To clarify…I know that extreme cases of highs and lows are fairly easy to spot. It’s the less drastic cases I’m curious about.
Angel, if you are interested in some assistance finding employment that accommodates your illness, I would recommend looking to your State VR agency. You do not have to be on SSDI to receive services, although there may be a waiting list. That’s assuming you are in the US, of course.
I would also like to point out that there are so many varying degrees of severity of Bipolar Disorder. To say that all people with bipolar should work, or need to take time off for recovery, or are self-indulgent, or whatever, paints with way, way too broad a brush.
The DSM-IV lays out the standard for diagnosing bipolar disorder. The standard to diagnose Bipolar I requires one or more manic or mixed episode, and possibly one or more depressive episodes, without it being caused by drugs or disease.
Criteria for a manic episode: a week or more of persistently elevated, expansive, or irritable mood, during which at least three of the following symptoms are present to the degree that normal social and/or occupational functioning is markedly impaired:
- inflated self-esteem or grandiosity
- decreased need for sleep
- increased talkativeness, sense of pressure to keep talking
- flight of ideas, sense that thoughts are racing
- distractability (attention easily diverted to irrelevant stimuli)
- increase in goal-directed activity and/or psychomotor agitation
- excessive involvement in pleasurable but risky activities (buying sprees, hypersexuality, etc.)
Criteria for a major depressive episode: Five or more of the following symptoms are present in a two week period; must have either 1 or 2; must cause marked impairment in social or occupational functioning and/or cause significant distress.
- depressed mood most of the day, nearly every day (could be irritable mood)
- marked decrease in interest or pleasure in nearly all activities, nearly every day
- significant weight loss or weight gain
- insomnia or hypersomnia
- psychomotor agitation or retardation
- fatigue or loss of energy
- feelings of worthlessness and/or excessive, inappropriate feelings of guilt
- diminished ability to think or concentrate
- recurrent thoughts of death and/or suicide
Cases of Bipolar I tend to be pretty clear-cut, although sometime it is a matter of getting the doctors to see you when you’re manic to get a diagnosis. I was misdiagnosed as having recurrent severe depression until I had a manic episode that my psychiatrist saw. I had had one in the past, but was not under the care of a doctor then, so they didn’t want to make a diagnosis without seeing it for themselves.
To diagnose Bipolar II requires one or more Major Depressive Episodes and at least one Hypomanic Episode.
Criteria for a Hypomanic Episode: A distinct period of persistently elevated, expansive, or irritable mood lasting at least 4 days, that is markedly different than usual mood, observable by others, without severe impairment of functioning, with three or more of the following symptoms (four if mood is only irritable):
- inflated self-esteem, grandiosity
- decreased need for sleep
- more talkative than usual, pressure to keep talking
- flight of ideas, racing thoughts
- distractability
- increase in goal-directed activity, psychomotor agitation
- increase in pleasurable but risky activities like buying sprees, sex, etc.
So Bipolar II tends to be a pretty clear-cut diagnosis as well.
Cyclothymic Disorder is where a person cycles regularly from hypomania to mild depression, but none of them ever become major depression or mania. This can be harder to diagnose because it doesn’t cause severe impairment. However, it is often a precursor to developing Bipolar I or II.
A Bipolar Not Otherwise Specified (NOS) category exists as well. People who get this diagnosis are the “close, but not quite” types. Maybe they have bursts of mania that don’t last a full week, for example.
Difficulties in diagnosis are there, though, despite how clear-cut this can all look. Some I’ve seen are:
- Sometimes patients lie about their symptoms. (Self-report is important.)
- Sometimes patients don’t recognize their symptoms.
- Maybe not sure whether symptoms quite meet the diagnostic criteria.
- Doctors don’t get to see a person every day or track them for their whole life.
- Bipolar people have higher rates of drug and alcohol abuse than average; this skews the picture for doctors.
- Legal and illegal drugs can both cause mood disturbances that look like bipolar disorder.
- Some people have rapidly-changing mood cycles. This is not a part of the classic profile of bipolar disorder and there is not a lot of research or knowledge about this phenomenon. It might be a different kind of bipolar disorder. It might be triggered by medication or drugs. It might be a non-bipolar kind of illness, like borderline personality disorder or an anxiety disorder. Basically, nobody knows, but a lot of them get a diagnosis of Bipolar Disorder NOS, which is sort of an “I don’t know” category.
