensionally? Which is to say, into your chest or belly, but not into your back, or armpits? What happens if you don't breathe into your back? Are you tense? What if you were less tense all the time? Would that improve your moods? Can you manage a mood or is it too late? What if you practice presence? Would your mind become more subtle and powerful if you didn't ignore your emotions and feelings as they arise? What if you weren't subject to your thoughts and emotions? What if they stopped and you could just breathe for a while? What's there if you were to lower the volume on your thoughts and emotions? Is it fear? Pain? Is that why you never stop? What are you avoiding?
Did you ever ask yourself where your heart is? Is it in your throat? Is it too much in the world? Do you know how to take care of your heart? What about the pericardium? What are the waters around your heart like? Are they sludgy or dark? How might that affect your current state of mind?
What about your brain? Is it dry and overheated? Have you ever looked at it? What would you need to look at your brain? How about imagination? What will your imagination tell you about the physical state of your brain? Have you ever compared the front of the brain to the back? Did you know that the visual cortex is in the occipital lobe at the back of the brain? What does the front of the brain feel like compared to the back? What does they left hemisphere feel like compared to the right? Does it matter? Are they working together or separately? Is your brain working in service to your heart or your ego? What about your gut? Do you override your gut with logic? What are you listening to? Did you know that statistically the majority of self-talk was negative and repetitive? Do you believe you could edit your thinking if you observed your thoughts arise from the back of the brain?
I have so many questions.
How do you experience time?
Are your brainwaves in synch?
Where does personal space end and interpersonal space begin?
Are people stealing your energy if you have no boundaries? How?
What does your core energy look like?
Did you know that there is a pyramid in the middle of the brain and that it's a triage center?
Do you know how to turn your head left and right, or do you do it without thinking?
Can you stand without falling off your arches?
Do you move reflexively or is every movement an effort?
Do you know how much energy it takes to sit and stand if you're not doing it reflexively?
What did your baby self believe about you? Did he/she hate you, or did you learn that?
My one quibble is that I don't think of this, or any other mental condition, as "either/or." I am not a psychiatrist or a student of psychology, but my inclination is to think in terms of a spectrum rather than either/or. I think that one can have mood swings that are very noticeable and somewhat debilitating but not extremely intense, and the decision about whether such a person needs treatment would be ambiguous.
Have not yet watched the video, but the posting itself strikes me as a good consumer's guide.
One question: Years ago I got the impression that the distinction between Bipolar Disorder I and Bipolar Disorder II was whether your illness was serious enough to warrant hospitalization, with (IIRC) hospitalization moving you up from II to I. Was that distinction ever a valid rule-of-thumb or was it just popular misunderstanding?
I mention this a bit - the way doctors have always discussed it with me, I is for people who go full out manic and II people top out at hypomania. But it's confusion and so I'm fobbing the question off to the DSM.
Freddie, the DSM uses your criterion 13, and there while there might be stealth indicators psychiatrists use to hint at one or the other, there aren't stealth criteria. If you have one proper manic episode you are Bipolar I, and psychosis is an automatic bump to mania from hypomania.. I think what you write in points 8 and 12 about mood state dominance is inaccurate and likely to lead to some confusion. (The majority of bipolar I people are also "depression dominant" in terms of time spent in depression vs mania.) Diagnostically it has nothing to do with how often you experience those states and everything to do with their intensity, and if psychiatrists are doing something else they are going rogue. Not that that never happens--I've also heard of people wind up with schizoaffective diagnoses because the schizoaffective/bipolar I line is fairly technical (as is the difference between hypomania and mania in the absence of psychosis) and some clinicians--wrongly!--round off to "presence of psychotic symptoms in bipolar --> a schizoaffective dx." And to point 14, actually, you can receive a bipolar diagnosis in the absence of depressive episodes, and some people do seem to present with manic episodes only.
When I say "depression dominant" or "mania dominant," I'm trying to refer to intensity, not to frequency. I will add a note to that effect. See if it looks any better now.
It's really only the intensity of the manic symptoms that's determinant. (How and why the mood-state space got carved up this way is probably an interesting story.)
Thanks much though Freddie, I'll stop nitpicking to say I'm always glad when you shine some light in this corner.
"aside from perhaps a few of the most advanced Buddhist monks"
--Smeh, they're the most messed up of us all.
