The Bipolar Puzzle
Photo by Dimitar Belchev
Bipolar disorder can be a challenging condition to manage. For starters, the symptoms can vary from individual to individual and the speed of cycling — from mania to depression and back again — is rarely predictable. Because the presentation can be quite different, many people are unaware of any existing patterns of erratic thinking or behavior until after a significant episode of decompensation. Even then, they often dismiss any concerns or calls for action, choosing to understand their symptoms through rose-colored glasses. For them, medication non-compliance is common. It often takes repeated episodes over the course of months or even years before they are ready to concede the issue.
Many factors need to be considered before treatment can be effective. As always, understanding the nature of this confounding illness plays a key role.
Bipolar disorder used to be called manic depression. Both names help to conceptualize the illness — there is mania; there is depression; and there is vacillation between these two polar opposites. Depression is easier to understand for most people. Because even if they have never suffered from clinical depression, they can relate to the symptoms of depression — sadness, fatigue, insomnia, etc. On the other hand, mania is a lot harder to pin down. It is not because the symptoms are subtle; in fact, some are quite extreme and nearly impossible to miss. Those include not only drastic mood swings, but also erratic changes in sleep, energy, memory, cognition, speech, concentration, self-image, goal-setting, and decision-making. In extreme cases, mania can significantly impair one’s judgment, self-care, and even reality-testing. It can knock people way off their baseline.
So, the reason why bipolar can be difficult to diagnose is not for a lack of outward signs. Rather, it is because not everybody with this illness will have the same presentation every time. Furthermore, some of these symptoms are interpreted as part of one’s personality, and therefore not any signs of an illness. Impulsivity may be experienced as spontaneity; excessive goal-setting, as indomitable ambition; not sleeping for days, as thirst for life; hallucination or delusion, as spiritual awakening. Because of the bipolarity, the inevitable shift to the other end of the spectrum will follow and some of these symptoms will eventually begin to abate. Without treatment, however, these bouts are likely to grow worse over time, resulting in devastating manic or depressive episodes that require hospitalization.
If your loved one with bipolar disorder asks for your help, the best thing you can do is to have a candid conversation about what to do if you see any warning signs. Ask your loved one how you can provide feedback and, if necessary, intervene. It is very possible that your loved one genuinely does not notice anything erratic before an episode; poor insight is a part of the illness. Have a discussion about how to ensure medication compliance and how to respond in a crisis. Do so when your loved one is stabilized and clear-minded. It will not be an easy conversation, but it is one that needs to happen if long-term stability is ever to be achieved.