Mania, Depression, Psychosis, Oh My! A Whirlwind Tour Through the Episodes of Bipolar Disorder
The following is an excerpt from the new book Welcome to the Jungle, Revised Edition: Facing Bipolar Without Freaking Out by Hilary Smith (Conari Press, March 2017):
States of human experience are extremely difficult to classify. Where does a mood end and a physical sensation begin? Where does a mental experience end and a spiritual experience begin? What’s the difference between a bad mood and a bad day? Are some days just inherently sad or manic, or are “sad” and “manic” things that only happen inside individual people, and not in groups of people or in the wider world? Can a person be “depressed” or “manic” in a vacuum, or are those states in constant interplay with other people in the outside world?
Are you still “manic” if you feel really sad while you rearrange your furniture at three in the morning? Are you still “depressed” if you have two really bad days, then three really great ones, then two bad ones again? Is it still “psychosis” if you perceive your experience to be the result of intense yoga practice? Is it still “depression” if you have lots of energy and will to live, but feel overwhelming grief that they drained your favorite swamp to build a shopping mall?
These are all questions the Diagnostic and Statistical Manual of Mental Disorders (the book psychiatrists use to diagnose mental illnesses) does not get into. The DSM is all about putting human experiences into categories—drawing lines even where it doesn’t make sense to draw them.
Think about a tree in the forest. It has bark and leaves and branches, which are obviously part of the tree. But what about the moss growing on the bark, and the ferns growing on the branches, and the mycelium intertwining with the roots, and the insects nesting in the wood? Are they part of the tree? Are they separate? Are they somewhere in between? A claim in either direction is very much up for debate. (The tree would die if you stripped off all the moss, or killed the mycelium—then again, can you really say that moss is part of a tree?)
Mood descriptions are no different. Take depression, for example. There’s a feeling of sadness and a physical heaviness which are “obviously” part of being depressed. But your knee hurts from where you tore your meniscus, your job is entering data into a computer all day, and you hear cars and trucks driving past your house all the time, and you feel really, really down about that swamp. Are the cars and the job and the swamp part of your depression? Or is the feeling of sadness and the heaviness in your body the only part of depression that counts?
In this piece, I am going to go through the DSM definitions of bipolar mania, depression, and psychosis because you are probably going to Google them anyway (don’t lie!). But listen to me: even if some aspects of these descriptions sound familiar to you, don’t let them overwrite the details of your personal experience. It’s easy to read this stuff and say, “Oh yeah, I guess my mood lasted for four to seven days, and come to think of it, I did sleep less that month,” even when that isn’t the whole story. There’s a strong human impulse to identify with categories (that’s why people get so obsessed with their astrological signs). At its worst extreme, the DSM can act as a script for “how to be bipolar” even if that’s not how you experienced your moods before getting diagnosed.
So please keep perspective as you read this. Even if the DSM description of bipolar sounds just like you, don’t lose sight of the moss and ferns and all the other unique details that make you you.
I’m Not Manic, I’m Just Hyphy
Before we get into all this bipolar stuff, let’s talk about hyphy. Hyphy is a Bay Area hip-hop style characterized by people dancing or acting in a hyperactive, ridiculous manner. You put on your stunna shades, get blasted, and “go stupid.” One particularly prestigious way of “going stupid” is to put your car in neutral and dance on the hood while it rolls forward without a driver; this is called ghost-riding the whip. E-40 and Mistah F.A.B. wrote entire songs about ghostin’.
Now, when you think about it, all this going stupid sounds a lot like a manic episode: substance abuse, hyperactive speech and dancing, risky and grandiose activity—feelin’ like a star. Yet thousands of otherwise sane, asymptomatic people get hyphy every day, and nobody accuses them of having bipolar disorder. What’s the difference between being manic and plain old gettin’ hyphy?
Mistah F.A.B.’s Guide to the DSM-V
Hyphy: “Dude, Bro, let’s ghost-ride your car then put it on YouTube, Bro, ha ha ha. Babes will dig it. Wooooo!”
Hypomanic: “Dude, bro, stop the car, we’re going to ghostride the whip right-now. Yeah yeah, stop the car. We need to do it right now right now right now, ha ha ha!”
Manic: “I am Mistah F. A. B. I’m the hyphiest motherfucking ghost-rider in West Oak. I’m gonna buy this Lexus with my credit card and ghost-ride that.”