To disavow all 'things' but then need special robes, special haircut, idols ... special markings--mysticism--for the purpose of setting themselves apart from the masses of humanity, positions, trappings, they become sought after things themselves, with what end goal, but to gain mystic respect, to master others in a hierarchical organization.
To engage in advanced naval gazing to the point of enlightenment?, or perhaps delusion.
Do you think it's possible that alcoholics are commonly misdiagnosed as bipolar? Is there an association between alcoholism and bipolar disorder?
I think substance abuse and mood disorders in general are very often comorbid, yes. Don't know about alcoholism and bipolar specifically.
There’s definitely an association. Alcohol is frequently used by people in states of depression and mania as a means of self-medication, and alcohol can exacerbate both depression and psychosis. I think my doctor told me that about 40% of people with bipolar have a diagnosable alcohol problem and about 50% have comorbid ADHD or another intellectual disorder. One of the reasons diagnosis is so complicated is that it’s rare for someone to just have one thing malfunctioning in their brain/body, and bipolar in particular tends to couple up with other health conditions.
"I think my doctor told me that about 40% of people with bipolar have a diagnosable alcohol problem and about 50% have comorbid ADHD or another intellectual disorder."
It's also true that medications used to treat inattention – or even stuffy sinuses – may have side-effects that might be mistaken for anxiety or inappropriate mood elevation. Checking for this is one of the basic responsibilities of medication management, but could get overlooked. (And may especially get overlooked if mental-health clinicians telegraph that patients who mention physical issues will get labeled with "health anxiety"/SSD: https://www.bmj.com/content/346/bmj.f1580/rr/638352#:~:text=In%20medicine%2C%20differential,are%20mistakenly%20diagnosed. )
The answer isn't always reducing medication, or just accepting a side-effect rather than treating it, but sometimes it is.
Thanks for opening up and sharing deep personal thoughts and experiences. I do think you're providing a valuable gateway to acceptance of mental health conditions.
It breaks my heart that you have to tell people clinical depression is no less "cool" than bipolar disorder. But I get why you do.
My experience was that my first manic episode was actually triggered by receiving SSRIs for a misdiagnosis of MDD, and I’ve heard similarly from a few other people with diagnosed bipolar. That’s one of the many reasons “response to medication” is such an important screener in diagnosis and why self-diagnosis checklists are incapable of capturing the complete story.
For me, mood cycling isn’t like quickly switching between emotions predictably. It’s more like rolling the dice every few weeks. Even numbers I’m fine, odd numbers I’m depressed, snake eyes I’m manic. I never know when it’s dice-rolling time but some events (substance use, breakups, life events) are more likely to kick it off. There’s a unique horror that comes from, even with perfect treatment compliance, just never knowing if today’s the day your brain decides to shit itself again.
I shall take this opportunity to give thanks that my mental fucked-up-itude is both manageable to the point where I cannot label it a disorder, and also the result of material intrusions into my brain from my environment and not an internal matter.
"People self-diagnosing as bipolar based on moving quickly from happiness to sadness are doing themselves a disservice and misunderstanding the diagnosis."
True. It's also worth noting that clinicians may do the same thing, especially when they're overworked.
"Psychiatric diagnoses such as bipolar disorder remain defined purely by their phenomenology, akin to migraine, Meniere’s disease, tinnitus... But it is hard to discriminate among possible conditions that fall within a differential diagnosis if the component elements of a defined syndrome are deconstructed and evaluated without considering the broader clinical context in which they arise. A young adult woman with high interpersonal sensitivity who becomes upset after quarreling with an intimate relation does not consequently 'rapidly cycle' all night. The businessman who rises to the occasion of increased work demands with gusto cannot volitionally summon up hypomania at will, nor does a manic episode typically end in convenient synchrony with the completion of an arduous work or social obligation."
^ That's advice written to clinicians, who don't always consider the broader context in which patient behavior arises. In fairness, many clinicians work under circumstances that aren't conducive to gathering context, even the context heading the patient's chart.
https://www.psychiatrist.com/jcp/assessment/diagnostic-tools/commentary-lowering-diagnostic-threshold-bipolar-disorder/
Allen Frances, chair of the DSM IV committee, now regrets having added bipolar II and Asperger's to DSM IV:
"We had excellent empirical evidence for including both bipolar II and Asperger’s in DSM IV, but both did more harm than good. Data drawn from research studies on highly selected patients in the hothouse environment of a university research clinic generalize very poorly to the hustle and bustle of primary care" (or even resource-strapped secondary care.)
https://www.psychiatrictimes.com/view/conversations-critical-psychiatry-allen-frances-md
"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."