On average, it takes seven years for a person to be diagnosed with bipolar disorder after they actually begin to have the disease. Even if you have one of the most classic, clear-cut kinds of the disorder, you still need to get to a competent doctor, have them see you while impaired, and get them a full history. This is harder than it sounds. Many people don’t want to see a psychiatrist. They don’t want to admit they might be crazy. They might think they have a problem and want help, but not know what information is important to tell a doctor. A doctor will want either a very clear-cut report of both mania and depression, or to see each mood state for him/herself. That can take years.
There is, however, one (unofficial) test for whether an impaired person is bipolar or not. In the book Of Two Minds, in which an anthropologist followed psychiatric residents during their training, they were taught to prescribe lithium for a patient with suspected bipolar disorder in an acute state. If s/he gets better, it’s almost certainly bipolar disorder. While this might sound a touch like Dr. House, it’s really the only biological “test” available.
Hope that helps.
Thanks so much for this info. Very interesting and thorough. I have a BIL who was diagnosed 30 years ago with bipolar and has been living unmedicated (with the exception of Xanax, which I’m not even sure was prescribed for him).
He has extended periods of mania and depression. I’m talking months-to-years of hyper productivity and then in bed (I believe he went 3 years one time). He is seeing a counselor who, as far as I know, is not a psychiatrist. This was court-ordered because he was terrorizing my SIL – calling the cops on her for things like making a local phone call on her mother’s phone, flicking a candy wrapper at him, etc. Is that kind of extended symptom indicitave of BPD?
As a former cashier here, no, no you don’t. You really, really don’t.
Trust me.
Bipolar, that accursed blessing! What can be better? The mental energy of three brains pouring through one body! The illusion of genius that comes from incredible productivity–those occasional errors just get chalked up to statistical anomolies by the bewildered onlookers. The beautifully intricate solutions you come up with as you hyperfocus and obsess over an issue which is largely ignored by others (but you’re convinced this is because they consider it un-solvable). The wit and warmth others sense in you that draws them near, filling your life with joys of a height few can dare to dream…and then, in a flash of rage, you change. You alienate all as that mechanical hum of a machine tuned to brilliance speeds past the red line, ripping through your life leaving a sordid path of broken hearts, shattered images and torched bridges. And when you finally sieze up and copllapse, you turn and see what you’ve wrought. And then the shame and sorrow sprout and blossom, filling the void once kept by pride, competence, belief. Days? Weeks? Months later, you slowly you crawl out from under a rock because you must, and start over. And after a few cycles the heights are always illuminated with the memory of where they will inevitably lead, so rather than joy, any successes you will ever see will be tainted by fear. Fear that this is just another delusion destined for the plunge. Pride becomes shame as you begin to realize, whether true or not, that you are allowing others to respect you when you deserve none at all–and they will soon find this out–you should never have let anyone near you this time, because you know, you know, how it will end. How they will be crushed by you in the end. And so it goes.
And so it goes for years. And while you sound the depths of the abyss, it gets just a little worse. For in the pelvis-crushing loneliness of it all, you grow just a little mad. Your senses turn on you and play little jokes. Was that someone tapping on the desk just now? Why can’t anyone else hear that siren off in the distance? Does nobody else feel that tree staring at them, or is it just me? Why does the floor pitch and roll like the surface ofa lake–it didn’t used to? And in the confusion, you are scooped up once again by the illness and hurled to the heavens…and so it will continue to go. Until you end it for the sake of others, and for your own. End it. Just end it. Whatever it takes, whomever it hurts it will hurt less than if you don’t. You know this, you must make it stop, bring it all to an end. And so the voices, your voices, and the faces of those whom you love, plead with you. And you inevitably end up with only one answer when alcohol fails you. Nintendo.
That, my friend, is why you will be looking to antipsychotics. It’ a disorder that underlies and exacerbates mood swings, but it is not a mood swing disorder.
Joder, Inigo, I’d send you hugs but right now I’m not sure you wouldn’t bite me… that sure sounds painful 
It’s safe enough. I’m in that foggy, but relatively painless alternative induced by medicine. It’ much less painful here, but oh how I do miss the texture of my old reality.