Psychotic: “A tribe of angels is watching me ghost-ride the whip, and Satan is broadcasting the lyrics to Ghost-Ride It directly into my brain.”
Unhyphy: “Dude, I just wanna park somewhere and get a Slurpee.”
Depressed: “Watching YouTube videos of people ghostin’ makes me incredibly sad.”
Hella Depressed: “I haven’t gotten out of bed in a week because all I can think about is how horrible my life is compared to Mistah F. A. B.’s.”
Suicidal: “I’ve said goodbye to my family and friends and am actively seeking out people to roll their car over me as they dance on the hood.”
As you can see, there’s a broad behavioral spectrum to ghost-riding the whip, and in this case, I’ve categorized behaviors as “manic” or “depressed” based on how far they deviate from the hypothetical Mistah F.A.B.’s normal hyphy or unhyphy mood states. In the following section, I’m going to be discussing the criteria physicians use to identify the different aspects of bipolar disorder as outlined in the DSM-V, that big fat book published by the American Psychiatric Association that contains the diagnostic criteria for all the psychiatric disorders our society currently believes in. Like the songs in a jukebox, the stock of “mental disorders” in the DSM changes all the time—up until 1973, homosexuality was listed as a mental disorder (message to APA pre-1973: you guys aren’t doing your credibility any favors...) It hardly needs saying that the DSM-V is not a perfect guide to mental illness, and that some of the “illnesses” that have been described there in the past are no longer considered illnesses at all. Unlike pregnancy, you can’t pee on a stick to find out if you have bipolar disorder. Definitions evolve over time, and in a hundred years, the category “bipolar disorder” might be as antiquated as the category “hysteria” is today. The purpose of the following section is to discuss the common symptoms of mania, hypomania, and depression and what they can feel like—and also to help you resist the urge to dump every experience in your life into one of those categories.
Normal Happiness and Normal Energy—Huzzah!
When you’ve just been diagnosed with a major disorder like bipolar, you might have the urge to reinterpret everything in terms of either mania/hypomania or depression. But honestly, not every moment in your life is depressed or manic: much of the time, you’re just plain old you. Normal happiness and energy are just that—normal. You don’t need to pathologize your enthusiasm for flying kites or attribute your last romantic success to hypomania. You’re probably a charming, loveable, energetic person in “real life”—good for you! You can be ambitious, adventurous, and fun loving outside of mania.
The key difference between a “normal” state and a manic or hypomanic state is whether or not your perceptions of reality and your own abilities have shifted, and whether this shift messes up your ability to relate to other people or get your work done. If you’re normally a beast on the dance floor who loves to hook up with hot strangers, good for you! If you’re a lifelong wallflower who is suddenly electrified with the belief that you’re Justin Timberlake bringing sexy back—well, maybe that’s not normal. Let’s be perfectly clear: you’re allowed to grow and change, try new things, whatever. If done with a clear mind, almost any action you undertake can be considered normal. You should worry about it only if you start basing your actions on unusual logic or logic radically different than your default setting, or if people around you start noticing a marked departure from your usual behavior.
Going skydiving because you think it’s cool = normal. Going skydiving because you temporarily believe you’re an invincible god = not normal. Being a talkative person = normal. All your friends are staring at you because you’ve been talking like an auctioneer all day = not normal.
Mania
All ghostin’ aside, what is mania, and how can you or other people tell if you’re manic? You’re manic if your belief about your own capacities expands drastically, if you start engaging in activities that are drastically out of character, making plans drastically out of sync with reality, or behaving in an overblown, irrational, out-of-control manner. It can be hard for you to tell if you’re manic, at least immediately, but it’s pretty easy for other people to tell. You think you’re a celebrity, believe you can walk in front of traffic, and obsessively call the Federal Reserve to tell them your brilliant solution to the economic recession. You feel like you don’t need to eat or sleep, and feel a vast and potent connection to complete strangers. Words tumble out of your mouth in a great flood. You start taking your job as a mall cop too seriously and stay up all night drafting a new and improved plan for mall safety, which you work on tirelessly with no breaks for several days. It’s the key, the key. People spend all their time in malls, right? Safety is key, right? Mall safety, that’s where it’s at, that’s where it’s at.