Still, there is such a thing as too adversarial. Making snap social judgments about people is a normal human heuristic when bandwidth is low, and clinicians may do it, too. Whether it's a judgment that Black patients must just be seeking recreational drugs, or that women who believe the can succeed in STEM inherently have delusions of grandeur, or that the default assumption should be that patient reports that medication isn't helping shouldn't be believed, some clinicians may strike adversarial postures that make it more difficult, not less, for them to provide appropriate treatment, at least to someone like you.
And, if your problem is that you're down on yourself, inclined to lend too much credence to the least-charitable takes on who you are and what you're doing, you might be particularly vulnerable to putting up with this kind of inappropriate treatment. Being honest with yourself typically doesn't require accepting a cartoon version of yourself that's unrecognizable to you or to those who know you well, just because some official said so. But if you're down on yourself enough, you could be persuaded that it does.
Dr Frances wrote an entire book about his concerns around overdiagnosis after DSM V was released. I tend to agree with many of his concerns, but it's worth noting that he seems like he has a stake in defending his position here. He may not be a good objective source.
I don't expect Dr Frances to be objective. Psychiatry itself isn't on an objective footing yet. What I expect from interested experts is honesty, including honest dialog where interest counters interest.
In that respect, I regard Dr Frances's stake in defending his position as mostly good. DSM 5 did come with serious risks of compounding psychiatry's diagnostic inflation, and, given that risk, it makes sense for experts in the field to speak up about it, even if they stand to gain something by making it their pet issue.
When objectivity isn't a feasible standard, I expect honest advocacy, even if I don't entirely agree with it.
I admit Dr Frances's interests and mine coincide somewhat, since I'm in one of the patient populations disproportionately threatened by the DSM 5's "SSD":
https://www.psychologytoday.com/us/blog/dsm5-in-distress/201212/mislabeling-medical-illness-mental-disorder
It's bad enough when medically *un*explained symptoms are assumed, absent other supporting evidence, to "prove" a mental disorder. Now medically *explained* symptoms may, too. Yes, I'm glad old lions of the field speak up against that, and other risks of diagnostic inflation, even if it helps them sell books.
I think he'd be a more effective advocate if his arguments were more objective and less rhetorical. I read part of his book for a paper a few weeks ago and found it full of exaggerations and misrepresentations of the sources he cited. But, as I said, I mostly agree with his conclusions.
If it's any comfort, my classes, teachers, and other students are all very skeptical of the DSM in general and specifically the diagnostic inflation we're talking about. I think that's a good sign for the future, at least. But the trouble for me is this: depression, bipolar disorder, schizophrenia, ptsd, anxiety - these do seem to be real. But they are listed alongside nonsense in the DSM that no one should take seriously. Apart from trial and error and clinical experience, how is anyone going to know what to believe? The whole thing is pretty messed up.
I hadn't seen SSD before. That one is especially awful.
"But the trouble for me is this: depression, bipolar disorder, schizophrenia, ptsd, anxiety - these do seem to be real."
Perhaps they're recognizable "types" that emerge from mutually-reinforcing networks of symptoms? (I'm choosing the following paper because of its pretty network diagram):
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0137621
Pain, the body's alert system for damage, seems to really be a system – and that's just for one sensation!:
https://www.bettermovement.org/blog/2014/a-systems-perspective-on-chronic-pain
Pain is also weird – and its weirdness may shed light on mental weirdness more generally:
https://www.painscience.com/articles/pain-is-weird.php
"Pain is not just a message from injured tissues to be accepted at face value, but a complex experience that can be tuned by your brain — and probably more than you think it can, and for weirder reasons..."