One clarification.
Not every bipolar person takes an antipsychotic, or needs an antipsychotic to be properly treated. Not by a long shot. The first-line treatment for bipolar disorder is, and always has been, lithium, which is a mood stabilizer. Seventy percent of bipolar people receive full or partial relief of symptoms with lithium alone. No other drug comes close to matching that kind of success.
Now, a lot of people do in fact get psychotic while they are manic and/or depressed. I was psychotic at various times at the heights of both types of episodes. But, for many people with bipolar disorder, all it takes to get rid of the psychosis is a drug in the mood stabilizer category–lithium or an anticonvulsant like Depakote, Tegretol, etc. For example, for me, lithium alone has shaved off the abnormal highs and lows, and in doing so, ended all psychosis.
Antipsychotics are increasingly used to treat bipolar disorder, but they are not considered the first nor the best choice for treatment (and are typically given in conjunction with a mood stabilizer).
Yes, mood cycles can be stretched out that long, and that is actually the classic profile for a person with Bipolar I. He sounds like a nearly textbook case.
Actually, anyone who has more than four distinct mood states/phases/cycles per year is considered to have “rapid cycling.” My reading of more popular sources on the disease (like on the Internet) shows that a lot of them are written by people who claim to have their moods change very frequently. But if you read most of the older, scholarly, traditional literature on the disease, you find that the classic profile of the disorder describes much less frequent changes in mood.
Just googled Joder…you naughty girl.
In my experience, Kalhoun, it is. When my Mom was manic she’d watch and criticise and verbally attack my Dad constantly for nothing at all. I’m sure the highs are incredible, but to those outside it still looks like you’re about to dig up people because you’re convinced they’re not really dead, convinced that you’re God, randomly buying houses, and accusing everyone in the world of being ‘out to get you’.
Sigh. It would be so much nicer if Mom would admit she has a mental illness, just once.
My next questions are kind of rude and nosy, so just tell me to go to hell if you want.
I’m kind of wondering if you are still trying out different medicines to see if you can find one that doesn’t make you feel “foggy,” or if you couldn’t find one, or if you would rather settle for foggy because you don’t want to go through the incredibly sucky medication tryout merry-go-round–?
I’m also wondering exactly what you mean by “foggy.” Does that mean, “less fun/energetic/exciting than mania,” or is it more like “can’t concentrate,” and a comparison to your pre-bipolar disorder normal self?
I’m curious because I have heard and read this complaint before, and that this is a big reason why bipolar people go off their meds. But every time I complained about a foggy feeling, my doctors adjusted my meds until we found something that worked better. Now I feel pretty normalish, though the meds have created some (fairly minor) memory problems. So when I hear people say, “Oh, meds make me foggy-headed,” I wonder why they’re stuck with that.
Can events trip the change from manic to depressed? He was on a roll (again…probably a couple years) where he was daytrading and making a shitload of money. He was the God of the Stock Market. He decided he could invest for two family members and both investments tanked. Shortly after that, he became non-functional, and remains there, for the most part.
What can I say, dear, English cussing will just never sound strong enough for me. Not enough Js, although you have some Ks.
Middlebro is… maybe not bipolar, but quite “moody”. He’s one of those people who go from being “on top of the world” when others know very well it’s not warranted to “this is horrible I’ll never do anything right” when it’s not anywhere near as bad either. Usually there’s some kind of external trigger, but not always and anyway the reactions are just real extreme. Having known him and helped him through much of that since he was counts 7 hours old has helped me in knowing how to deal with people who is down (the “ups” vary more through people, depression seems to be more universal); the information I get from you guys I think helps me understand him a bit more. Hopefully.
Oh. My. God. This is exactly how he is. His current “job” is suing people. He’s suing the homeowner’s association for a fist-sized indentation in the lawn (he twisted his ankle). He’s suing Catholic Charities because they took his sister’s side regarding his bizarre behavior. He wrote hundreds of letters to his sister complaining about “egregious infractions” like the phone call, putting knives in the dishwasher pointy-end-up, etc. My SIL’s life has been sheer hell. At the moment, he’s not being an evil motherfucker, but it’s just a matter of time before Satan’s Scaly Cock (I’m so glad I found an appropriate place to use that) rears it’s ugly head again.