Your friends and family notice a difference and try to talk you down. “Dear, can we not talk about the menace of escalators tonight?” Technically, mania is defined by the DSM-V as “a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary).” Therefore, drinking too much coffee and running around like a ferret for one day doesn’t qualify as a manic episode (unless you get caught by animal control and hospitalized for it). The DSM-V lists seven symptoms of mania, at least four of which are usually present in a full-blown manic episode.
1. Inflated self-esteem or grandiosity
You (mistakenly) think you’re famous and important or think you have special powers. You suddenly realize you’re a better painter than anyone else in your art class, and start plotting an elaborate gallery opening at the Museum of Modern Art, featuring your work next to Van Gogh’s. Your teacher is confused because this represents a major change from your normally humble personality.
2. Decreased need for sleep
You keep coming home from the bar at 3 a.m. Tonight you take a one-hour nap, then go for a run, paint the house, and organize a dinner party for all your friends. Sleep is a bad word.
3. More talkative than usual
You have pressured speech (the sensation that you need to be talking) and a flood of ideas you need to express. Friends and teachers ask you to slow down and explain your thoughts, but it’s too hard.
4. Flight of ideas, racing thoughts
Your mind is like a speeding train, or several speeding trains on different tracks. You can’t slow down your thoughts, and your ideas fly to their wildest conclusions. You might enjoy the sensation of being flooded with ideas at first, but later become overwhelmed and terrified by it.
5. Distractibility
What?
6. Increase in goal-setting activity or psychomotor agitation
You’re working on a very important project and realize there are three other side projects you should be doing to really get it off the ground. You check twenty books out of the library and start researching every aspect of your subject area. You don’t understand why other people can’t see the importance of your project. You feel the need to move around a lot.
7. Excessive involvement in pleasurable activities (such as buying sprees, sexual indiscretions, or foolish business investments)
You run to the bar and make out with three different people over the course of a Rihanna single. You buy everyone a round, then flag down a taxi and give the driver a $100 tip for driving you home. You want to buy expensive presents for everybody you know.
The DSM-V definition goes on to state that the above symptoms should not be the result of illegal drugs and must be severe enough to really wreak havoc on your normal life. Psychosis is sometimes a feature of manic episodes, too.
Everyone’s experience of mania is different. Some people experience it as a fabulous period of elation, while other people get extremely agitated and experience no pleasure at all. Mania is on a continuum—it takes your normal behaviors and personality and amplifies them. A manic episode can lead to hospitalization or self-harm, and the tomfoolery you get up to while manic can demolish your savings, land you in prison, and make you feel embarrassed later on. Mania can also give you a unique drive and a window into realms of the mind that are inaccessible to most people. In other cultures, mania might be given a different name and be seen as a religious experience. The important thing isn’t definitions, which change over time, but effects, which vary from person to person. For some people, mania has the effect of a revelation or mystical experience, while for others it only causes misery.
Putting It All Together
Here’s how mania might look. The numbers below refer to the symptoms listed previously. Let’s say you work at a call center for IBM. You spend all day on the phone to customers, helping them fix their computer problems. You’re also in charge of logging their questions and complaints in a database. Over the course of a week, you start to notice connections between calls that you never noticed before (4). You realize there’s a pattern to the database that could revolutionize the future of IBM (1). You start staying at the office long past closing time, working on solving this pattern far into the wee hours (6). Solving the pattern is more important than eating or sleeping (2). When you tell your coworkers and supervisors about the pattern you discovered, they seem confused, though you talk about it incessantly (3). You get frustrated because nobody else can see how important and revolutionary your discovery is. Even your girlfriend doesn’t understand your great discovery, but she wants you to tell Dr. Brunner about it because she thinks she will.
Hypomania
For hypomania, take the mania section and turn the volume down several notches. You talk faster, walk faster, and think faster—enough for other people to comment. Maybe you start writing a novel, building a sailboat, and recording an electro album all on the same day. Or you join a rock-climbing gym because you “suddenly” realize you’d make a fabulous rock climber. It’s hard to sleep and hard to sit still and listen when someone else is talking. Other people seem to be talking and moving incredibly slowly. Sitting in class is torture because it seems to drag on for hours and hours, and you’ve got more important things to do! You might be agitated and elated at the same time, the life of the party, but your engine’s running a little hot. You dance down the street, filled with this wonderful sense of how happy the world is, or flit around your room like a trapped fly.