Appealing to predictive coding may explain mental illness. Excessive surprisal could create the delusions of salience leading to schizophrenia, for example:
"Bottom-up processing would become more powerful, unrestrained by top-down models... In extreme cases, the 'handshake' between exuberant bottom-up processes and overly timid top-down processes would fail completely, which would take the form of the sudden assignment of salience to a random stimulus. "Schizophrenics are famous for 'delusions of reference', where they think a random object or phrase is deeply important for reasons they have trouble explaining."
https://slatestarcodex.com/2016/09/12/its-bayes-all-the-way-up/
Meanwhile,
"Depression, traditionally viewed as a disorder characterized by negative cognitive biases, is associated with disrupted reward prediction error encoding and signaling... [D]isrupted generative predictions about the sensorium could lead to depressive symptomatology..."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8927302/
About those "disrupted generative predictions about the sensorium"... I'll digress on what it's like to have a biopsychosocial predicament split into bio- or psycho- or social, with overworked behavioral-health services wishcasting the whole problem as psycho-, since maybe it sheds anecdotal light on systems models for behavioral health:
I grew up in a fluctuating but dull roar of noxious sensation I was expected to ignore, either because it was presumed treatable (atopy) or not recognized for what it was until now (EDS). If "MDD is accompanied by an inability to accurately predict forthcoming sensory information", well, then, that would be me. By world-historic standards, shifting, low-level, discomfort is hardly extraordinary. But, in a social milieu where such discomforts are presumed vanquished, the mismatch between presumption and sensation can be jarring. Well-meaning advice taught me that "healthy attitudes" ignore the dull roar and avoid predicting it, lest focusing on negatives become self-fulfilling. Ignoring a distractor can be mentally taxing. So can repeated, socially-invalid violations of sensory expectations. I may be innately prone to depressive glitches, but pressure to treat sensory discomfort as irrelevant to "health" likely didn't help.
Fatigue and distraction with physical causes can cause ADHD-like symptoms, and ADHD meds might reduce them. May as well call that "having ADHD". I certainly get depressed. While "yellow zone" asthma often disrupts both waking and sleeping, it doesn't normally trigger suicidality, for example.
It's most convenient to providers if mental illness is self-causing. Patients – particularly women – who report physical influences on mental state can't expect to be believed in a psychiatric setting: the presumption that psychologically-disruptive physical sensation is either psychogenic or salient only because of catastrophizing is often too strong: hypothesized somatizing and catastrophizing reduce the messy biopsychosocial stuff down to something "workable", just psycho-mediated. Besides, depression affected by unchosen shifts in physical state might present as... weird... Labile. Like there's gotta be some other mental kink, some secret anxiety, mania, or obsession, at work, too – if non-mental influences are discounted, as they often are. Nonetheless, conditions causing physical discomfort, not necessarily strong discomfort, but unpredictable, belonging- and agency-thwarting discomfort, remain suspiciously correlated with suicidality...
From a systems view, the influence of unchosen physical state on mental state is unsurprising. Heck, it's unsurprising, period, at least in presumed-normal people. If someone presumed mentally-normal is a wreck the day after losing a night's sleep to a fire, that's not betraying "maladaptive decisions" to skip sleep or to find fires and alarms alarming, it's just... normal. Coping with life's vicissitudes while mentally ill takes better coping skills than while mentally healthy, but imperfect coping is normal, not always a sign of abnormal psychology even in the psychologically-abnormal: overworked providers seem extremely bad at recognizing this.
Since familiar mutually-reinforcing clusters of behavioral symptoms do repeatedly emerge in the population, some way of binning sufficiently-similar clusters into "types" makes sense. The bins are psychiatric diagnoses. Binning risks artificially severing what the clusters have in common, though, as well as severing the clusters from the physical and social influences we'd normally expect to influence behavior. The biopsychosocial model of medicine can't be truly bio- and psycho- and social if it's too quick to wall the psycho- part off from the bio- and social part.
Great post.
Did you mention mixed states (negative emotions, manic energy) in here at all?
Also what the typical frequency of rapid cycling is actually? I think the most frequent i ever had was about a day, but that's anecdotal.
(Obviously, i am not a doctor either, so this is just my own experience talking.)
I didn't mention mixed states, simply because I don't experience them myself so I don't have any insight to share. No idea on the percentage of rapid cycling - I just anecdotally encounter more people (in Zoom support group for instance) who claim to have it.
Your notes are excellent. With regard to hospitalization for depression, the ER doc takes it seriously, but the insurance companies long ago discovered the magic of "No." Even if admitted, your care in hospital may be rushed, and you'll likely do better in a day program or just outpatient visits. If you can get those, alas.
