Hypomanic and Depressed at the Same Time

I read an article today and now my world makes so much more sense. In a Depression Bipolar Support Alliance (DBSA) “Ask the Doc” article, Dr. Mark Bauer, MD states that:

“[T]he most common mood state in bipolar disorder is a mixture of hypomanic/manic and depressed symptoms. In fact, the classic picture of bipolar disorder having a course alternating between the poles of high and low moods is an over-simplification.”

He goes on to explain mania and hypomania more clearly, basically describing them as hyperactivation – feeling “sped up” and driven. This can feel good (e.g. grandiosity), bad (e.g. irritability), and everywhere in between. In other words, mood and activation level are two different things.

Ergo, we can think of bipolar disorder as

“a condition of recurring depressive periods punctuated by periods of hyperactivation – and sometimes these periods of hyperactivation alternate with slowed down, depressed periods, but at other times they overlap.”

That. Is. My. Life. It’s very rare for me to experience a period of time with no depressive symptoms; at best my symptoms become few and mild enough that I don’t meet the criteria for clinical depression for a couple days to a few weeks. But periods of hyperactivation… just look through my blog and you’ll see my posts about “I’m going to do this new thing that will change the world,” staying up all night composing, “now I’m getting better and I’m mad at Fox all the time,” and most recently “Let’s Play Skyrim!”

I usually feel better during my periods of hyperactivation because 1) I have energy to do things and 2) I’m hyper-focused on something that’s meaningful to me, at least while the hyperactivation lasts. Sometimes I don’t feel so good because I want to Do All The Things!!! but I can’t focus on one thing to do, so my mind is a jumbled mess. I’ve also tried to be a part of too many different groups at once, which invariably results in me feeling overwhelmed, backing out, feeling guilty, and my depression symptoms becoming more severe. As far as I can tell, all of my periods of hyperactivation have occurred at times when I also met the criteria for mild depression. (Possibly also moderate depression.) In other words, I’ve never had a discrete hypomanic or manic episode.

I try not to put too much importance on labels; what’s really important is that the needs of the person with a mental health issue are being met. But having a label creates a container for my experience; I can understand it and talk to other people about it and know I’m not the only one who’s had that experience. Finding labels that accurately describe my experiences helps me feel safe. I obviously can’t diagnose myself, but the label “bipolar disorder” seems to become more accurate the more I learn about the experiences it’s intended to describe.

I know I’ve been “depressed” lately because I’ve been feeling sad and/or grumpy, isolating, having trouble eating full meals, apologizing for my existence, and thinking “I want to die” when I’m tired. I feel like it’s only a matter of time before my world starts unraveling (again): I worry about Fox’s safety, our rats’ health, my own health, the house burning down, etc. Calling these experiences “depression” helps me separate a bit from them, accept them, and engage in self-care.

a day with episodic mood disorder not otherwise specified

Today I asked my APN what her official diagnosis for me is, hoping (among other things) it might help me present myself more accurately on my blog. She confirmed that, especially based on my past response to anti-depressants, uni-polar “depression” doesn’t capture the whole picture of what’s going on. I guess she’s not sure what’s going on. To the extent that I do know, I have no idea what to call it. I was hoping she could give me an idea. But “episodic mood disorder not otherwise specified” just doesn’t have a good ring to it – even when shortened to “mood disorder NOS.” I might as well just say I have emotional issues. Well, almost. I have clinically-relevant emotional issues.

In other news, she decided to lower my Lamictal dose from 75 mg to 50 mg due to concern about possible side effects. On the one hand I’m glad she’s taking my concerns seriously and being cautious with the only brain and body I have. On the other hand, Wakana had suggested I should increase the dose – that the lower doses aren’t enough to be therapeutic – and I’d been expecting us to move in that direction. I guess there’s still the possibility of increasing the dose if that seems to be the best course of action; it’s probably better to trust the person who has the required training, certification, and experience to make decisions about this sort of thing.

But APN is talking about adding a new medication (that I’ve never taken or heard of before) to help fight the chronic lethargy I’ve been experiencing. I’m really not a fan of taking multiple medications. Even just being on one medication has me concerned about long-term effects and my ability to safely be a biological mother on my own terms someday. Let’s say I do experience side effects: how am I supposed to know which medication is causing them, or whether it’s an interaction between the two? More medications also means more risk of interaction with environmental factors, food, caffeine, and alcohol.

I may not be too thrilled with how today’s appointment went, but I still have confidence in my APN. She’s not just prescribing medications, she’s looking at the whole picture. She suggested I get blood work done so she can get a better picture of my physical health, including how it might be affected by the new medication she’s considering. She also re-encouraged me to have a sleep study done. Maybe if I do that, they’ll address the lethargy well enough that I won’t need to take a second medication! Finally, I appreciate that she asked me if I was seeing a therapist or would be interested in therapy. It shows she considers therapy to be an important part of treatment. She also encouraged me to work on setting boundaries, so I can distinguish between what I’m feeling and what others are throwing at me. That’s what most of the posts in this blog and the work I’ve been doing with Wakana are about, so I guess I’m on the right track. It’s just taking an uncomfortably long time to get where I need to be.

Diagnosis and Identity

A trusted friend who has bipolar and works in a mental health setting pulled me aside the other day; he said he’s observed some possible symptoms of mania in my behavior. He presented the information as something that might help explain some of what I’m going through, and more importantly as a tool I can use in my creative endeavors. Use the unbridled, chaotic energy to create; edit when the mind is calmer. I don’t think I want to edit when I’m depressed because then I’ll probably get rid of a lot of good material, but I digress.