The DSM-V definition of hypomania includes the same seven symptoms as for mania, but the difference is that the episode is not severe enough to land you in the hospital or make it impossible for you to get through a normal day at work or school. It also notes that a change in your mood and behavior should be observable to other people (i.e., that your parents or friends notice that you’re talking faster and making uncharacteristic judgments). A hypomanic episode marks a distinct change from your usual self, and the elevated, expansive, or irritated mood should last for at least four days. Hypomania usually isn’t accompanied by psychosis, and it doesn’t count (at least, not to the guy in the white coat) if your symptoms are due to your taking a drug like ecstasy.
Hypomania can imbue you with wonderful feelings of confidence, talent, creativity, self-esteem, charm, and intelligence, all of which can help you achieve great things. It can also feel distinctly uncomfortable and irritating—sometimes both at once.
How Might My Friends React to Mania or Hypomania?
A good way to gauge whether or not you’re acting abnormally is to pay attention to your friends’ and family’s reactions. Sometimes, nobody will realize you’re manic until it’s too late. But people who know you can usually sense when something is a little off. From a friend’s perspective, your “perfectly reasonable” obsession with the pattern in the IBM call database is not perfectly reasonable. A friend can have good insight even when you’ve lost it. Here are some comments friends might make if you’re acting unusually.
“You’re acting really intense.”
“You’ve been working on that project nonstop for a week. Don’t you ever sleep?”
“Are you high?”
“What are you talking about? You’re not the CEO of Microsoft!”
“Slow down, you’re not making sense.”
“Are you drunk?”
If friends know you have a bipolar diagnosis, they might give feedback like:
“You’re getting a bit speedy.”
“Have you been sleeping?”
“This is really out of character for you.”
It can be really annoying to hear these comments, especially if you feel strongly that you’re not manic or hypomanic. But it’s worth being patient with them, because a trusted friend’s insight can help you rein in your energy before it gets out of hand.
Depression and Sadness: What’s the Diff?
A bunch of nerds had a conference in Las Vegas. After enjoying steak and strippers (male strippers! lots of male strippers!), they defined clinical depression as having a handful of symptoms that persist for at least two weeks and represent a change from your regular functioning. If you’ve experienced depression, you can probably list the symptoms yourself: a sad, depressed mood for most of the day; a loss of pleasure in activities you normally like; changes in eating and sleeping; crying a lot; fatigue; recurring thoughts of death. At the extreme, people can become catatonically depressed: too depressed to move or speak. The symptoms of depression overlap with conditions such as vitamin deficiencies and chronic fatigue. So it’s important for doctors to rule out other factors when making a diagnosis. Unfortunately, many people with bipolar disorder experience more depressive episodes than manic or hypomanic episodes in their lifetime.
How do doctors differentiate between depression and normal sadness or grief? Back to the DSM-V!
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful)
You feel sad, down, and empty. Maybe you cry a lot. This feeling persists from day to day.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
You don’t feel like going out with friends, doing your laundry, calling your girlfriend, or going to the gym. Activities you normally enjoy feel sad or painful to you.
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5 percent of body weight in a month), or a decrease or increase in appetite nearly every day
You find it hard to eat, or you eat a whole box of ice cream just to distract yourself from the sadness. Your body feels strange and makes different hunger demands than usual.
4. Insomnia or hypersomnia nearly every day
You have a terrible time getting or staying asleep at night. Or all you want to do is sleep—you start sleeping twelve hours a day, every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, no merely subjective feelings of restlessness or being slowed down)
You look and feel like you’re moving through molasses. It takes you thirty seconds to take your bowl of oatmeal out of the microwave. Your friends get impatient because it takes you forever to put on your jacket. Or you feel agitated and move around like an angry old man.
6. Fatigue or loss of energy nearly every day
You dread the time between periods when you have to walk from one lecture hall to the other. You feel really tired—too tired to do the things you normally do.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
You feel extremely guilty about being a terrible friend or being a bad person, for no apparent reason. You feel like you have no worth as a person.
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
You can’t make decisions or prioritize tasks. Thinking about whether to go to the bank or the library first nearly kills you. You can’t concentrate on a dinner menu, let alone your thesis.