Thank you for the excellent post. If a patient has ever experienced an episode of mania, the diagnosis is bipolar type I, if not (i.e. they have experienced episodes of depression and episodes of hypomania, which literally means below mania) the diagnosis is type II.
There is evidence of people who only have episodes of mania without depression (called unipolar mania) but it’s uncommon https://pubmed.ncbi.nlm.nih.gov/31818781/
This post is the deciding factor for subscribing. You have the compassion and grace to treat this subject with the responsibility and discernment it commands. A much welcome perspective.
>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.
A thousand yeses to this, but I have more thoughts.
Among lay people often no attention is paid to what bipolar disorder is--episodes of severe and persistent elevated and depressed mood over the lifecourse--to favor of a stereotype of some touchy asshole who's always flying off the handle. But on the flip side, the informed narrative can look a little too clean: mania, depression, normality, rinse and repeat. The mood extremes themselves often come with volatility and irritability, and irritability (heads up, fellow travelers, I've found this fact helpful) is often a leading indicator of an oncoming episode. And I think the relationship between macro-mood episodes and micro-mood instability is fairly well known. But having struggles with mood lability and irritability even when "euthymic" (in the relatively normal mood periods) is not uncommon and not necessarily a sign of a separate issue (although it could be, as far as determining that ever goes**). I say this based on my own experience, my anecdotal experience with other bipolar people, and some pubmed'ing I've done that supports the notion (cf. https://www.sciencedirect.com/science/article/abs/pii/S0165178107001941). So while mood swings are not at all used to determine whether someone has bipolar, and shouldn't be used as an independent indication that anyone is bipolar, bipolar people may be more likely to be mood-volatile, in a trait-like way the persists over macro-mood courses. But I'm usually loathe to mention this lest I add fuel to the idea that bipolar people are just moody jerks who will crank at you if you cross them. Or contribute to the swell of diagnostic inflation for that matter.
I feel like I need to add a bit on what I mean by macro-mood and micro-mood. Your mood can change a lot, from moment to moment, day to day, etc. But on the clinical mood scale most people will live their entire lives in what I was referring to as normality, in euthymia. People who experience depression will go further down the scale than most and people who experience mania will go further up the scale than most. But when you're briefly very sad or briefly very happy you aren't experiencing "mini depressions" and "mini manias". And a lot of very sad or very happy feelings chained together does not a mood episode make. Mania and depression are about dispositions to behavior, not feelings per se, and represent a shift the whole organism undergoes, with attendant changes in eating, sleeping, goal-directed and social behavior, and emotional patterns as well. Come to think of it, I might as well have just called the micro-moods "emotions" and spared myself this whole paragraph. Anyhow If you understand that you can feel down for awhile and not want to go out as much but also laugh at something funny during that time you understand the difference between mood and emotion I'm pointing at.
[**"Maybe my mood swings are caused by something else, like ADHD or child abuse hx...but wait! Maybe my bipolar is just a manifestation of the child abuse! Maybe there's a lurking temperamental variable mediating an interaction between the two!" I have to make fun of myself because I start to feel very silly very quickly discussing diagnostic categories assembled by committee like they have independent causal powers.]
I definitely resonate with the idea of people thinking having bipolar is somehow 'cooler' then having depression, my thought is that it might be less common and therefore adds to your 'unique' experience of mental illness. Depression is 'basic' but bipolar makes you more extreme?
I'm diagnosed as bipolar 2. It was actually quite a shock to me because I went through a period of very typical depression. Then I started to experience what I didn't understand at the time was mania. I just believed I was better.
When I got to my senior year of college I went through in retrospect a very manic episode that lasted about 4 months. I spent a ton of money on credit cards, was using substances constantly, was extremely irritable, wasn't sleeping, ended up taking 25 credits in my last semester of college because I believed I was extremely intelligent and could do much better than all these other kids in college who were only taken a pitiful 14 credits. I was convinced that I was just a better artist and student than everyone else and definitely had a period of deep grandiosity. I was young, 21, and didn't really have a lot of information about bipolar disorder so I assumed that I was just healed from my depression and had become myself again. Then right after my graduation I crashed overnight into one of the most depressive periods of my life.