My brother is more like what Inigo described, when he’s high. He doesn’t attack people, but he’s got some of his most creative moments at those times. Problem is that as soon as he’s got an idea and it’s proven to be wrong, or he has some kind of test and fails it, or misses a deadline… hello, floor, here I come!
He’s been like that since his age was in single digits.
There’s got to be some legal way to get him taken into the hospital so he can see a psychiatrist and be put on some meds. My Dad got Mom committed a few times through ‘danger to herself and others’. I’m afraid I don’t know the exact process- the last time she had to be put in hospital was fifteen years ago. I think he saw a Justice of the Peace.
It’s so, so much more difficult if the family member in question is absolutely certain that they don’t have a mental illness. A friend of mine went manic, realised he had the whole universe and All Truth figured out… and checked himself into the hospital that night. That way beats hell out of having to get the cops to take someone because during their lucid periods they have never once admitted they need help, and so you can’t discuss medication or mood cycling or anything.
My Mom is normally a very calm, intelligent, insightful woman. Her illness has always been this behemoth, looming. She’s on lithium, and I have no idea how she explains it to herself, because we can’t talk about it.
There’s got to be a way. When he’s not manic or depressive he’s an okay guy, right? When we were worried about having to get Mom committed a couple of years ago twickster was enormously helpful to me, with support and advice. Paging twickster!
Go to hell! heh…and say hi to Grandpa for me.
As for “foggy,” I mean that where I am now is kind of boring but safe. For most of 2006 I was rapid cycling between depressed & suicidal. Once or twice I rose above the negative, but those times were dreadful respites like when there’s a pause in the beating while the school bully is really winding up for a jaw-breaker. This, I guess, is what happens when you stay on the wrong meds for too long. Spent a couple months purging the Prozac (don’t start…) and then jumped on the Wellbutrin wagon. It, or rather “I” am working just fine now. All is very predictable and stable, I’m much nicer to be around even if I am a bit less talkative and charming… As for mania, I’ve come to dread it, it’s no longer fun because I see it for what it is: the precursor to 4-6weeks of hell. Mania for me is the weightlessness and absolute mobility and freedom you feel as you hurtle toward earth with your parachute flopping in the breeze behind you. It should be fun, but I can’t get my mind off the crash that is coming.
Maybe it’s not the right word, because I’ve only ever been truly foggy for the precious hours between mania & depression. I’m exhausted, my body is buzzing faintly, I’m wide awake but almost stunned. I can’t hold eye contact and can barely form coherent sentences let alone work through any problems I have just caused. And then I sink and, well, boo-frickity-hoo, right?
For those watching at home, while there is often an “onset” for the disorder, I really think this milestone is just when the owner has had enough or has finally noticed a problematic pattern. Because for as long as I can remember, I’ve been given to extremes of emotion with little or no reason. My world has always been hostile to me, I’ve always felt hunted, singled out, different, secretly mocked, patronized. Rage, self-destruction and euphoria have always been the default emotions, everything has always been disproportionately good, evil, important or insignificant. This is the world I grew up in and it is as familiar to me as it is dangerous. At least it is home. Medicated, everything is moderated. Rage becomes a flash of temper and is soon mellowed, Euphoria has given way to laughs and smiles, etc. What most people would call “normal”, I call “boring.” Oh sure, I can hunt these rabbits all day long, but they’re nothing compared to the slinking tigers of my world.
He will admit to being a little anxious (hence, the Xanax) but he categorically denies his bipolar diagnosis. He hasn’t done anything physically dangerous, but because Catholic Charities went to court with my SIL (when he had her arrested for the egregious flicking of the candy wrapper) the judge told both of them they were required to attend counseling sessions.
I have no idea what degree of information he gave up to the counselor, but even if he spilled it, could they do anything more than suggest that he admit himself? He has a real problem with being called “mentally ill.” He gets extremely defensive and paranoid about it. He gets that from his mother, who has been a card-carrying lunatic for most of her life. The best way to start the fireworks is to tell her she’s crazy.
I seem to remember him being a nice guy, but the illness pushes that guy further back in my memory with every episode.
This is ultimately what destroyed my marriage. Well, that and my wife is a twit.