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
You can’t stop thinking about all things death related. Even if you don’t want to commit suicide, you can’t stop thinking about how you would do it.
The DSM-V goes on to note the same “ruling-out” clauses as for mania and hypomania: that your symptoms aren’t better accounted for by drug abuse, a medical condition like hyperthyroidism or chronic fatigue, or bereavement following the death of a loved one. The depressive symptoms must represent a marked change from your regular functioning and persist over at least two weeks.
The key words are “change from your regular functioning” and “persistent.” If you feel like the world has become inherently more depressing and your prospects in life fundamentally bleaker—and these feelings last for a long time and deplete your functioning—it might be depression. If you’re just having a bad day and temporarily feel down on yourself, it’s probably run-of-the-mill sadness. If you’re just not hungry one day, it’s probably nothing. But if you lose all desire to eat, have sex, or go outside for two weeks, that’s depression. Sometimes you might have a couple days of real depressive symptoms, but manage to pull yourself up before they develop into full-blown depression (tips on doing that later!). In some ways, depression is like the common cold: you can feel it coming on and try to stop it from developing if you catch the symptoms early enough. But once it sinks its teeth in, it can stick around for a long time.
Just like mania, depression can make you do stupid things. On one end of the spectrum, there’s suicide, which we’ll talk about later. Way on the other end of the spectrum are the stupid thoughts you have when you’re depressed. One time when I was depressed, I burst into tears at the sight of a normal white fence and insisted to my boyfriend that it was the saddest fence I’d ever seen in my life. (If you want to see the world’s saddest fence for yourself, it’s located at 2761 West Seventh Avenue in Vancouver, British Columbia.) Depression can also lead you to lash out at people around you, make poor decisions, and sabotage your life in a hundred different ways. We’ll talk more about those in a later chapter.
On the other hand, depression can also be harnessed for good. Maybe you take advantage of your reduced energy to spend time reading, or maybe your experiences with depression lead you to write great poetry. Or maybe you embark on a mission to catalogue the world’s saddest fences. Who knows?
Tripping the Light Psychotic
When I first told one of my friends I was taking antipsychotics, she smirked and said, “Oh, you’re a psychopath?” Psychosis and “psychotic,” its accompanying adjective, are some of the most misused mental-health words out there. First of all, antipsychotics are commonly used for reasons other than psychosis (such as sleep and mood stability), so don’t be freaked out if you get prescribed an antipsychotic if you’ve never been psychotic. Secondly, being psychotic is a totally different thing from being a psychopath. “Psychopathy” means the tendency towards violent, antisocial behavior. Psychosis is when you have delusional beliefs and hallucinations; it can range from experiencing a completely different reality from other people and having no insight, to experiencing voices and visual hallucinations and having some insight into the fact that this experience is not being shared by people around you. Psychosis is on a continuum: some experiences are very close to “normal” reality and some are quite far away. In some cultures, what we call psychosis is associated with shamanism and celebrated as a connection with the underworld. I’m just sayin’.
Hallucinations
Hallucinations can be auditory, visual, tactile, or even olfactory. You might see people who aren’t really there or hear voices giving you commands. Hallucinations can be more or less scary, and they can also be caused by lack of sleep. Like the other aspects of psychosis, hallucinations are on the spectrum of normal human experience and can range from interesting to terrifying and dangerous.
Delusions
Delusions are tricky, because there is such a fine line in our society between which beliefs are considered acceptable and which are considered insane. For example, millions of people hold the same “perfectly normal” religious beliefs that would be considered bizarre and outlandish if they were held by a single person. The DSM-V defines a delusion as “a false belief based on incorrect inference about external reality that is firmly sustained despite what almost everybody else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person’s culture or subculture.” A good example of a delusion is the belief that you’re being held captive by kidnappers, when really the “kidnappers” are your stoner roommates who wouldn’t even notice if you left the house. If you’re delusional, it can be hard to believe friends who tell you your delusions are false. You might believe they’re lying, thereby interpreting their comments in a way that confirms your version of reality.
Thought Disorder
Thought disorder is easiest to identify in a person’s speech or writing. It’s characterized by a person not making sense from one sentence to the next or making associations that don’t make sense to anyone else. For example: “The plane left the airport at three o’clock, and therefore the daisies in the bowl were put there by the dragon.”