I had taken anti-depressants before and they had never worked. When I finally went to another psychiatrist after college I was told that maybe I should try mood stabilizers because this sounded like bipolar disorder. I was horrified because I associated bipolar with people who were REALLY crazy vs depression was sort of just a justifiable disorder. Taking lamictol changed my life and I began to accept that maybe I did have bipolar disorder and this was something I would have to own and live with. It was very difficult for me but I recognized that being able to function was superior to being shamed by a label and therefore not taking care of myself. The diagnosis is difficult to deal with and I still do feel shame occasionally, especially because my family. I have never understood the pride of putting it as the first line of your dating profile, but everyone is different. I think being more aware of symptoms is helpful and allowing people to not feel shame about their diagnosis is important, but this disorder is something I would never wish upon anyone, no matter how seemingly 'cool' it makes you.
Can you rewire your brain? Can you rewire how your body works? Would that begin to alleviate symptoms if you could step back from your thoughts and emotions and feelings as they arise? Have you ever looked at how you breathe or do you believe that you know how to breathe. Do you think breathing effects your mind? For instance, which way is your diaphragm moving on the inhale? If it moves up that's your body telling your brain that you're in fight, flight, freeze, fawn, flop. What if you had more control over your breathing. Breathing affects all your physical systems, even the flow of fluid in your spinal cord.
Where does thinking occur? Are you trapped by your inability to manage your thoughts or is there a way out? Are you your thinking? Do you identify your self by the thoughts you have? Is there anything more powerful than thinking, or is thinking actually a weak force? If you had zero thoughts would you have emotions? Do you know the difference between emotions and feelings?
Where do you place your ego? What is its job? Is the ego creative? Or does that come from somewhere else? Does your ego convince you to speak or act in a way that you know is wrong but you believe that it's protecting you?
Do you feel safe? How do you measure safety? Can you feel safe ever if you have no real way to control your thoughts or emotions or your body? Take a big breath and observe. Is your inhale smooth or staticky? Long or short? Slow or fast? Do you breathe differently when you're manic or depressed? Are you storing past emotions in your body and are they then being triggered, unconsciously?
Do you know what attention is and how to use it? Same question for intention? Do you use your imagination? Can you control it? If not, what if you practiced controlling it? The same way you could practice breathing consciously. How might you approach breathing so that your mental/emotional state would be positively affected? Are you breathing two-dimensionally? Which is to say, into your chest or belly, but not into your back, or armpits? What happens if you don't breathe into your back? Are you tense? What if you were less tense all the time? Would that improve your moods? Can you manage a mood or is it too late? What if you practice presence? Would your mind become more subtle and powerful if you didn't ignore your emotions and feelings as they arise? What if you weren't subject to your thoughts and emotions? What if they stopped and you could just breathe for a while? What's there if you were to lower the volume on your thoughts and emotions? Is it fear? Pain? Is that why you never stop? What are you avoiding?
Did you ever ask yourself where your heart is? Is it in your throat? Is it too much in the world? Do you know how to take care of your heart? What about the pericardium? What are the waters around your heart like? Are they sludgy or dark? How might that affect your current state of mind?
What about your brain? Is it dry and overheated? Have you ever looked at it? What would you need to look at your brain? How about imagination? What will your imagination tell you about the physical state of your brain? Have you ever compared the front of the brain to the back? Did you know that the visual cortex is in the occipital lobe at the back of the brain? What does the front of the brain feel like compared to the back? What does they left hemisphere feel like compared to the right? Does it matter? Are they working together or separately? Is your brain working in service to your heart or your ego? What about your gut? Do you override your gut with logic? What are you listening to? Did you know that statistically the majority of self-talk was negative and repetitive? Do you believe you could edit your thinking if you observed your thoughts arise from the back of the brain?
I have so many questions.
How do you experience time?
Are your brainwaves in synch?
Where does personal space end and interpersonal space begin?
Are people stealing your energy if you have no boundaries? How?
What does your core energy look like?
Did you know that there is a pyramid in the middle of the brain and that it's a triage center?
Do you know how to turn your head left and right, or do you do it without thinking?
Can you stand without falling off your arches?
Do you move reflexively or is every movement an effort?
Do you know how much energy it takes to sit and stand if you're not doing it reflexively?
What did your baby self believe about you? Did he/she hate you, or did you learn that?