Useful Notes: Bipolar Disorder

And when you're up you're up
and when you're down you're down
and when you're only halfway up
you're neither up nor down
The Grand Old Duke Of York, Traditional Nursery Rhyme

Most of the time, when a character portrayed as having bipolar disorder, they are usually shown as being uncontrollable, hair trigger Mood Swingers - swinging from affable and pleasant to suicidal or raging in the space of minutes. Or, in constrast, a character will be called bipolar if they are moody, but are never shown actually suffering from their mood swings. Either way, as the disorder is only rarely portrayed in the media beyond these and other unrealistic, simplified forms, most people are unaware that in reality, bipolar disorder is a complex, multifaceted illness.

In the most basic sense of the term, bipolar disorder is defined by the presence of mania. This means that someone who is depressed for the vast majority of the time but has had a single manic episode is as bipolar as the rapid cycler who goes through different moods in months, weeks, or even days. As you can see, this definition still leaves a lot of room for all the forms bipolar disorder can take.

Bipolar disorder is essentially a cycling disorder. Someone with it is assumed to always be in a state of flux, cycling from one mood state to another - technically meaning that someone can never recover from bipolar disorder, but only be 'in remission.' These cycles can speed up and slow down abruptly, ranging anywhere from one episode of mania/depression every few years to one every other minute (this is called Ultradian cycling, and is so rare it is suspected that it may be its own illness altogether.) Moreover, the extent and severity of the moods that a sufferer goes through can vary. The DSM lists three different varieties of bipolar disorder:

  • Bipolar I Disorder, which is defined by the presence of full-blown manic episodes - depression is not required for diagnosis, but almost always occurs;
  • Bipolar II Disorder, where milder hypomanic episodes occur instead, but often with longer and more severe depressions;
  • and Cyclothymia, which has hypomanic episodes and milder episodes of depression called dysthymia.

A good metaphor for the inner life of a bipolar individual is a roller coaster. At various points in the track, the rider can be moving fast or slow, and up and down, in various combinations. A bipolar person has no control over when their mood swings occur, but swings can be triggered by things like overstimulation, drug use, and positive or negative experiences. While a "normal" individual may experience such highs and lows, in the bipolar individual emotional shifts are far more sudden and extreme, and are only tangentially related to the events experienced by the bipolar individual: The upsurge after a promotion at work may trigger an immediate crash into depression, the loss of a job may trigger a counter-surge of devil-may-care optimism. For the most part the symptoms of bipolar disorder are governed by semi-regular cycles, and many who are aware they have the disorder take steps to preserve routine and keep this modicum of stability.

Challenges For Diagnosis

While becoming less of an issue as public awareness and professional understanding of the disorder rises, there are many challenges to diagnosing bipolar disorder. By its fluid, intermittent nature it is easy for the disorder to be mistaken for other issues, or missed entirely until an extreme manic phase reveals the true nature of the problem.

There are several gender specific issues in the diagnosis of Bipolar disorder, not least that the Hysterical Woman trope frequently leads to dismissal of even blatant symptoms in women. Even in a professional context, extreme bipolar disorder is difficult to differentiate from borderline personality disorder, clinical depression, or even abnormally extreme PMS. note 

While women are more at risk of having symptoms misdiagnosed or dismissed, bipolar men in both Eastern and Western cultures can are more likely to go completely undiagnosed. A facade of stoicism is a hallmark of depression in many men, and the manic phase can be taken as a Hot-Blooded Broken Ace "getting their act together" for a time- both of which are seen as positive attributes in men. This often leads to the man working hard to cover his Unmanly Secret of inner emotional turmoil, sometimes even from himself: many men self-medicate with drug abuse, alcoholism, and other high risk, "manly" behaviors to try to "snap themselves out of it".

The cyclical nature of the disorder can also mask the disorder in both genders if a doctor only sees an individual at particular points in their cycle note .

Finally, in both genders, there is a tendency to either give in completely to ones own chaotic emotions and impulses, often on the misguided advice to Be Yourself note  or decide that their fluctuating emotions cannot be trusted and attempt to suppress them entirely. Both of these can further mask the disorder as impulse control issues, or antisocial behaviors.

The Various States of Bipolar Disorders

But what exactly do we mean by mania and depression? In the context of bipolar disorder, these are both abnormal and often disabling mood states, much more severe than anything a healthy person would go through for any prolonged period of time. They do not merely affect mood, but impact every part of how a sufferer thinks, perceives and interacts with the world, and in many cases even biological rhythms like sleep cycles, metabolic rate, blood pressure, and even body temperature. The name "bipolar" is actually somewhat of a misnomer: there are several states commonly experienced by bipolar individuals, with the manic and depressive states only being the two most extreme and recognizable.