To be honest I’ve been wondering about the possibility of there being a manic – or, more likely, hypomanic – component to my… madness. I do seem to have times when the depression lifts – just enough that I think I’m starting to get better, but not enough to say I’m “in remission” or “have recovered.” These times are often accompanied by a whirlwind of energy in which I become engulfed in a new project – which I tend to abandon completely when the next wave of depression hits.

I never really pursued the possibility of mania/hypomania being part of my madness for a few reasons:

  • I thought it required elevated mood; to the degree that my mood becomes “elevated” it would probably fall within the range of “normal” non-depressed emotions.
  • Questions on screening tools that explore the possibility of mania/hypomania tend to begin with “a period when you were not yourself and…” I’m always myself.
  • I’m not comfortable talking about some of my experiences with mental health professionals because I don’t want them to pathologize experiences I consider(ed) to be spiritually meaningful.
    • Some of the voices in my head may become abusive, but others can be supportive. It might be different, but I often find it adaptive. I’d be lonely if they all went away.

But now I’m thinking this is a possibility worth looking into. I pulled out the DSM-IV-TR and reviewed the relevant symptoms with Fox. (We don’t have a copy of the DSM-5 and I’m inclined to keep it that way, considering the concerns people have raised about it.)

The DSM-IV-TR clarifies that the mood in mania/hypomania can be elevated, expansive (?), or irritable. We’ve both noticed that I seem to have some of the additional symptoms: (3) more talkative than usual or pressure to keep talking, (4) flight of ideas or subjective experience that thoughts are racing, (5) distractibility, (6) increase in goal-directed activity. Additionally, it is possible for depressive symptoms to be present at the same time as manic/hypomanic symptoms. Hypomanic episodes can be as short as 4 days and do not require there to be marked impairment in functioning (e.g. taking huge risks) to be diagnosed.

I’m not really in any rush to ask a professional to put a stigmatized label on me, but I do think this is important. It can help me understand myself and navigate my life and experiences. Awareness of it might help me find useful ways to channel the energy when it hits and possibly even cope better when it dissipates.

If I pursue treatment, particularly medication, it changes what I need; Fox said that medications for bipolar disorders are better understood and tend to be more effective than those available for unipolar depression. I’d need to do some research, but I do feel more hopeful about finding something that works for me (preferably with minimal side effects / other health risks).

Finally, it’s very important to me to represent myself as accurately as I can on this blog. One of my goals is to give people who have never experienced madness / mental illness an insider’s perspective of what it’s like (for me). If I say I have one disorder but I “really” have something else, I’m misrepresenting the first disorder and doing a disservice to everyone involved.

For now I just want readers to know that I’m not sure what my diagnosis should be. At the end of the day we’re all people with dynamic issues and behaviors that don’t really fit into neat categories.

Thoughts on Mad Pride

I’d like to encourage readers to check out a new blog, Radically Mad, where cheshirekit will also be writing about experiences with mental health issues. Although she has several psychiatric diagnoses, she prefers to consider herself “mad and neurodivergent.” Near the end of her Introduction, she explains the meanings of these terms:

Neurodiversity and disability rights refer more to physical and cognitive disabilities, while mad pride and radical mental health refer to psychiatric diagnoses.  The basic idea is that humans are meant to be diverse and have diverse ways of perceiving, experiencing, and acting on the world, and this actually improves society as a whole rather than hurting it.  Having a brain that is wired differently, though it can be challenging at times since our society at large is set up to be convenient people with “typical” brains, does not have to be a bad thing, and can in fact be a source of pride.

I like this way of thinking, but I have yet to examine my own relationship with it.

Whatever labels people might stick on me, my basic experience is that I have very strong emotions. I’m learning what to do about / with them – how to express them safely; how to channel them into a healthy activity; how to respond to the situation in which they are arising so as to meet my own needs while still respecting others; etc. Right now I’m taking medication intended to make them a little bit easier to handle, but most of my work is on coping with them.

I don’t want my intense emotions to go away – they are an important part of who I am! They give me energy, creativity, the passion and drive to do amazing things. I often find it difficult to function in a society that devalues emotions, demands conformity, sensationalizes tragedy, and over-stimulates the senses. Worst, I’ve internalized messages from society that take the form of very harsh, critical thoughts with the power to decimate my self-esteem. But as painful as the lows may be, on some level I value them just as much as I value the joy that can rise in response to the simplest things. The depth of the emotions I can experience is meaningful to me; it is the genesis of my art. Having experienced the lows helps me to appreciate the highs so much more. They’re also an important part of how I connect with other people – empathy.

So I guess for me Mad Pride is recognizing these aspects of who I am as a way of being that, while undervalued by society, is valuable in its own right. My emotions aren’t “pathological,” society just isn’t really built to handle them. My journey isn’t about “recovering” from an “illness,” it’s about learning the skills I need to live and function in society, while still valuing, expressing, and utilizing all of my Self. It is in this way that I can make the most meaningful contributions to society.

… Though any change that can occur in society, to make it more accepting of and accessible to people who are mad and/or neurodivergent, is certainly a big help. That’s where activism comes in: changing the structures of society to be more inclusive; to make diversity more visible; to value respect the myriad of ways humans can be in the world – rather than considering one way “normal” and marginalizing everyone who doesn’t fit into this narrow mold.