Hypomania

The best comparison of hypomania for those who are not bipolar is an adrenaline rush or extreme stimulant use. If you have ever had any sort of "mountain top experience", had way, way too much caffeine, or chain-smoked cigarettes, you have had an experience similar to a brief bout of hypomania-except that hypomania typically lasts anywhere from several hours to several days.

Hypomania is essentially very similar to The Madness Place trope- it is characterized by intense focus on tasks, Hyper Awareness; high mood and energy; extreme levels of optimism, creativity, productivity, and inner motivation; high mental endurance, and reduced sleep cycles. This, to some, may sound desirable, or even pleasant. Indeed, it is true that many successful artists, inventors, and entrepreneurs have been formally diagnosed as bipolar, and one of the most common motivations for bipolar individuals who stop taking their medication is missing the "rush" of hypomania.

The catch, however, is that humans don't handle being overclocked and run at full capacity for days on end any better than computers do, and that the entire madness place trope applies, including the issues it causes with relationships and neglecting their own health in the name of pursuing their goals. This is particularly true when it spills over from hypomania into full mania.

Mania:

Mania is described by the DSM as at least a week (or any amount of time that requires hospitalization) of "severely elevated mood and energy."

If hypomania is comparable to having had too much caffeine, a full manic state would be comparable to the effects of a high dose of amphetamines or cocaine- but with the effects lasting for days. The manic individual has a very short attention span for anything outside of whatever they are currently fixated on, including things like eating and sleeping. They have little impulse control with regard to their fixations- many find themselves spending everything they have on a whim that they rapidly forget about; compulsively pursuing a task to completion with no regard to whether it is productive, unproductive, or simply inane; or giving in completely to hedonistic behavior. The manic frequently experiences what is known as "Acromegaly"- the feeling that they are invincible and can accomplish any task.

Much of the Hollywood Psych behavior attributed to Paranoid Schizophrenics is actually result of a person with both paranoid schizophrenia (or just simple paranoia) and bipolar disorder note  a week of living with racing thoughts and no sleep gives plenty of time to build a Room Full of Crazy, and would make it hard for anyone to tell reality from their own delusions or construct coherent sentences. Its no wonder they have to plot everything out with string to keep track of it all. To make matters stranger, even a diagnosed individual aware of their condition may not be aware that they've transitioned from a hypomanic phase into a full manic phase: the same tunnel vision that gives them focus prevents them from noticing or caring about things like that they haven't slept in three days, so it's easy for those with more extreme bipolar disorder to begin with a perfectly reasonable task in mind and end deep in the madness place.

Depression

What goes up, must come down.

When a Bipolar person does crash, the landing is often hard. The depressive state can be thought of as the natural result of the manic state's overclocking of the mind and body- after running for so long at full tilt, it takes time to recover during which time they are Brought Down to Normal. Given the contrast to high of the manic state, its little wonder the bipolar person is left feeling dejected, burnt out, and uninspired, and often regretting impulsive decisions and damaged relationships of the manic phase. This leads many to self-medicate with stimulants and alcohol, to artificially extend or trigger the manic phase and blunt the misery of the depressive phase.

Some bipolar individuals also experience depressive phases prior to their manic phases- this is hypothesized to either be the body and mind "charging up" for the manic phase, or possibly a minor depressive phase triggering a much larger counter-mood swing.

Mixed States.

Most with Bipolar Disorder actually spend most of their time in something vaguely resembling a neutral, relatively normal, state. Its only when the metaphorical roller coaster hits an extreme extreme hill or drop that a series of manic and depressive phases occur. In many cases, the name "bipolar disorder" is a misnomer, because the experiences are not a simple matter of pure off and on.

A mixed state is a bipolar episode in which a person experiences mixed aspects of mania and depression at the same time. It can range from experiencing energy without joy, which leaves them feeling like they're going too fast, to being happy and sad at the same time, to being content to do nothing at all. These states tend to be the most dangerous and unpleasant for the bipolar individual: the prolonged Mood Dissonance one experiences can be a grating Mind Screw, note  and the inherent issues of combining a misanthropic mood and low energy, emotional burnout and intense focus on a goal, or lack of concern for ones own life and Suicidal Overconfidence are obvious.

An individual with bipolar disorder is wise to learn to recognize the signs of these states, and respond accordingly to minimize their impact (I.E. seeking out friends and positive situations when in a high mood with low energy, or avoiding high stress situations and focusing on a constructive project when feeling angsty and restless).

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